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31B-311 • c/ „I.>%'i � G l�7l „,„ / Ii ��C 2� �fi�LE GG ;1 e cif /J" 3-,„<„,,,,,,,/„.7,/,,,,,,, z.,,,6 r t j _ 0.,.....„...7„,9,,,,,g....„,/cy.„ efro,. JANE SWIFT c9Z.O?rc ( /7} -c20 Governor / JANE PERLOV cJ ILQi (1j Secretary JOSEPH S. LALLI Commissioner Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 1 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111,S 150A. The debris will be transported by: Waste Management (name of hauler) The debris will be disposed of in : Waste Management of Western Mass. (name of facility) New Ludlow Road Granby, Ma. 01033 (address of facility) / ' ."':: z Signature of pe Id applicant qiih0 date dcbrisaff.doc AcG CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 8/3/2010 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: James J. Dowd & Sons Ins PHONE FAX 14 Bobala Road (A /C, No, Ext): 538_-7444 (A/C, No): 4 1 3 - 536-692.0 E -MAIL P.O. Box 10300 ADDRESS: Holyoke MA 01041 CUSTOMER ID #_ INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A:Acadia Insurance Company 31325 Construction Corporation 40 Old James Street INSURER B: Chicopee MA 01020 INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 441826560 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. ADDL SUBR POLICY EFF POLICY EXP INSR TYPE OF INSURANCE LTR INSR WVD POLICY NUMBER (MMIDDIYYYY) (MM /DD/YYYY) LIMITS A GENERAL LIABILITY CPA005404920 7/18/2010 7/18/2011 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X 250,000 COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $250,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $5, 000 PERSONAL 8. ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $2 , 000,000 PRO- POLICY IFCT LOC A AUTOMOBILE LIABILITY MAA004293121 7/18/2010 7/18/2011 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) X NON -OWNED AUTOS A UMBRELLA LIAB X OCCUR CUA004292821 7/18/2010 7/18/2011 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $5,000,000 DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION WCA004290821 7/18/2010 7/18/2011 X ORYLMTS OTH- ER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A - -- (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION 10 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Northampton Memorial Hall 240 Main Street, Suite #3 AUTHORIZED REPRESENTATIVE Northampton MA 01060 ,40` 2 # © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD . The Commonwealth of Massachusetts ;' Department of Industrial Accidents IP MOM AP —....T - ° ..... Office of Investigations 4 1 600 Washington Street WOW Boston, MA 02111 as - www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /organization/Individual): Garland Construction Corporati on Address: 40 Old James Street City /State /Zip: Chicopee, Ma. 01020 Phone #: 413 533 7699 Are you an employer? Check the appropriate box: Type of project (required): 1. I�� I am a employer with 4 ❑ I am a general contractor and I X 1 6 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 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 capacity. employees and have workers' g any P Y . 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.D Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[I] 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. Insurance Company Name: Acadia Insurance Co. Policy 4 or Self -ins. Lic. 4: WCA 004290821 Expiration Date: 7118/11 Job Site Address: 4 2 C;ni - h i C Street City /State /Zip: Northampton, Ma. 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 t . copy of this statement may be forwarded to the Office of Investigations of the DIA for i nce coverage verificati t . 4 ,3 I do hereby certify er t • and penalties of /ry that th'e ormation provided above is true and correct. Signature: �K-� 5 � �f' ' Date: 8/11/10 Phone #: 413 53 3 7699 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 #: Aimilimmommommow 1 ilteM 01 PiWIR 1 Bil,iril 01 Utitit1H1.:. Rt",:jit<Ititift ,; it `-q 1. # LI , :cql SO CS 13888 Restricte(i to 00 . .. , EDWARD L ORWAT ..... .. 40 OLD JAMES ST CH ';',OPEE, MA 1020 E x. )rat on 8/7/2011 20279 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 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT David Pomerantz, Director of Central Services I, , as Owner of the subject property Garland Construction Corporation h- eby authorize to a.` \r, veh. lf, in all matters relative to work authorized by this building permit application. '►\r► 4 D .1O Si. . l o -':' Own:& Date Vii IF David Pomer. tz , 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. David Pome tz P �t • r �, •n. e of Owne • -nt Date S : CTIO 12 - C • RUCTION SERVICES 10.1 ice sed Construction Supervisor: Not Applicable ❑ Name of License Holder : Edward L . Orwat CS 1 3 8 88 License Number 40 Old James Street Chicopee, Ma. 01020 p 8 / 7 / 11 Address Expiration Date (413) 533 -7699 Signa ee/ Telephone SECTION 13 - WORKERS' COMPE TION 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 4. 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 ID Dietz 8,- -Company Architects; Inc. Name (Registrant): 17 Hampden Street Springfield, __Ma. 01103 Registration Number Addres (413) 733 -6798 E Date %' _____ Si! • . ure Telephone 9.2 Re *' • • rofessional 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 Garland Construction Corporation Not Applicable ❑ Company Name: 40 Old James Street Responsible In Charge of Construction Edward L. O • . p Address � .��!� � (413) 533 -7699 Signature Telephone • Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZANING 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 : 30''' NA Bldg. Square Footage 9 9 8.9 9 r 9 _8 9 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 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 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 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES l 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 1Z Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Remove existing interior partition walls and re configure classroom spaces with new layout, Of Proposed Work: doors, frames, hardware and all finishes, to include floors and ceilings. 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 ❑ 1B ❑ B Business 12 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S =1 ❑ S -2 ❑ 5B IS 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: Business Proposed Use Group: Business 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 3,255 1st 3,255 2 3,255 2nd 3,255 3rd 3 rd 4 th 4 Total Area (sf) 9,989 Total Proposed New Construction (sf) 9,989 Total Height (ft) 30 ! Total Height ft 3 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public p Private ❑ Zone Outside Flood Zone is Municipal 0 On site disposal system ❑ . i Versionl.7 Commercial Buildin• Permit May 15, 2000 a � rt e tt ae' only City of Northampton , , ' of r'� Building Department GurbCti t , 212 Main Street Sewer /Septic Availability'. i Room 100 Water/Well Availability ;, /' 1 W p Q+ll6 t)ham ton, MA 01060 Two Sets of Stcturat�t i t phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans " father SPefy i . 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 42 Gothic Street (James House) Map ' j tot 3 1 ? i Unit Northampton, Ma. 01060 Zone Overlay District Elm St, District;, CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: "0 City of Northampton a - Main Street 11 Name (Print)bl'U11V Current Mailing Address: " OI 1 1 ; '�il.)L (413) 587-1249 Signature �11M0111/i. Telephone ... I 2.2 Authori.ed A. •nt: David ' antz mi 240 Main Street 0 Name (Pri 1, eVe Current Mailing Address: 1 587 -1260 , . Signature � , ` A Telephone 1m ki SECTION Zt` NSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building $181,950.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing $20,000.00 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Tot =(1 + j3 +4 +5) 4 • heck Number A , �� ildi • 'ermit .: Date Issued Signature: Building Commissioner /Inspector of Buildings Date X " • File # BP- 2011 -0119 APPLICANT /CONTACT PERSON GARLAND CONSTRUCTION CORP ADDRESS/PHONE 40 Old James St CHICOPEE (413) 533 -7699 PROPERTY LOCATION 42 GOTHIC ST - JAMES HOUSE MAP 31B PARCEL 311 001 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 .— Fee Paid C/ Tvpeof Construction: REMOVE PARTITION WALLS & RECONFIGURE CLASSROOM SPACES W/NEW LAYOUT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 13888 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APP I ATI N BASED �rT INFORMATION PRESENTED: proved Additional permits required (see below) PA R17Az. A P PPI VArt. -' , ) EMo AN D P/Lc SECT Pi-4P A /LATIQ /.) 0/./ Y P6 NAII PLANNING BOARD PERMIT REQUIRED UNDER:§ f12E b Pik (CC inA.6,kfr Al' P(zaJlgZ— Intermediate Project: Site Plan AND /OR Special Permit With Site Plan A Major Project: Site Plan AND /OR Special Permit With Site Plan D L AO 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 c t-lo 04A- 21(8110 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. 2 GOTHIC ST - JAMES Housx, BP- 2011 -0119 GIs #: COMMONWEALTH OF MASSACHUSETTS i 1ap:Block: 31B - 311 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- 2011 -0119 Project # JS- 2011- 000209 Est. Cost: $201950.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GARLAND CONSTRUCTION CORP 13888 Lot Size(sq. ft.): 16814.16 Owner: NORTHAMPTON CITY OF CITY PROPERTY Zoning: CB(100)/ Applicant: GARLAND CONSTRUCTION CORP AT: 42 GOTHIC ST - JAMES HOUSE Applicant Address: Phone: Insurance: 40 Old James St (413) 533 -7699 Workers Compensation CH I COPEEMA01020 ISSUED ON:9/8/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE PARTITION WALLS & RECONFIGURE CLASSROOM SPACES W /NEW LAYOUT 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 9/8/2010 0:00:00 $0.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner