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23B-046 (7) • ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) Q4X08F6A 08/03/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MARSH USA INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ONE STATE STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR HARTFORD, CT 06103 -31e7 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A:Hartford Fire Insurance Co CARRIER CORPORATION ONE CARRIER PLACE INSURER B: Ins Co of the State of PA FARMINGTON, CT 06 034 -4 015 INSURERC:Illinois National Ins Co. INSURER D:American International South Ins Co INSURER E:New Hampshire Insurance Co 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. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM /DD/YY) DATE (MM/DD/YY) LIMITS A GENERAL LIABILITY 02CSET10004 04/01/2009 04/01/2010 EACH OCCURRENCE $ 1,000,000 DAMAGEIO REM rho X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurence) $ 300,000 CLAIMS MADE X OCCUR $2 , 000 , 000 general MED EXP (Any one person) $ 10,000 aggregate per PERSONAL & ADV INJURY $ 1,000,000 location /project GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $10,000,000 policy PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY n PECOT- n LOC A AUTOMOBILE LIABILITY 02CSET10000 (A /O) 04/01/2009 04/01/2010 COMBINED SINGLE LIMIT X ANY AUTO 02CSET10019 (HI) (Ea accident) $ 1,000,000 ALL OWNED AUTOS Hartford Underwriters Ins BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WC STATU- B WORKERS COMPENSATION AND 35669:MA,NJ -20, CA -24 04/01/2009 04/01/2010 X TORY LIMITS O ER EMPLOYERS' LIABILITY C TX -21, FL -28 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 D OFFICER/MEMBER EXCLUDED? MULTI -23, OR -25 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E If yes, describe under MN -22, MULTI -26, 27 SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CT WORKERS COMPENSATION (SIR 2.5MM) EXCESS COVERAGE - NATIONAL UNION FIRE INSURANCE CO - POLICY NO. 4801324 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATETHEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICETO THE CERTIFICATE HOLDER NAMEDTOTHE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Carrier Corporation 14 Industrial Park Place AUTHORIZED REPRESENTATIVE Middletown, CT 06457 Page 1 of 1 ACORD 25 (2001/08) © ACORD CORPORATION 1988 The Commonwealth of Massachusetts T m Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information p Please Print Legibly Name ( Business /Organization/Individual): CA1z -t CC' RP61iT1Ot4 Address: 5J CAM ER. PtAc- "FaP,lvilN6f6 N, CI" QGO - 1 - ( lot City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. 111 New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 1 their exercised ex h officers ofis ave er tr 1. plumbing repairs . ❑ I am a homeowner doing -all -work -- - - -_- - -- ❑lbin or additions _ - .� P. myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no �� � ANT-- emplo [No workers' 13.Other�G - 6� G comp. insurance required.] ` *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. r 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' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. A �� Insurance Company Name: t"� 1 -S K USA, /V C' / _ Policy # or Self -ins. Lic. #: ,�____,� '35 G (9' Expiration Date: _V i/ (31 D Job Site Address: 3o Ldp-' 1 5 . Nbt2TktAMr"'fntvl ,4it /State /Zip: 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 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 Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: g��J� ©� Phone #: C7€ �' `77q ��33 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 May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ! +61 ! DieecCoa "t.r .... . ...... as Owner of the subject property hereby authorize v V�G� o act on my behalf, in all matters r ativ to by this building permit application Q 210 2 Signature '---1 f caner Date 12AUtA +'Oa ......._.. , 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 ID( t Name ., Signature o Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : _, License Number Address Expiration Date Signature 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 he b ilding permit. Signed Affidavit Attached Yes No C 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: Not Applicable 0 Name (Registrant): ___ ,, ,, ,, ,,,,,, ,,,_ _ ...,. .... ._....., , . Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): A V I, A \ A .QUES ? j 2 , k E $ ) ' i - A Q A , t r : A M t/tN11 kL EA)6 /AAE 51Z Name Area of Responsibility 2 MA(A) 5i . EAST ft4J h42b , C, l a „ 6l tg . `'t •5' Address ?av1M Q,pcor 51Ve,Q.v. . (_J/e. Registration Number Signature Telephone Expiration Date $4.(4N GC tli , cs E N61n9FR)11 . SE> tCS ._. (_ CCcTClIC C_!v Name Area of Responsibility - AMC/ SR u ,:sA D DAAt g c5RY, CT g l 6 Address ( O/ . C ron h C saes .COIM4 Registration Number (Z03) 2 • 6 3z5 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 £ /” p p hRIC m ( PST _... ._..CUT - ) _. _ Not Applicable ❑ Company Name: 161- c am} ' } J / . . 1 4 V Responsible In Charge of Construction 6b y . P M CT- EU. _(ca ceiArrA � AAA Address ,�.— 1 . .. Signature Telephone Versionl.