17D-012 (5) 'Tom: Maria Gadziala At: Phillips Insurance Agency FaxID: To: Building Department Date: 5/1612008 01:35 PM Page: 2 of
•
A CDRD OP ID MA DATE (MMJDDlYYYY)
. CERTIFICATE OF LIABILITY INSURANCE LACR -1 05/16/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PHILLIPS INSURANCE AGENCY INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
97 CENTER STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
CHICOPEE MA 01013
Phone:413- 594 -5984 Fax:413 -592 -8499 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER' A Essex Insurance Company
INSURER B. Travelers ma - mane crngany _ - -'
Lacrosse Builders, Inc. INSURER C U S Liability Insurance Co
86B Center St INSURER D
Chicopee MA 01013 •
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
1N511 AWL POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM(DO?YY) DATE (MMIDDIYY) LIMITS
GENERAL LIABLn'Y I EACH OCCURRENCE $ 1000000
A X COMMERCIAL GENERAL LIABILITY ' 3CW2509 03/14/08 03/14/09 PREM ES (E a o arena) $ 50000
I CLAIMS MADE i OCCUR MED EXP (Any one person) $ 1000
PERSONAL & ADV INJURY $ 1000000
- -- -- ., - - --
GENERAL AGGREGATE s 2000000
GENII_ AGGREGATE LIMIT APPLIES PFR PR6lx lr :TS - COMP/OP A( $ 1000000
— 1 POLICY — a LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY
NON -OWNED AUTOS (Per accident)
_^ PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY A(JTU EBLY- EA T- JCTDENT $
ANY AUTO OTHER THAN ' '
AUTO ONLY. AGO
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 5000000
C X l OCCUR 1 CLAIMS MADE XL1110196 01/16/08 06/18/08 AGGREGATE $ 5000000
$
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND X ITOORY S L MITS I �
EMPLOYERS' LIABIdTY
B ANY PROPRIETOR/PARTNER/EXECUTIVE 6KUB0479L93108 04/03/08 04/03/09 E.L. EACH ACCIDENT $ 100000
OFFICER/MIEMBERERCLLIDED'? ( ( E.L DISEASE - EA EMPLOYEE $ 100000
If yes. describe under I !
SPECIAL PROVISIONS below E.L DISEASE - POLICY LIMIT $ 500000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Refrence: MeadowBrook Apartments, 494 Bridge Road, Florence, MA
CERTIFICATE HOLDER CANCELLATION
CITYOFN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
City of Northampton IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Building Department
125 Locust Street REPRESENTATIVES.
Northampton MA 01060 AUTH DREPRE ATIVE p�
ACORD 25 (2001108) Q ACORD CORPORATION 1988
The Commonwealth of Massachusetts
___,> - Department of Industrial Accidents
", ' .. Office of Investigations
t . 600 Washington Street
•=1 ` v Boston, M4 02111
-,�% j
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): Lao CI - 0650 u 1 t S 2v+ e.
Address: 869Z Ce. t+e. 'r
City/State /Zip: C-� 4bQt';/ AAA D 10 i Phone. #: `{ i 3 — 2 - 44 ' - 2°T3
Are you an employer? Check the appropriate bo Type of project (required):
1. ❑ I am a employer with 4. I am a gene. -a] contractor and I li
employees (full and/or part- time).* have hired the sub- contractors 6. E] New c ns�uction
2. ❑ I am a sole proprietor or partner - listed on the attached sheet 7. Remodeling
ship and have no employees These sub - contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' coma. insurance comp. insurance.:
9. ❑ Buildin addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have ` "exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
C. 152, § 1(4), and we have no
12.0 Roof repairs
insurance required.] t
[No workers' 13.❑ Other
employees. [N
comp. insurance required.] •
Any applicant that checks box #1 trust also ED out the soon below showing their workers' compensation policy information_ .
t Homeowners who submit tins affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub- contractors and state whether or not those =titles have
employees. If the sub - contractors have ettmloyees, they must provide their 'workers' comp_ policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: L Expiration Date: -
Job Site Address: 1 0 a.4
I 4 e 6 i , D 1 City /State /Zip: . .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fie
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance cave.. • :•-.:cation.
I do hereby certify under . • . '. ns an' , . erjury that the information provided above is true and correct.
Siam Lure: deo.. 41110/1110" Date: - Z — e) IS
Phone #: 14 13 . - 4 - Z 6°13
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CityrTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone =:
Versionl.7 Commercial Building Permit May 15. 2000
I SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
■
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , , as QQw�n r o th subject property
MecncPavbra3t P re SeAA)Cz Zvi Assnua)�; LI ,1/ r4 6 26.0-H- ,lloac oii„ c K . 1 c,
hereby authorize ).t 06'SS -Q ,. BO (d0.4.--- to
act on my behalf, in all matters relat' e rk authorized by this building permit application,
ti-c.
Signature'—of—Owner Date
i, , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : G'"tre 1 0 7.1 Z y d'' ✓(C GS O 4 c -i.
License Number
alp Ce- -4 u/ T CA-. 7 nP-2 t., ..A A .. _ 010 13 . ' \ (a - . (b eeb 8
Address Expiration Date
—
u i 3 -2.- -20
Signature Telephone
�i
SECTION RS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 No 0
Version 1.7 Commercial Building Permit Mav 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name (Registrant): �....... �_ ,. ..
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
rrraerI c 1. T. Dztc1/4 O -' 'eu�
Name Area of Responsibility
j 9 P t `e C.c s C..k tA " \I t e w Dr. tai Ct,t ul i P4R, 6/ 3-at(O
Address Registration Num er
I sL 9 7 -S CIO ) 7 6 67
Signature II .0 Telephone Expiration Date
Name Area of Responsibility
Address Registratio n Number
_
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
s
Signature Telephone Expiration Date
9.3 General Contractor
L pf Cre L .._..., v; , S 10C- Not Applicable ❑
Company Name:
&itegdi S '2 y c ✓1G
Responsible In Charge of Construction
04$ Cam, -t er -- Sr GLred(' - A o to I13
Address '
a ilIll.
y13 . 246.2093
Signature Telephone
Versionl.7 Commercial Building Permit May 1 5, 2000
8. NORTHAMPTON ZONING
Existing Proposed I Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location) . .
A. Has a Special Permit /Variance /Findin er been issued for /on the site?
NO Q DON'T KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Regist f Deeds?
NO Q DONT KNOW YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW ES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q ,Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration 0 Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use 0 Other ❑
Brief Description Enter a brief description here.
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 0 A -3 ❑ 1A I ❑
A-4 ❑ A -5 ❑ _ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 0 F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 R -3 0 5A P J�
S Storage ❑ S -1 0 S -2 ❑ 5B ❑
U Utility ❑ Specify`
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): ___.. Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
15' 15
2 nd 2nd
3 d 3rd
4`"
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system 0
Versionl.7 Commercial Building Permit May 15. 2000
Department use only
City of Northampton Status of Permit:
ir' Building Department Curb Cut/Driveway Permit -
. ' ------ , 212 Main Street Sewer /Septic, Availability
. Room 100 Water/Well Availability
�,n
g0,1\\a 1 3 2 .,;08 Northampton, MA 01060 Two Sets of Structural Plans
phone 413- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
4■ ;5 \ Other Specify
;APPLIeoiT..K6N TO ,CONSi' ; REP?1,IR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
Ilk i j
411 �R.TOU� , �1 //' _ Map Lot Unit
3 t3 / Zone Overlay District
- Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
1 t e �ofbroc- ieseeQA11Yn ss� i- 46 ici Si �; -
Name (Print) vy J%SAH ectrxC'wia' Ay, 6 J Current Mailing Address:
4 0. , 4 4 9 -0643
Signature G ����� `� Telephone
2.2 Authorized Agent:
1 p �� oesf j 0•1 Ge t •
ldeisg C�►ie� 5 , ,moo
Name (Print) / ,/ Current Mailing Address: 0103
L ill -246 -Z-C13
Signature Telephone
�1i�
SECTION 3 - ESTIMATED CONSTRUC ' ON COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building LO� OG D (a) Building Permit Fee
2. Electrical 3 (b) Estimated Total Cost of
�� 0o d Construction from (6)
3. Plumbing 3e , oc D Buile g Permit Fee
4. Mechanical (HVAC) 340 'p ®a U FPI\
5. Fire Protection I 0 i 049 0
6. To 1= 1 +2 +3 +4 +5) Z So ere' Check Number l8 ; (� /
This Section For Official Use Only 4 rrrlll
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
Sep 10 08 10:44a F.J. Dzialo & Company Inc 413 247 -5740 p.1
■ U .
(-7D, Oi
Gt
-is uP a
Frederick J. Dzialo Sc Co., Inc.
September 8, 2008 Consulting
Structural
Engineers
Building Inspector
City of Northampton
Northampton Massachusetts
Re: Meadowbrook Apartments
Apartments 411 -415 Registration
Florence, Massachusetts Massachusetts
Connecfrcut
Rhode Island
Dear Sir:
derrnare
This is to confirm that on September 8, 20008 I had made a final inspection of the above reference.
New Hampshire
My inspection indicated that all work appeared to have been accomplished for occupancy. I am New York
therefore, requesting that occupancy permit be issued by your office for the above apartments. New Jersey
Yours truly, Pennsyrlvan
I Cotora
51(406144) 1 , . 4..., , , td
Frederick J. Dzialo Ph. D.
3 � * %tK oF u4s
a FREDERICK r aw
J.
DZIALO
No. 17G5�
°.P 4 4 1 1STEA E C , ` t . 1p
9f8' 4 �+ 19 Pleasant View Drive, Hatfield, MA 01038 • 413 - 247 -5740
File # BP- 2008 -1019
APPLICANT /CONTACT PERSON LACROSSE BUILDERS INC
ADDRESS /PHONE 86B CENTER ST CHICOPEE (413) 246 -2093
PROPERTY LOCATION 491 BRIDGE RD - BLDG 4
MAP 17D PARCEL 012 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid (31%)- 5 �-�
Typeof Construction: UNIT 5 - RECONSTRUCT INTERIOR WALLS & MECHANICALS
New Construction
Non Structural interior renovations
_ddition to Existing
Accessory Structure
Buildin Plans Included:
Owner/ Statement or License 067404
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
f9i 9/ 7 ,4 472 . ,57
i f 41 /
A
4) 2 1 }AA
-rg, --- 64I/V
491 BRIDGE RD - BLDG 4 BP- 2008 -1019
GIS #.F: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D - 012 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
P ; :ri :,it,', BP-2008-1019
Project # JS- 2008 - 001518
Est. Cost: $40000.00
Fee: $200.00 PERMISSION IS HEREBY GRANTED TO:
Coast. Class: Contractor: License:
Use Group LACROSSE BUILDERS INC 067404 ,
Lot y z+lscL_ft 1: 1169150.40 Owner: MEADOWBROOOK PRESERVATION ASSOC LP
iAty; ` Applicant: LACROSSE BUILDERS INC
ti; T. r- - - PI Pi A
-pp ict nt Ai dress Phone: :111P rttiict
86B CENTER ST4 (413) 246 -2093
CHICOPEEMA01013 ISSUED ON :5/16/2008 0:00:00
TO PERFORM THE FOLLOWING WORK :UNIT 5 - RECONSTRUCT INTERIOR WALLS &
MEC:'. NIGALS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET .
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Und3:•;raund: Service: Meter:
f r Footings:
€,,, "s: &lam a s , ' I Rough: , j' House # Foundation:
v /O� Driveway Final:
t�inal : -pgk � , ,� Final:
/ / / / / /�����V 7�;°�, „a Rough Frame: Ok G "(1 -0 6
(p 4; 4, ) - ..ptl54.)
6 7 g W
C,s: Fire Deartment Fireplace /Chimney:
. f.-ft Insulation: OX 0 6 /19/0 (.ate iS
Final: Smoke: g tt =- L,. - Final: OKPEN0/a,c2 etocr1 t S(PoFf
G 9 / (� at 6IK dWeel0g
THIS PERMTT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY Of ITS RULES AND REGULATIONS.
Certificate of Occupancy ^- � t ` ' Signature:
Feely e: Date Paid: Amount:
Building 5 /16/2008 0:00:00 $200.003023
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo