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17D-012 (2) 'rom: Maria Gadziala At: Phillips Insurance Agency FaxID: To: Building Department Date: 5/16/2008 01:35 PM Page: 2 of ACORD ID MIL DATE IMMIDDlYWY) _ CERTIFICATE OF LIABILITY INSURANCE P LACRO MA -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 Insurance company 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 WE 1ERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1N4rt ALM l POLICY Eti FECT VE POLCCY EXPW4TION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MMIDOIYY) DATE (MM/DDtW) LIMITS GENERAL LIABILITY � $ 1000000 A X COMMERCIAL GENERAL LIABILITY 3CW2509 03/14/08 03/ 14/09 e4a� PREMISES (Feoccurence) $ 50000 CLAIMS MADE 0 OCCUR MED EYJ' (Any one person) $ 1000 PERSONAL & ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GFNY. AGGREGATE LIMIT APPLIES PER PRODUCTS - CCMWIOP AGG $ 1000000 — 1 POLICYa LOC AUTOMOBILE UABLLITY 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 acciderd) GARAGE LIABILITY 'AU ° "CINLI "- EA AC $ ANY AUS ^v P AUTO -THA I o OTHER AGO ,R EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 5000000 C X OCCUR I ] CLANS bvsoE XL1110196 01/16/08 06/18/08 AGGREGATE $ 5000000 $ DEDUCTIBLE $ RETENTION $ $ • WORKERS COMPENSATION AND X ITORY L MITS I B EMPLOYERS LIABILITY 6KUB0479L93108 04/03/08 04/03/09 EL. EACH ACCIDENT $ 100000 ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICERIMEMBEREllTYUDED? E.L. DISEASE - EA EMPLOYEE $ 100000 I f yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 53QQU0 OTHER I [� II I I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Refrence: M:eadowBrook 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•Ti• DREPRESE ATIVE ek t :U tjoei ACORD 25 (2001108) © ACORD CORPORATION 1988 The Commonwealth of ilassachusetis - --_-- n Department of Industrial Accidents o�,�= - i—��,' Office of Investigations • 600 W Street = Boston, MA 02111 ' � ` www.massgov /dip -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Or�nization/Individual): L j14CS OSS�, V i t cle4-s v,, e. i Address: 84 Z Ce4*Veaa . r City /State /Zip: C T`'b1' '�i AAA D 1013 Phone. Li i 3 - 24 - 2013 Are you an employer? Check the appropriate bo 1. ❑ I am a employer with employees (full and/or part-time).* Type of project (required): � 4. I am a gene aI contractor and I 6. ❑ New c ns action have hired the sub- contractors 2_ E I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling shin and have no e. -^^lo; ees working for me in an These sub - contractors have g. ❑ Der,�oli ion capacity. employees and have workers' comp. Y p tY 9. ❑ Building addition [No workers' comp. insurance insurance.: required.] 5. El 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' corm. right of exemption per MGL c. 152, §1(4), and we have no 12. ❑ Roof repairs insurance required.] t ' employees. [No workers' 13.❑ Other comp. insurance required.J *Any applicant that checks box #1 must also El 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 snowing 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. Insurance Company Name: — Policy # or Self ins. Lic. #: Expiration Date: - Job Site Address: 4 11 � 2 51 , Or cam Ci /State/ gDi2edlc� ty 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 fine 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 Investisations of the DIA for insurance cov ,K ! cation. I do hereby certify under • • • •• s an' • s • • erjury that the information provided above is true and correct Signature: — # : Date: 6- - '2 - — 0 8 ,,,,o ....... Phone #: 1 -1 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 # 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 =`: • Version 1.7 Commercial Building Permit May 15. 2000 I SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No O ■ SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as wn r of the subject property AI ed2( a)brrz3k PreseAvafi 21-...( j L e „b `1'Ap G-' 2,,,411 .t!tear,��rruw6tic� 1 1s - P7 c, hereby authorize 1.,ee LOSS -le - BO (.4,01. to act on my behalf, in all matters relate rk authorized by this building permit application. 0----....„ ) - 4 r ` _ Signature` -ef Ow'ner 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 : i r t ✓ 'e 1 o - 7 y t ' ".lC e' ©4'4- 4 CP License Number 13 CL -' S C t.,, : e ° .�� 1 A ... 0 1013 c., to °ze:b 8 Address Expiration Date _ -- C4 X3 .2-44 -zd'3 Signature Telephone 411111 SECTION " - ' RS' C OMP E NSATION' 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.', 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): Name Area of Responsibility 1 ci r7 Necks v■r- v %e w Dr. 14cc -Ci.1d, t4% 6/3-a jG Sr' Address Registration Num er 0 A 97 -s 7 vo ) 7 6 57 Signature OF 4/ 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 L� Not Applicable ❑ Company Name: Responsible In Charge of Construction GLT4 n o t i13 $4a Cep, -�� Sr ,.. Address '., / A(S'1 4- 1(0•2093 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 b_v 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 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regist f Deeds? NO 0 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 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 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 Q 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versioni.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: cervtis vd-T v tk 1,,,44 10 gte 110 Avid 1ne-c- ■►!Prvi 5.....1►7 J u n45 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 ❑ I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 E R -3 ❑ 5A PJr S Storage ❑ S-1 ❑ S -2 ❑ 5B I ❑ 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) l 1 st 2 nd 2 3rd ... 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 ZoneD Municipal ❑ On site disposal system Versionl.7 Commercial Building Permit May 15. 2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - 12 Main Street Sewer /Septic Availability , Room 100 Water/Well Availability 1 3 20O8 Northampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify +' iAPPLIei4T16N TO PAIR, 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 411 a.ro4f- *to / / / . 14 Map Lot Unit NbiZTVVICArrtrn AkA Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: /Ule oacvfbrao c ,sscc, L 5 Cove.1 Si 1,;te65 &won , j1il Name (Print) by P6A eur�cnvlr�x lc �b, C. �'' Current Mailing Address: .... - 4�1 `� - a81o3 Signature �.� x Telephone on AMP' 2.2 Authorized Agent: LRC►l049 v 11.4 e4 g Ceiv►tof ST , 614 z4-vP02-, ,tt Name (Print) ,I Current Mailing Address: O 10 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 3 (b) Estimated Total Cost of �� � Construction from (6) 3. Plumbing 30 oc O Buiid g Permit Fee 4. Mechanical (HVAC) - 3p, o o -a I_ 5. Fire Protection I O 00 0 6. To I= 1 +2 +3 +4 +5) ZO acre Check Number 7��� #11,°° This This Section -For Official Use Only 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 T ug' Ak-Gt G p 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: Vermont 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 Pennsylvents Yours truly, 1 ^Atoradc Frederick J. Dzialo Ph. D. FREDERICK e . • DZIAL0 ` No. 17657 °p . fsStGMii �x6`� oti Q�8 j 19 Pleasant View Drive, Hatfield, MA 01038 • 413- 247 -5740 File # BP- 2008 -1016 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 �� /AWi '% • ' " Typeof Construction: UNIT 2 - 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. / ft /---( 1 7°4-') ," , ,..., ..,,,g,,„ , ...,,,.,,,.... 4 'P 5'4 Cr/ C {7, , i-di 4/ - 71 2/ a. Ti ' - ;7 = ' LI ..r / 7 ‘°,--- U 4 7 , ..,...' - A i - ,4.1-tifril ,f-v .4 4 /,,,,,-:. 1 ,,, I / 1 4 ;4 1 1 4'4 i / e i, ryPelq-vci 'I 'I i - & I ,. - r e .7 ,••-#• E. 1 ( C: -- - 4- , ..,---. ',/ - ;: . ( 2 / 7 1: 7 .■_,,,::-., / j..1 .1 , r , ' 3 N 1 )1 .7) r , -% ----, r /4 A, . _ /,,,,,,,,,_ avec/ I '4 L\(7. 491 BRIDGE RD - BLDG 4 BP- 2008 -1016 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 Perinit f' BP- 2008 -1016 Project # JS- 2008 - 001518 Est. Cost: $40000.00 Fee: $200.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Grou__ LACROSSE BUILDERS INC 067404 Lot Size( scL ft.): 1169150.40 Owner: MEADOWBROOOK. PRESERVATION ASSOC LP Zoning,: ORB Applicant: LACROSSE BUILDERS INC t AT: 491 B DGE RD - SLOG 4 Applicant Address: Phone: Insurance: 86B CENTER ST (413) 246 -2093 CHICOPEEMA01013 ISSUED ON :5/16/2008 0:00:00 TO PERFORM THE FOLLOWING WORK :UNIT 2 - RECONSTRUCT INTERIOR WALLS & w% ME.CtH POST THIS CARD SO IT IS VISLBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: ?Z :)li�ii :640.0.6 Rough: / �) / g ,, House # Foundation: !! Driveway Final: Final :` . `�. Final: / .7 �"Y �' 1'0 Rough Frame: 0 /C y " —if —d- E)--14, _ , e s, ..,..„,/,p, �'. Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: pK o6 1 VON vit 3 Final: Smoke: y / 7 v /5 ,_,- Final: OK Pety p Ec6cT t ?itC,4 c.' e !'a. r� k_.___ - Vf 05 (ti_1 c - t i j6YaS tc s THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 7 Ol Certificate of Occupancy (1---%--- Signature: 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