24C-019 (3) B arcrofui ing eC gu�at iofis an tan a ds
Construction Supervisor License
License: CS 47414
Expiration: 10/6/2009 Tr# 9452
Restriction: 00
o
ROBERT K STETSON JR !�
45 LYNDALE ST
SPRINGFIELD, MA 01108 Commissioner
AUG 2 5 2009
e
AUG -26 -2009 11:07 From: To:4135871272 P.2•2
CERTIFICATE OF LIABILITY INSURANCE ° 08/17 ' 2009 '
08/17/2009
enaoultan THIS CERTIFICATE 181 • A MATTER • F INFORMATION
Aon Risk SeMces Southwest, Inc *KY AND CONFERS NO RIGHTS UPON me CERTIFICATE
Fort Worth TX CtNob MOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
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ACORO IS 120011181► Page 1 of 2 0 10118-20011 ACORO CORPORATION, All riots resorted,
The ACCIRD nets. meta 10410 ore reisisIened msits of ACORD
a,
The Commonwealth of Massachusetts
nT =' Department of Industrial Accidents
Office of Investigations
600 Washin Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �'� l ►- _ v 61r; _
Address: v 40r,J q+
City /State /Zip: Phone #: I " — _ .7 ?c 0
Are ou an employer? Check the appropriate box: Type of project (required):
1. I am a employer with J1 4. ❑ I am a general contractor and I
6. ❑ New nstruction
employees (full and/or part- time).* have hired the sub - contractors
listed on the attached sheet. 7. ❑ odeling
2. El I am a sole proprietor or partner-
ship and have no employees These sub - contractors have g. Demolition
working for me in any capacity. employees and have workers'
Y P ty. $ 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11.
3. ❑ I am a homeowner doing all work f h id hi
❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill 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 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. C� .
Insurance Company Name: �-M \ ,4-; S ok-V_ l
Policy # or Self -ins. Lic. #: /3PC, 1 6415 7 Expiration Date: O
Job Site Address: f 42..e ' '' City /State /Zip: { o - (( t,010
►►
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 cer ify under t1 • pai s and . enalties of perjury that the information provided above is true and correct.
Signature: I� - J /L Date: AL, .�
l
Phone #:
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 #:
, ■r ,
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 No O
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Ref ( /.,
I, fDr tic t q C1f�T as Owner of the subject property
hereby authorize 1 ' 4✓4 .. A l 110[1 �. to
4
act on my a 7`n all after r elative to work authorized by thi�buildii g�mit
' --- .._ ,,
Signature of Owner fit. Date
I, �/�ti _ _ , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing applic ion are true and accurate, to the best of my knowledge
and belief.
Signe. nder the pains and penalties of perjury,_ .._w _ _ ..
Pr Name _
i . 4 A sa v1 /LiAti.;. • lAtes k _., . _.., . , .. .
Sig -ture of Owner • gent V Dat-
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: .._ � . '�? �._ .. i - � ( i ,
License Number
9
Addre _ ,.__ .. ,_�_. _.. _ ___e ._., _. r__ �c._. -. Expiration
on Dat
1 4 -or' ...
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M. G. L. c. 152, § 25C(6))
Workers Compensation Insurance affi vit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the b ing permit.
Signed Affidavit Attached Yes No 0
Versionl.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):
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
."-f' . --,... Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
`fib 1 L$'_ > 3-11
Signature 107 Telephone
0
~
Version 1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be tilled in by
Building Department
Lot Size ____, '_„ , __— _-___'___-'
r ------ , , -- ---, '----------
Frontage ___ _
Setbacks Front
- -
-__-
�'-- --- �---7 r---� -- --
Side ��----B��--- ���F��' ,___ __
F--� — � —,
Rear -
Building Height ---- F---1 �---
_ �
Bldg. Square Pootagc � 7 % F r �---�
___ __
Open Space Fvotago �6 --
p'v'uoaminus bldg &paved �- -- � --- � --- �---
parking)
-- r--- �---
# of Parking Space , -- -
Fill: �—'--- -- ----- F ------ --- -- ! - — -- - -'- -
(volume & Location)
A. Has a Special Permit! Variance/Findingbn been issued for/on the site?
NO 0 /-\ � DON7KNOVY \�' YES �_� r-�
IF YES, date issued: �
IF YES: Was the pe rded at the ry of Deeds?
��
NO �� DONT KNOW YES
--_
IF YES: enter Book �� �� Page /d/or Document #
__
__-
8. Doesthesitecuntainabnouk NO ON7KNOVY �~� YES \_�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained /�� Obt /�� Date Issued:
[----------'�
�~� =''=" \_� ' ' L__--______J
[. Do any signs exist on the property? YES NO c_
_ __--___ -
IF YES, describe size, type and location. �
�11^~^A =^^ 1)'ii
D. Are there any proposed changes to or additions of signs intended for the nperty? YES K ) NO V
___'_______'_________,
IF YES, describe size, type and location:
E. Will the construction activity disturb (claadng.grading, exca ion, nrM||ing)over1acreor/sitpartofmoommonp|an
that will disturb over 1 acre? YES �� �-\ NO
�J
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. R
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 0 Repairs ❑ Additions ❑ Accessory Buil - rig ❑
Exterior Alteration 0 Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other
Brief Description Enter a brief description here.
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ j 1A 1 0
A -4 ❑ A -5 ❑ j 1B ❑
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 0 R -3 ❑ 5A ❑
S Storage ❑ S -1 0 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): _ __.__._,_i 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"'l ,.. , .. .,,.... ,. 2 nd
3rd _, �._..,. _..___ _ 3 rd
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 0 Municipal 0 On site disposal system
wn
• .
Version1.7 Commercial Building Permit May 15, 2000
.~ Department use. only
Cjfji of Northampton Status of Permit
\, 'Building Department Curb Gut/Driveway Permit
212 Main Street Sewer /Septic Availability
�t�) Room 100 Water/Well Availability
tUG 2 Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 - 1240 Fax 413 587 - 1272 Plot/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
._
Map Lot Unit
?-V6 0 QcF S-+
Zone Overlay District
O " - -A C ( A0 , - • Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Own r of Record:
r
Vic, k. ..i _ ..'
Name rint) Current Mailing Address:
Signature i UUU l./
f>,i� / d i✓ 'V Telephone
2.2 Autho ized ent:
9 er y 1 'r.. L,, o 7 A
Name (Print) Current Mailing Address:
1 113 ?9'? . . g _ .
Signature t .' A ft r j i0: r _ 7 /' Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building Qfr (94 �% �� 4, (a) Building Perm Fee
2. Electrical _ ' • - (b) (b) Estimated Total Cost of
Construction from (6) ._ .._ ..
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) _. ...._., .,.,.. ..
5. Fire Protection
6. Total=(1 + 2 + 3 +4 + 5) Check Number
36/
This Section, For Official Use Only
Building Permit Number Date ,
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0219
APPLICANT /CONTACT PERSON INSTAR SERVICES GROUP LP
ADDRESS/PHONE 100 STATE ST LUDLOW (413) 594 -7800
PROPERTY LOCATION 286 PROSPECT ST
MAP 24C PARCEL 019 001 ZONE URA(15)/URB(85)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 3� Pil Fee Paid
Typeof Construction: INTERIOR DEMOLITION FROM FIRE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 047414
3 sets of Plans / Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
1
i
. s
Signature of Building Offi '. Dat-
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.
r ,
F/ /&y,//_‘
°Pt e. 2
s 9"?r ° • i // 61 / 1 / ( 9 � d t /b
286 PROSPECT ST BP-2010-0219
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 019 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0219
Project # JS -2010- 000273
Est. Cost: $200000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: INSTAR SERVICES GROUP LP 047414
Lot Size(sq. ft.): 190792.80 Owner: HAMPSHIRE REGIONAL YOUNG MEN'S CHRISTIAN ASSOCIATION
Zoning: URA(15)/URB(85)/ _ Applicant: INSTAR SERVICES GROUP LP
AT: 286 PROSPECT ST
Applicant Address: Phone: Insurance:
100 STATE ST (413) 594 -7800 Workers
Compensation
LUDLOWMA01056 ISSUED ON:8/27/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR DEMOLITION FROM FIRE
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:
vii.
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL . S NS.
Certificate of Occupancy ►' si nature:
FeeType: Date'Paid : Amount:
8/27/2009 0:00:00 $100.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo