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32C-067 (3) a _ A c p ® CERTIFICATE RTI DATE (MM /DD/YYYY) `.--- FICATE OF LIABILITY INSURANCE 12/20/2011 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Lisa Lemon PHE Berkshire Insurance Group, Inc. At EXtY_ -120 N�_(413)567 -5300 E-MAIL l lemon @berkshireinsurance rou com 138 Longmeadow St . ADDRESS: 9 P PRODUCER 00018084 CUSTOMER ID # Longmeadow MA 01106 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA:Hartford Casualty Insurance 29424 INSURER B :S a f ety Indemnity Co. 33618 Charista Construction Services, Inc. iNsuRERC:Savers Property & Casualty 38 Harkness Avenue INSURERD INSURER E : East Longmeadow MA 01028 INSURER F : COVERAGES CERTIFICATE NUMBER :11/12 master REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSR WVD POLICY NUMBER (MM /DDIYYYY) (MM /DD /YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300 000 X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ r A CLAIMS -MADE X OCCUR 08SBAVU0093 5/6/2011 5/6/2012 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 2,000,000 X POLICY JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ B ALL OWNED AUTOS 5021567 6/2/2011 6/2/2012 - BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ 100,000 X NON -OWNED AUTOS PIP -Basic $ 8,000 Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ ___ DEDUCTIBLE - $ RETENTION $ $ C WORKERS COMPENSATION , WC STATU- OTH- TORY LIMITS ER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR /PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER /MEMBER EXCLUDED? N N / A WC0002537 6/8/2011 6/8/2012 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory In NH) - If yes, describe under PERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF O DESCRIPTION OF OPERATIONS / LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Proof of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FOR REFERENCE ONLY AUTHORIZED REPRESENTATIVE Judi Mabee /JU ` ..:), r-, =__.r%:-,,,er :77'%��_.,€C�_ ACORD 25 (2009/09) ©1988 -2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD ,e° the Commonwealth of Massachusetts M » f ,Department of Industrial Accidents t '1,,1, , Office of investigations Washington , • i . t r r 644 W� dolt fit► ed r y e tIt P Boston, MA (/2711 1 ' wi.viv, mas'i.gov /dia Workers' Compensation Insurance Affidavit: Buildr.rs /Corttr act( trs /ElectriciausfPItimbers 1,pnircant fnlffolInai n ^ _... __ Please Print I, Oily Name (Nisi nev t/Urgat i�tarir.bt /fntlit iclual): f 1 S� C 1-1 S---\ / V (-�-4:, L Address ' Sr _ - - - S 0 O l t a2 ° cv . - - -- C:i /Braze /Z,ip IV 0 o ? Phone #,_ L( / ?.- c ) c 1 7 ?5 Are you 1111 employer? Check the appropriate box: Type of project (required): 1. I ff1 a employer vvitll „ l __ -_ l n am a• enernl contractor and I .New consrfu.ctiott employees (full and /or part - Hine:). * have hired the sub -contractors 2. E] I an a solo proprietor or partner., listed on the attached sheet. 7. 0 Remodeling, ship oral Nye no t: mplovees These sub.corttractors have g, 0 Demolition wot'lc.ittg for me itt any capacity. employees and lkwT workers' I11 Uratice,'l 9 0 Building addition INo workers' comp. insurance comp. required) 5. We are a corporation and its 10 [J Electrical repairs or additions, 3. (_7 I am a hoineowney doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. 1No worlrt r5` comp. right of exemption per MOL insurance required] C. 152, ;51(1). and 1F 11 have 110 .12.0 Roof repairs employees. (No workers' 1.3 [� Other Vi. �k Sa l _ __ _ _ ______comp. insurance required.,__ __ ^'.Aay ;rpplicant s chechh bor 11 allot nt,vo Jill cart the Se'clian below s er+ showing the work' coutpeusntioa policy information �`��� r IIomcowI1 l talk) ytihtnil Otis Iftidavil indicntiug then are doing alt ■•orn nud area bu'e ootyicle cootrectUIB now submit n now affidavit indicmint: such. ''Conlracial tbnt cltdek this boc yam attached an ndditionnl :heel showing Ilia name of the Yub ontrnctors pad Nhne whether nr" I thine ,,tit;,,„ h:IVe employees tithe suh- conhm,to's hm•e ontployeei, Ines tnnat pinvitle their workers' comp. policy number. . r=: - -= ;:ate= ur- -:.= _....., ,_.. cc = __...-..__.,,...._- ac=e. - --.. ._ ....., .. _____•----,—.• 1 asst an employer that is , 7rorietiog workers' kers' compensation istsurunce no employees. liefnrt■ is the policy and, job site information. f I nsurance Company Name: 5CLU ?l' c .Y cu t`- ,n Pc. C(")a l /,: — �_ _ __— __ Expiration Date b I a 1 • Policy # or Self -ins. Lie. Job Site ncldrc:ss: - .-a _ -- G . - _._ - 5 -- •,-- - - -.._ _— Cit /State / it�� �i( • kochR�-eut _ G. 0 ( 060 Attach :I ropy of the rvor°Icer•s' compensation police declaration page (showing the policy number and expiration date). Failurr to Secure coverage as rrgttir d under Section 25A of MI;I, c. 152. can. lead to t1ae. imposition of criminal penalties of a fine up to 51 and /cr 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 clay aw inst the violator. Be advised that %1 ropy of this statement may be forwanled to the Office of hivestigations of (he.1)1.A 'or insurance verage verification. /do hereby erti> v under ( c l ins t ,$ pen i.• that the information provided above is true and correct. sis; „, ..— . ..:_. r ?alt __.. / ?. .s r- ..- .,_....._.-..ra . - - Offleia,. use anti I)o not tvrit►s in this area, to be contpleterl by city or town tdriclal. City oc'l<'owtt: _ - ,_,. _ ___�,...._-,�__..._._..._...._— Pertttit /l,ict lac #- ,----- ._...