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17D-012 (4) 'rom: Maria Gadziala At: Phillips Insurance Agency FaxID: To: Building Department Date: 5/1612008 01:35 PM Page: 2 of ACORD OP 1D MA DATE (MMIDDmWJ . CERTIFICATE OF LIABILITY INSURANCE LACRO-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 Essex Insurance Company _________ INSURER El Travelers InSUTance cox¢an.. Lacrosse Builders, Inc. INSURERC: 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. I p� UUt POLICY EFFECT VE [POLIO EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM!DO!YY) DATE (MMIDDIYY) LIMITS GENERAL LIABILITY } I EACH OCCURRENCE '$1000000 I txnras rs A X COMMERCIAL GENERALLIABILI W2 TY 3C509 03/14/08 03/14/09 PREMISES (Ea oc e cu e1 rence) $ 50000 CLAIMS MADE ri OCCUR MED EXP (Any one person) $ 1000 PERSONAL &ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GENT. AGGREGATE LIMIT APPLIES PER PROD: I:TS - COMP/OP AGG $ 1000000 1 POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY (Per accident) $ NON -OWNED AUTOS PROPERTY DAMAGE $ "- — (Per acnderd) GARAGELUIBIITY 'ACTIO"ONNLE - EAiNU DEcO $ ANY ALSO OTHER THAN cr;,�CC AUTO ONLY: AGL-- I $ EXCESS/UMBRELLA LIABILRY EACH OCCURRENCE $ 5000000 C X l occur.? I 1 CAJUNS MADE XL1110196 01/16/08 06/18/08 AGGREGATE $ 5000000 $ DEDUCTIBLE $ RETENTION $ $ WC SLAW- WORKERS COMPENSATION AND X TORY LIMITS 1 B EMPLOYERS' LIABILITY 6KUB0479L93108 04/03/08 04/03/09 E.L. EACH ACCIDENT $ 100000 ANY PROPRIETOR/PARTNER/EXECU ME OFFICERMEMBEREXC.`LUDED? [ I E.L. DISEASE - EA EMPLOYEE $ 100000 If yes. describe under SPECIAL PROVISIONS below I E.L. DISEASE - POLICY LIMIT $ 500000 OTHER ! I 4 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 AGEN OR Building Department 125 Locust Street REPRESENTATIVES. Northampton MA 01060 AUTH■l DREPRESE ATIVE , ACORD 25 (2001/08) a ACORD CORPORATION 1988 o The Commonwealth of Massachusetts . _ t _ Department of Industrial Accidents " z ; ; r Office of _Investigations �:� c 600 T ash ington Street � fi , �^ Boston, M4 02111 www.mass .b ov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers ADD licant Information Please Print Legibly Name ( Business /Orcanizat on/Individual): �,A. CrrOSSf_ t0 i t 2 v. e.. Address: 848 Ce✓t4ea. ''1" City /State /Zip: C C -/ AAA 0 I 13 Phone #: Lt II- 244. - 2013 Are you an employer? Check the appropriate bo • Type of project (required): �' 1. ❑ I am a employer with 4. I am a gene. - aI contractor and I employees (full and/or part- time). * have hit ed the sub- contractors 6. ❑ New c ns�uction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no employees working for me in any These sub - contractors have g. ❑ Demolition capacity. employees and have workers' Y p ' 9. ❑ Building addition [No workers' comp. insurance cow insurance.: required_] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have `exercised their 11.❑ Plumbing repairs or ar7ri;tions myself [No workers' corm. right of insurance required.] MGL Y �` 12.D Roof repairs insurance required.] t c. 152, §1(4), and we have no ' employees. [No workers' 13.0 Other comp. incmmrance required.] *Any applicant that checks box #1 roust also fill out the section below showing their workers' compensation policy information_ - t Homeowners who submit this 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 entities have employees. If the sub-contractors have employees, they must provide their 'workers' corals_ 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. #: Expiration Date: - Job Site Address: 4it 1 -0 Ridge 57 , p aee;" 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 Iead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment; as well as civil pen. sties in the form of a STOP WORK ORDER and a 'rr 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 ii prance cave. cation. I do hereby certify under . ' . '. ns an � s • • erjury that the information provided above is true and correct Sionature: — Date: - Z.. — 0'B Phone T: L113-- G - 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. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone it: 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 1, as Own r of the subject property �ll ecr bra" Pi'eseivuo �vt if spc�`�e l� L io ‘..by 7'Ap 6-P 204-H- ,11vadcyv 0c4C . �'1 C, hereby authorize to (4 to act on my behalf, in all matters relaf e rk authorized by this building permit application. g` ° titV Signature o€ Date , 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 : !y GS 4 *e ' T License Number (3 4 e- v- j-f _ � A 0 %O 1 45 8 . �1 , t (O �Z Address Expiration Date ti 13 - • Signature ' Telephone 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 C.) No C) • Versionl.7 Commercial Building Permit May 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): f G \ Z , \ Z. iC. C2. 5- ,/i' k�_ Name Area of Responsibility 1 9 r 1 s tA yew Dr. I-&1 `PC C1,_ f4q 6/ 345 b er 6 Fr" Address Registration Num cam._ • AZ.r ; SL Y7 -57 v0 ) 7 6 57 Signature 40 Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date • Name Area of Responsibility Address Registration Number • Signature Telephone Expiration Date 9.3 General Contractor 1.1 Cross f. ; \ S �- �- � _ ..... Not Applicable ❑ Company Name: Responsible In Charge of Construction $G3 Cam,, r- Sr C1..reo( -- / t / LA- 0 to �3 Address IS 2- 4(0.20g3 Signature Telephone Versionl.7 Commercial Building Permit May 15, 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 L: R: L:. R: 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 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regist f Deeds? NO (3 DONT KNOW YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 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 0 NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • Versionl.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 ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other 0 Brief Description Enter a brief description here. Of Proposed Work: ce o v�T _ ► �'1, r►?tn _ ,w , 11.5 .. _+v � ! 1rm ....1 n .. .5.. _'? n.; 5 SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑ A -4 ❑ A -5 ❑ _ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 0 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I -1 ❑ I -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 R -3 ❑ 5A Er S Storage ❑ S -1 ❑ 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) 1st _. 1 st 2 nd 2 3 d 3 rd 4 th 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 ZoneD Municipal ❑ On site disposal system Version) .7 Commercial Building Peewit May 15. 2000 Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit - -- ` 212 Main Street Sewer /Septic Availability rn Room 100 Water/Well Availability ,� Al 1 3 N� r$ Northampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans _ l ,2 •5 \ Other Specify' ;APPLIr4fl N TO.CON$ F; R EPAIR, 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 l 411 " Qr04L '►ir' / / ' I. Map Lot Unit NoirrfItAlt , AA,A Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: /etco2voc Qese,rN+xtam Ass LP 4b Coucc't �' bsb xrs�rar►, / Name (Print) C ur rent Mailing by e6AH �ac{�cnv�a (CC , G Address: 4 _ 08(03 Signature L�� ��� Telephone 2.2 Authorized Agent: L pLroes � .�'1lelet� Sig CP.•nter 'S 614iGOpeck" AilA Name (Print) Current Mailing Address: O 1013 y13— (0 -z Signature Telephone i"— — SECTION 3 - ESTIMATED CONSTRUC ' ON COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant ' �� OGO •., .. �. , . ._ . 1. Building (a) Building Permit Fee 2. Electrical 3 (b) Estimated Total Cost of �� �� d Construction from (6) 3. Plumbing 3e, . oeb O Buile g Permit Fee 4. Mechanical (HVAC) 3d a © -a 5. Fire Protection 1 0 , 0 ©O 1(11,//\A �j ., 6. To 1 = 1 +2 + 3 + 4 + 5) Z CO d , tad' - a Check Number 5 1023 /J1,, a�� �® This Section For Official Use Only + 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 ■at■ *(-t GP 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 Connecticut Rhode Island Dear Sir: Vern - on` 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 Pennsylvania Yours truly, p f Coforadc c ia."....) Frederick J. Dzialo Ph. D. -1.4‘ v olt OF U4s : G FREDERICK A J. DZIALO No. 17657 8 4 EOIS T EV c J 9 /8 ' /I / 19 Pleasant View Drive, Hatfield, MA 01038 • 413- 247 -5740 File # BP- 2008 -1018 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 0 d- 3_ 26 Typeof Construction: UNIT 4 - RECONSTRUCT INTERIOR WALLS & MECHANICALS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building 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. / i .5Q 97 -L /Or f 9 / 7 • _ p ; ,/ 6.rvpdo v vga?'p 2' / � �� 0 ,/,/6/6 IT`' sir A7 ga( 717- OLti.A" 1 41 491 BRIDGE RD - BLDG 4 BP- 2008 -1018 GIS #: 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 Permit # BP- 2008 -1018 Project # JS- 2008 - 001518 Est. Cost: $40000.00 Fee: $200.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LACROSSE BUILDERS INC 067404 Lot Size(sq. ft.): 1 169150.40 Owner: MEADOWBROOOK PRESERVATION ASSOC LP Loi i9 . IJR3 Applicant: LACROSSE BUILDERS INC T - 491 nr- r Pll E! !IC - - pptiicunt Arlilress: Phone: Insurance: 86B CENTER STE (413) 246 CHICOPEEMA01013 ISSUED ON:5/16/2008 0:00:00 TO PERFORM THE FOLLOWING WORK: UNIT 4 - RECONSTRUCT INTERIOR WALLS & ',/;EC H ANICALS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing . Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: 1 f Footings: Roligl:: y -/ 09(4 Rough: ' D� House # Foundation: 3 Driveway Final: ile Final: 7- 3''l�� Final: * f, �� . Rough Frame: oft_ G I 1 - 0t - -, /b o Gas: Fire Department Fireplace /Chimney: Kutign: r to _ Insulation: Final: Smoke: , d t <.,, Final: OK. . PO)Pit -- O(E fq-t, a . - c .L, 5"%t c N a £- o 9 /12,163 j ,� A t,t, 0K 46r(4 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF L ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy �-^ �� Signature: (1' FeeType: 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