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17D-012 (3) -rom: Maria Gadziala At: Phillips Insurance Agency FaxID: To: Building Department Date: 5116/2008 01:35 PM Page: 2 of ACORD OP ID MA DATE (MM/DDJYYYY) . 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 A: Essex Insurance Company INSURER B WV? biers Insurance company - -- -- -- - -- 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. IM3K POLICY NUMBER DATE EFFEt. flat POLICY EXPIRATION LTR NSRC TYPE OF INSURANCE /W (MMfDOI DATE {MM /DD/YY) LIMBS GENERAL LIABILITY I EACH OCCURRENCE '$1000000 A X COMMERCIAL GENERAL LIABILITY 3CW2509 03/14/08 03/14/09 P R M I Es (EA ccurence) $ 50000 I CLAIMS MADE [1 OCCUR MED EY,P (Any one person) $ 1000 PERSONAL &ADV INJURY $ 100.0000 GENERAL AGGREGATE $ 2000000 GENT. AGGREGATE LIMIT APPLIES PER • PRODUCTS - COMP/OP AGG $ 1000000 POLICY — I JECT LOC AUTOMOBILE LIABILITY C(M f3INED 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 $ T _.---- ---- I (Per acaderd) GARAGE LIABILITY 'AQfUONLt "- EA 7AUCTIS III $ ANY AUTO I OTHER THAN �.C. -+;CC I AUTO ONLY_ AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 5000000 C X - I O I l CLAMS MADE XL1110196 01/16/08 06/18/08 AGGREGATE $ 5000000 $ DEDUCTIBLE . $ RETENTION $ $ I WC: IAI U- IH- WORKERS COMPENSATION AND X TORY S LIMITS j GER EMPLOYERS' LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE 6KUB0479L93108 04/03/08 04/03/09 Et_ EACH ACCIDENT $ 100000 OFFICER/MEMBERERI;1UDED? E.L. DISEASE - EA EMPLOYEE' $ 100000 If yes, describe under SPECIAL PROVISIONS below I E.L. DISEASE - POLICY LIMIT $ 51Q DUD OTHER 1 ! I DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES ( EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS Ref rence: 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 D REPRESE ATIVE y /'y� ACORD 25 (2001108) rL � @ ACORD CORPORATION 1988 ° ti The Commonwealth of Massachusetts r-; Department of Industrial Accidents ,i --- , ,- ,- - ,- , Office of Investigations cy; -- 600 Washington Street . ,s,=-----;:,---, Boston, 111-1 0 �lll r `' j • H�W71.maSS.aOV�dda ' -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADa licant Information Please Print Legibly Name ( Business/Ornizaron/Individual): L C4' os _ t • t ra � • v+ C. Address: &j(o r"3 C e✓t -_a. 'T City/State /Zip: C T °bQ•e-Ar-'/ AAA D 10 t3 Phone. #: `{ 11 — 2 -' 44 ' - 2€7t3 Are you an employer? Check the appropriate bo • Type of project (required): i 1. El am a employer with 4. I am a general contractor and I J 6. El New c nstruction employees (full and/or part - time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling shin and have no employees These sub - contractors have 8. ❑ Demolition --�- ' vy employees and have workers' working for me in any capacity. Y " 9. ❑ Build addition [No workers' comp. insurance comp. insurance. required_] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work rk officers have `exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. - right of exemption per MGL 12.0 Roof repairs nsurance required.] t C. 152, §1(4), and we have no ' employees. [No workers' 13.0 Other comp. insurance required.] Any applicant that checks box #1 must also fill out the soon 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. iContractors 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' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Ins Company Name: Policy # or Self-ins. Lic. #: Expiration Date: - fob Site Address: H i o 2 td ge 5i , Or ems' City /State /Zip: " DQeirc.,e.. 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 frnP of no to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Invesnzations of the DIA forinstn cover - .:cation. I do hereby certify under . • . ,• ns an. s ■ • • erjury that the information provided above is true and correct Simat re: 41111111111' Date: - Z — p'8 - Phone #: ti I3 _ G – 2 6®13 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License T Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Version1.7 Commercial Building_ Permit May 15, 2000 I 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 Qwn r of th e subject property Ai ec�c�cwbra 3 t f�!'eS z`fi t f} CCOCi41�; Le d 7Ap 6-P Pooh ,tivadcne �cr,K . 1,c, hereby authorize Lt GC" _( S-e to (!L- to act on my behalf, in all matters rela e rk authorized by this building permit application. .. Y _ ` / � Lt G a 1 Signature'efOwner 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�fc 1 p - /- '' Z y L ✓jC LS en 4 '} 4 V'r License Number t3 -►e-.- S r CL,.e°r .e_ AA. A " . 1 01 3 1(.0 . to ea, 8 Address Expiration Date ....../.----- N 13 • C - 20-77 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 Versionl.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): Name Area of Responsibility 9 r ►ma's c.k.v\i \/ tew Dr. 1 - t ‘e1c.t, OR 6 /3-a / Address Registration Number �--, t 0 I I 62 97-67 4 /(1 ) '7 ( 5 Signature 11 . 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 It Signature Telephone Expiration Date 9.3 General Contractor k J Cross I, u; \ S 1 Not Applicable ❑ Company Name: Responsible In Charge of Construction 3 Ge,,,.k r sr. G ° . o !o i3 Address H13.24fo -2oq.3 Signature Telephone Versionl.7 Commercial Building Permit Mar 1 5, 2000 8. NORTHAMPTON ZONING Existing Proposed l 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 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 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. 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 0 Other ❑ Brief Description Enter a brief description here. Of Proposed Work: zieyry w,c..T Tnkt„trwt, L. to 1 Ot Ann -e Y inic .... n 5 v 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 ❑ _1 B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile 0 4 ❑ R Residential CI R-1 ❑ R -2 R -3 ❑ 5A Fr S Storage ❑ Si - ❑ S-2 ❑ _ 5B I ❑ U Utility ❑ Specify` M Mixed Use El 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) 1 s t 1 st 2nd 2nd 3 rd 3rd 4 m 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 Version] .7 Commercial Building Pe . wit Mav 15.2009 1 Department use only C ity of Northampton Status of Permit -= Building Department Curb Cut/Driveway Permit ' - -- ' ` 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability is, Y 1 3 2.008 Northampton, MA 01060 Two Sets of Structural Plans , phone 413- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Y5 I ' ,t Other Specify rtt' 1 APPLI6ATt(N TO CONS ' , 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 I • 4i I �rzroeac ; 0 / / i ' j Map Lot Unit Zone Overlay District j\)0i/TeoiCitt Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: M esec'A n A 1- ,/ 46 ourt'( Si ;tom bsb � CrsTah, / Name (Print) t_, QoAH e'ad -ia, iC ) g � f • Current Mailing Address: , 4449 -0 $349 3 Signature L ,t Telephone 2.2 Authorized Agent: �R� oes � '� )el a Ce -Ater S T , — t Q .. AA Name (Print) ' , /" Curr ent Mailing Address: 010 13 Signature Telephone ∎��� SECTION 3 - ESTIMATED CONSTRUC ' ON COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 3 O OG Construction from (6) 3. Plumbing 3e oc p Build g Permit Fee Il\J 4. Mechanical (HVAC) 3C>, © ®zo K ` 5. Fire Protection . 6. To I= 1 +2 +3 +4 +5) Z00 , adf> Check Number ,/o3 l p00 This Section For Official Use Only ��11 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 p[2 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: Berman. This is to confirm that on September 8, 20008 I had made a final inspection of the above reference.. 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, r uly < =? i Color��c Frederick J. Dzialo Ph. D. 4." 11444 o FREDERICK M DZ{ALO No. 17057 %ChM. 0°4 ;Or It 1 9 /IP/ I 19 Pleasant View Drive, Hatfield, MA 01038 • 413 - 247 -5740 File # BP- 2008 -1017 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 36 aJ 4 a 0 V Typeof Construction: UNIT 3 - 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. 4/, f fi ?,,,L.74fi/-96 op a t ., e CQ F, % r - 7 1 15-ire ct> Cy L/6 1517 17hz.41 e'r " IVCies titg — 40P V/ h UlAt+ 1 413 491 BRIDGE RD - BLDG 4 BP-2008-1017 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 012 CITY OF NORTHAMPTON Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Perm n: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND .(MGL c.142A) Category: renovation BUILDING PERI411T Permit # BP-2008-1017 Project 4 JS-2008-001518 Est. Cost: $40000.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Qiroup: LACROSSE -BUILDERS INC 067404 Lot Size( sq. ft.): 1169150.40 Owner: MEADOWBROOOK PRESERVATION ASSOC LP 2:onino: 1 JJ:E Apolicant: LACROSSE -BUILDERS INC 491 8RinGE - RI DG 4 An AddriTss: Phone: Insurance: Ei CENTER. ST (413) 246 CHICOPEEMA01013 ISSUED ON:5/16/2008 0:00:00 TO PERFORM THE FOLLOWING WORK:UNIT 3- RECONSTRUCT INTERIOR WALLS & MECHANICALS POST THIS CARD SO IT IS VISIBLE FROM THE STREET {)i Plumbing Inspector of Wiring Building Inspector U ntkrground: - Service: -.Meter: S , Footings: Rough: / r Rough: -House# Foundation: 1 26/ V4 Driveway Final: .Rough Frame: Oft- 9h 64 Gas: Fire Department Fireplace/Chimney: Insulaticn: of< 0, 6 it, J ‘ 1--- Smoke: (VVri OK P6/QD ik.) -n £C6C cit- 0 .2/ 6 c/ 67 c) 91V Lot% THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupanca— r Signature: — • / Feel's/pc: 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