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 /Fi sing ever been issued for /on the site? NO 0 DONT KNOW * YES 0 IF YES, date issued: IF YES: Was the permit recorded at the R,istry of Deeds? NO (:) DONT KNOW 1 °,1, YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO (3 DONT KNOW 0 YES o41 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained �4 Obtained Date Issued: C. Do any signs exist on the property? YES 141 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 )Z IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading •e ; .vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES (D NO 1'r;® 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 "1 0 CUBIC FEET OF ENCLOSED SPACE t - Interior Alterations ❑ Existing Wall Signs 0 Demolition ❑ Repairs ❑ Additions ❑ Accessory Building Ku) ; ' i 1 i Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other ❑ Brief Description Enter a brief description _ ,__ here. � _ Brief QQ ription h "T��C��►ICR�s'f�A�t �vI�BW�'S / ®N E C Of Proposed Work: / oseig. � hap ( OE(0 WELL- • LuitTR. %W A' lnts.N 8 �l SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ a 1A I ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B l ❑ F Factory ❑ F -1 ❑ F -2 ❑ r 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 ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: m _ S Special Use Specify.'L C , L 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"d 2 fNt _- _ 3rd 3rd ,, °_._ ._ 4th (A LL 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 0 Private ❑ Zone Outside Flood ZoneD Municipal ❑ On site disposal system 0 i Version1.7 Commercial Building Permit May 15, 2000 ' ' Department use only, 51 1 City of Northampton Status of Permit B uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer /SepticAvailability v Room 100 Water/Well Availability . .NOrthipton MA 0.1060 Two Sets of Structural Plans phone " 4 13= 587 -1240 Fax 413- 587 -1272 Plot/Site Plans rt Other. ' :, s 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: G This section to be completed by office (ooLe? 11. <I ), fc `J�IT 3© Lac )s-r ST' , , ,A� Map Lot Unit Al / cs�3 J IA/ . '' Zone Overlay District - - - - E l m St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: CO6 L V T ick / A/ _ SIAr NoSPt Name (Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: 4oseft-1 C{- 4M' +1.4N ZO t-tAm. 5 Su (7E _ C>T Name (Print) Current Mailing Address: 07 1 77'1 - X333 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ZO�t (a) Building Permit Fee $ 7, - 7 70 2. Electrical 49.25 GGb (b) Estimated Total Cost of l Z5 4 i Construction from (6) / .._.. Qc 3. Plumbing (�EiL, ( 5 � ' Building Permit Fee l 4. Mechanical (HVAC) "' 4. 7, 5. Fire Protection 4 I? . ,. 6. Total = (1 +2 + 3 + 4 + 5) $i,255 COL) Check Number (// 0 / J.4 '7/77o This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date � 5 L 6 crrCoIN L c PL,AINI_s Division of Carrier Uorpuiau.... Ca rrier 780 Dedham Street Suite 100 Canton, MA 02021 ( (781) 774 -6350 August 3r 2009 `, t\UG — 3 20 F. Fax: (781) 774-6351 s Ci ty of Northampton - r 212 Main Street r-- �� .._-- Northampton, MA 01060 L __ Attention: Department of Building Inspections Subject: Cooley Dickinson Hospital Carrier Project Building Permit Application Carrier Job # 912S00030 On behalf of the Carrier project management team I am seeking permission for overall project responsibility, along with my peer Andy Ashton also of Carrier Corporation, in lieu of a professional engineer or architect. The project management team for the project includes Charles Puckhaber, P.E., LEED -AP who is the projects supervisor based out of Middletown, CT; Gregory Hester, P.E., LEED -AP & Douglas Gline, CEM the project developers who work throughout New England; and Andy Ashton, PMP, LEED -AP who is the project manager responsible for the mechanical portion of the project. We bring extensive professional experience and certification to the installation of this co- generation plant and other energy conservation measures. at Cooley Dickinson Hospital. There are two engineers of record on the project, a mechanical and electrical engineer, whose information is included in the building permit application. I have been a project manager with Carrier for three years doing a variety of HVAC & energy efficiency based projects throughout Massachusetts. Andy Ashton has been with Carrier for seven years doing the same. I hope that you will feel confident in trusting our ability to move forward with the installation of this project. If you require any additional information please don't hesitate to contact me. Res ctful (y, oe Shanahan, PMP, LEED -AP Project Manager (781) 484 -6377 cell Joe S CC: Project file f' Mp ° aa Projects Supervisor `eF�ze '80 8`-'1"1 wh a m C arr' 78 84 2r U1/,, r a oe shy a1 �_037 e 5F 8 5 cn o9 %S c ^ ^Y U ICcoo 3 2 463 % _/ # BP- 2010 -0187 PLICANT /CONTACT PERSON CARRIER CORPORATION )DRESS/PHONE 780 DEDHAM ST, SUITE 100 CANTON (781) 774 -6333 ZOPERTY LOCATION 30 LOCUST ST - WOODCHIP PLANT AP 23B PARCEL 046 001 ZONE M(99)/URB(1) //WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE CONING FORM FILLED OUT Fee Paid Building Permit Filled out Q (� r Fee Paid oB Uo u Vito `R 7, 6 6 0 Typeof Construction: RENOVATE WOODCHIP PLANT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 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. a srsr-VOoDcHIPPLAIO BP- 2010 -0187 COMMONWEALTH OF MASSACHUSETTS ck: 2313 ors CITY OF NORTHAMPTON t PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT BP- 2010 -0187 t# JS- 2010- 000230 ast: $1295000.00 7770.00 PERMISSION IS HEREBY GRANTED TO: Class: Contractor: License: Troup: CARRIER CORPORATION_ >ize(sq. ft.): 1325051.64 Owner: COOLEY DICKINSON HOSPITAL INC ng: M(99) /URB[1)/ /WP Applicant: CARRIER CORPORATION AT: 30 LOCUST ST - WOODCHIP PLANT alicant Address: Phone: Insurance: DEDHAM ST, SUITE 100 (781) 774 -6333 C \NTONMA0202I ISSUED ON:8/21/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE WOODCHIP PLANT OST THIS CARD SO IT IS VISIBLE FROM THE STREET nspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Jnderground: Service: Meter: Footings: tough: Rough: House # Foundation: Driveway Final: ?inal: Final: Rough Frame: 3as: Fire Department Fireplace /Chimney: ough: Oil: Insulation: Final Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. .,ertificate of Occupancy Signature: FeeType: Date Paid: Amount: 3uilding 8/21/2009 0:00:00 $7770.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo