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17D-012 • =rom: Maria Gadziala At: Phillips Insurance Agency FaxID: To: Building Department Date: 5/16/2008 01:35 PM Page: 2 of • ACV OP ID MA DATE {MMlDD/YYW) RD 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. Travelers 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. 71E 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. IMrK NUVl POLICY EFFECTIVE POLICY ERPRtATIQN LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE IMMIDDIYY) DATE {MMtDD/W) LIMITS GENERAL LIABILITY j EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY 30+72509 03/14/08 03/14/09 P PR na REEMISES(Eccrrence) $ 50000 CLAIMS MADE [ OCCUR MED EYP (Any one person) $ 1000 PERSONAL & ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GENT_ AGGREGATE L..IMIT APPLIES PER: PROTXXI :TS- COMP/OP PNG $ 1000000 — 1 POLICY E& 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 acaderd) • GARAGE LIABILITY 'ACM ONLY - E,A ACTL73EA i $ ANY ATST3 OTHER THAN crr,"rfiCC AUTO ONLY. ACS I ." EXCESS/ UMBRELLA LIABILITY EACH OCCURRENCE $ 5000000 C X I OCCUR I 1 aAAMSMADE XL1110196 01/16/08 06/18/08 AGGREGATE $ 5000000 $ DEDUCTIBLE $ RETENTION $ $ WC SIARJ WORKERS COMPENSATION AND X TORY LIMITS I I B EMPLOYERS' LIABILITY 6KUB0479L93108 04/03/08 04/03/09 EL. EACH ACCIDENT $ 100000 ANY PROPRIETOIRJPAOR/PARTNER/EXECUBVE OFF10ER/MEMBERE7tCWOED? E.L. DISEASE - EA EMPLOYEE $ 100000 It yes, describe under E.L. DISEASE - POLICY LIMIT $ 500000 SPECIAL PROVISIONS below OTHER ! I 4 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 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 D REPRESS ATIVE /y� + j ACORD 25(2001/08) ! L 14x,@ ACORD cA CORPORATION 1988 The Commonwealth of %Massachusetts Department of Industrial Accidents Office of Investigations • 6., ,;—.,- 600 Washington Street ^ l Boston, M4 02111 • k� �� wrvw.mas -z, dig -W orkers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers AD olicant Information Please Print Legibly Name ( Business /Organization/Individual): L Crosse. v t • v• e.. Address: 84 fie +e a. .T City /State /Zip: GAn,:4ope.r. AAA 4 Phone. #: L(13 ... 2-44' - 2 Are you an employer? Check the appropriate bo Type of project (required): 1. 11:1 I am a employer with employees (full and/or part-time).* 4 . I am a general contractor and I have hired the sub - contractors 6. El New c rs action 2. 1=1 I am a sole proprietor or partner - listed on the attached sheet. 7. Remodeling shin and have L10 employ es working for me in any These sub - contractors have g, ❑ Demolition yaci employees and have workers' Y P n' 9. El Building addition [No workers' comp. insurance comp. insurance. required-] 5- ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3- 1.3 I am a homeowner doing all work officers have `exercised their 11.11 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL C. 152, §1(4), and we have no 1241 Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required] *Any applicant that checks box #1 rrn rst also fill out the soon below showing their workers' compensation policy information. t Homeowners who submit this afdavit 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 •worke s' 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 Datee:: Job Site Address: 4�1i Q 4C C 51 - O1 c am' City /State /Zip:•ktDRev1Ge. 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 tine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and ae 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 DLA for insurance coy -r• • 1-.: cation. I do hereby certify under .a.ptrfns ate, , ■ • -s , , erjury that the information provided above is true and correct Sian mure: - Date: - Z e:113 _ Phone #: Li l3 G .. Z 61 3 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 =: Versionl.7 Commercial Building Permit Mav 15. 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as qwn r of the subject property Alfc�cde/wbrr2.3r Pre s fi A S 'a ' ( L i° mob `rflp 6-P ?o4 H . acicyw tCe / - �-'i C , hereby authorize 1.4t C S e P✓1 (.4„0.4-5. to act on my behalf, in all matters relate rk authorized by this building permit application. ) -6. x; ,t..... ° ''' Signature` -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 : �!(f C - !� ' 5? y ...d IC GS le 4 License Number t 7a2 (3 4 Gv- ST AAA 0 to 13 . xco , to ,ZcB Address Expiration Date u 1 3 ?4 --zo°73 . 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 0 No O Version 1.7 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 e c e r t c 1•C T. 0-z. t c, to Name Area of Responsibility 1 9 r' 1 •e cc s (..k. v■ r- \ f % e W Dr. 1-14 .ei u(, Oct 6/ 2.-e,/ 6 Address Registration Num . � , 62 97 -S7 4'(1 ) 7 6 57 Signature II Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date _ Name . �._ e , .. _ __. Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number 10 Signature Telephone Expiration Date 9.3 General Contractor L i C4-0 _. e A 5 , J"Nc_.. Not Applicable ❑ Company Name: &7tre5ai) . 5=Y. 4 . ''k .... Responsible In Charge of Construction G� AAA- o to13 �a Cam,,, -��r -- Sr cam- _ Address '.� .......... L i 13 (0.20 Signature � Telephone Ago/010 Version1.7 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 Q DONT 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 Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q 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 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 0 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 ❑ Brief Description Enter a brief description here. Of Proposed Work: ,, � ,f�- Gemsl avG.T � ►'L{ ► (z . w � r ��9 And e� NPInre.^ !' .... 1 + .J t? r1 ' 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 El 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 R -3 ❑ 5A g 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) 1 st 1 st 2 nd 2nd 3 rd 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 El Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system Versionl.7 Commercial Building Permit May 15. 2000 Department use only City of Northampton Status of Permit: ,, I: , Building Department Curb Cut/Driveway Permit - 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability VII Av 1 3 2308 Northampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans i i ,;,: IS I Other Specify :APPLI4 - Tk6N TO CONS' ' ,-REPAIR, 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 1 1 4 4 1 I rZrOal£. ;'►Ar / ' . Li Map Lot Unit NDATWIMItTern / Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: /W eAt O eserv+aca n 4550c, 1-9 4bColatk't Si 6,. easran, l44 Name (Print) 4 Current Mailing .�y Q6>q H eacQcnvh 60 lc � g, C. �'' r ng Address: . 4 �t � - 08 5 4+' Signature (.. S. Telephone 2.2 Authorized Agent: LRGte f 0'11 A e4 5 Sig C ev►1 er 5T , .1.1, ;eoprs., AA Name (Print) Current Mailing Address: 010 13 ` Li3 -23- ∎ ze 0 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 t bl:, , OG O 2. Electrical ' ' (b) Estimated Total Cost of O! 00 Construction from (6) 3. Plumbing 3,, oes O Builds g Permit Fee ' 4 4. Mechanical (HVAC) 3n, d m a 5. Fire Protection l 0 0 ©O 6. To 1= 1 +2 +3 +4 +5) ZOC7 ace Check Number tlo #//,0 s 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 ■ . er (-11) -01 Ik IS ( ,P 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 Connectrcuf 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 Penns)lvanrs Yours truly, f otor2dc - Frederick J. Dzialo Ph. D. ���' t0. Of y4s : a 1 FREDERICK �� o .+ U J. M DZIALO No. 17657 ° .P 4 tois T Ett ' t * Brf sSrGMaLf• b\4 . y 9/8' D '' / 19 Pleasant View Drive, Hatfield, MA 01038 • 413 - 247 -5740 • File # BP- 2008 -1015 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 Buildin , Permit Filled out , Fee Paid Typeof Construction: UNIT 1 - RECONSTRUCT INTERIOR WALLS & MECHANICALS New Construction Non Structural interior renovations Addition to Existing Accessor Structure 13uildint Plans Included: Owner/ Statement or License 067404 3 sets of Plans / Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 /' .....--.........../ - ' .'-/''' _ cr_____;4Z:r2:53 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. , / c 4. 7 47v, 7 9 / 7' 7 /e7 1 )) a vl 0 a a-j 00 — 1 i „1,_.„ 4 .. _ .,,,., , i , , vii2 - IV af ---' (9 (15,/, ... ,...tv .._. ,, _ / 6,,, X111 491 BRIDGE RD - BLDG 4 BP-2008-1015 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 012 CITY OF NORTHAMPTON Pfi RSV $ CONTACTIN( WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND'INGL c.142A) Category: 'BUILDING i!IT Permit # BP -2008 -1015 Project rt JS- 2008 - 001518 Cost: $40000.00 Fee:$2.0000 . ERMIS ".S' N IS HER I:'BY GRANTED TO Coast. Class: Contractor :•. License: Use Group_ LACROSSE BUILDERS'I 067404 Lot Size(sq. ft.): 1169150.40 Owner MEADOWWrBROOOK PP'ESI?RVAT1ON ASSOC•LP Zoning UR& :_ACROS BOil DR:: 1 N 3 'L =1Q1 BRIDGE RD '..1 DG2 4 Applicant Address: Phone: Insurance: 86B CENTER ST (413) 246 _ CHICOPEEMA01013 , ISSUED ON:5/16 %008 0:00:00 TO PERFORM THE FOLLOWING WORK ,UNIT 1 - RECONSTRUCT IN FERIOR WALLS & MECHANICALS POSE- VMS CARD SO IT 1S VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. - Building Inspector Underground: Service: Meter: • / 7 ��,� Footings: Rough:g � "(� ti t Rough3 /449 . opse # Foundation: (? / 43 Final: / . Final: ''J =D(7 Final / G!� g I� tt . • Fr:atite: 'el' IC /i -'l t 7//b/DiF� " Gas: Fire Department Fireplace /Chimney, tz-, ,.?1- - .1.su!nt;;U: 6 Finr;l: Smoke: 'qi/ 9 05, ,,,e,� Final: 0K Otj Af,C 5F`aFr 09/ U7-1 a ca-, ° M16/6'8 0.�,,." THIS PERMIT MAY BE REVOKED BY T1IE CITY OF NOWTHAMPTON UPON VIOLATIC3►iI OF ANY OF ITS RULES AND (REGULATIONS. Certificate of Occupancy G ¢/^ / - signature: "" _ Fee':!'ti p1: . _ Date d: Amount': Building 5/16/2008 0:00:00 $200.003023 212 Main Street, Phone (413) 87 - 1240, x :'(413) -1272 Building Commissioner Anthony Patillo