�_:. �__,._, _ Issuing Authority (circle one): 1. Board of Health 2. iIoilrliug 1)ep.artrn,ent 3. City /Town Clerk 4. Electrical Lnrtpectnr q. Plumbing Inspector 6. Other' ._..._..,_.. Coot act rerstm:,_ _ Phone # :__- ____ _____ . —. Version1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ® No ii SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, t ' \ e L■ ? -P rp i ©k./. , as Owner of the subject property hereby authorize J O ' -e e LA ki,,, `e ,' to -ct on behalf, in . tte relative to work authori -d by this building permit applicatio ,b , rwrii 'a —'1 c _ ( a Signature of Own Date 1, -- yocoe L -1\ iik.Vl..0 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 an penal ies of perjury. C� Sr� Cpl & 6-et v. Prin Name • i i i ' )' ' a- - O Sign . ; e of • er /Agent 7 Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : �2) ( DL -N 1.1ti1�4' I7 0 S5 ( 4. G License Number t re 6 5A C ' ( ( V••C ( VM- o t 0 0 q - 7 - a 1 - a a l • ;dress -- Expiration Date -t ature Telephone SECTION 13 -WORKERS' 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 . 4 No Version1.7 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: t \ Not Applicable 0 Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): 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 Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor _ CLa U` i S` '1 O ti S r v C 1 d Not Applicable ❑ Company Name: - T - C 9 CQ D � , , t.kt.k -P Responsible In Charge of Construction S 1cwt R7„.e pa L y 0 Y O A dress t � �, tit? -sac - (74" Si ature Telephone Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed 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 /Finding ever been issued for /on the site? NO 0 DONT KNOW t]�� YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW ® YES l IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ,Date Issued: C. Do any signs exist on the property? YES t NO 0 IF YES, describe size, type and location: S1nnc..R v^00V ytntiuVt \ S ` Ks, I t� 1-c �(A) D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO A,4 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 ® NO 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 !'4 Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. (A 9 u ( r t L1 tvv\ a v. Of Proposed Work: 0 1 ,, iA- as , A i ,, e 2 �iQ it.y SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business Rt 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F -1 ❑ F-2 ❑ 2C I ❑ H High Hazard ❑ 3A I ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ SA ❑ S -2 ❑ 5B 1 ❑ 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 2`d 2nd 3 rd 3 rd 4 th 4 Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) Total Height ft 7. Water S pply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage 9isposal System: Public Pnvate ❑ Zone Outside Flood Zone ►:i Municipal On site disposal system a ��SS a Version! .7 Commercial Building Permit May 15, 2000 tECE ,� Department use only V t City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - 1,. d 'AR — T 2012 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability - . of BUILDING INSPECTIONS N. rthampton, MA 01060 Two Sets of Structural Plans + atIAMPTON ' ''': ' -587 -1240 Fax 413 - 587 -1272 Piot/Site Plans Other Specify APPLICATION TO CONSTRUCT, 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 Cat Z SA ) 0 r AA c+. u, 3 Le q Map Lot Unit V'-& - Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: f`(� • • , ` . w 2 3, ,ykvfr w--e C—. L (!lt 0 ( ap Name (P " Curr ent Mailing Address: � II/ ?' S a r- 1 ?55' Signature -. '. Telephone 2.2 Authorized Agent: — TO - ' •U,vi_o cr 3 b" 4 I,err c u-40 £ .L. ithct a (0)' Name (Print Current Mailing Address: L ) f J / I " Sar- 01,r Signature d J. ,1 Telephone SECTION 3 Ik L$i STIMATED CONS - UCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 13, g o C. (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 0 ll� Q Construction from (6) 3. Plumbing l V a Building Permit Fee 4. Mechanical (HVAC) e ! 5- Fire Protection W 0 t, 6. Total= (1 +2 +3 +4 +5) Check Number 9o 1573 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0773 APPLICANT /CONTACT PERSON JOSEPH KENNEDY ADDRESS/PHONE 38 HARKNESS AVE EAST LONGMEADOW (413) 525 -1735 Q PROPERTY LOCATION 2 CONZ ST - #22 MAP 32C PARCEL 067 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out j Fee Paid J� Typeof Construction:_ INSTALL VINYL SIDING & TRIM New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included: Owner/ Statement or License 055440 3 sets of Plans / Plot Plan THE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ORMATION 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 L!� ~, 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. k 2 CONZ ST - #22 BP- 2012 -0773 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C - 067 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit # BP- 2012 -0773 Project # JS- 2012 - 001355 Est. Cost: $13900.00 Fee: $83.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH KENNEDY 055440 Lot Size(sq. ft.): 30666.24 Owner: MAPLEWOOD SHOPS INC Zoning: CB(100)/ Applicant: JOSEPH KENNEDY AT: 2 CONZ ST - #22 Applicant Address: Phone: Insurance: 38 HARKNESS AVE (413) 525 -1735 0 Workers Compensation EAST LONGMEADOWMA01028 ISSUED ON :3/8/2012 0 :00 :00 TO PERFORM THE FOLLOWING WORK :INSTALL VINYL SIDING & TRIM POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 3/8/2012 0:00:00 $83.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner