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32C-067 (7)
A , -, Boar o u g egul : . ons : • A • • :1 • 41 i k ik...., -;,- - --,- One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 112807 Type: Private Cpyporatien Expiretion: 8i4/2011 'no 284888 __. CHARISTA REAL ESTATE INV., INC,.. - -, - . _____ WAYNE BERGERON PO BOX 706/ 38 HARKNESS AVt 2 ,... % 4 --7--.:.= -, E. LONGMEADOW, MA 01028 2 7 i ' --- _, -- ti z.t . ' 4, . . • . , . Update Address and return card. Mark reason for change. ri, Address 7 ' Renewal r''' - Employment — 7 Lost Card -CM 0 40M-WMIZSLIFORMA10112121)0B . . . , License or registration valid Air individol toe only '1 HOME INPROVEMENT' CONTRACTOR before the expiration date_ if bond return to: Board of Building Regulations and Standards One Ashburton Place Rut 1301 .. - - ,. 0 ".. . • 4. , 284888 Boston, Ma. 02108 • - - a - , , 1 COIPID • . '5. ',am ..77, CHAR1STA RM., - - , tr. WAYNE BERGE1,10i,:, PO BOX 70W 38 14ARlittlild.** C;;:l.4.040 - E. LONGMEADOW:W Administrator Not valid without signature It Massachusetts_ Department of Public Safct� Board of Building; Regulations and Standards Construction Supervisor License License: Cs 55440 JOSEPH A KENNEDY PO BOX 1358/18 FOREST ST BONDSVILLE, MA 01009 -- - — " 1 ° Expiration: 7122/2012 (u nmiiyionrr Tr#: 29581 From:413 447.1977 ' 07/0212010 12:54 #369 P.0011002 A�, CERTIFICATE OF LIABILITY INSURANCE 7 / PRQOUCSm (413) 935 -1200 PAXz (413) SO- 5300 This tENT ►TE III ISSUED AS A HATTER OF INFORMATION ONLY AND CONS NO RIGHTS IP'ON THE CERTIFICATE HOLDER. THIS C8fl1PC*iE DOES NOT AMEND, EX1Hd} OR Berkshire Insurance Group, Inc. _ ALTER OW COVERAGE AFFORDED BY THE POLICIES BELOW. 138 Longmeadow, St. dr7M NA. 01106 INSURERS AFFORDING COVERAGE NAiC# assume "mum k BartfOrd Casualty 7208arauce 29424 liguRER k Safety Insurance *maw 344114 Charista Construction Services, Inc. assuRERaSirsers Property & Casualty 3$ Harkness Avenue issumem Salt Lc g eadoar Na 01028 amiassie COVERAGES TIE POUCIE S OF 14SURANCE US LED BELOW ROE MEM MOM TIE INSLMED NAMED ABOVE froR 771E POLICY PE3il0D OpicAtED. NOTIATTHS'fAN0MIG ANY RE0tARETSENT.113e4 OR CONDITION OF ANY CONTRACT OR OiHER DOGGIEST WITH RESPECT TO VMIECH THIS CERTIFICATE MAY RE MED OR mAY PERTAIN. ints.MANCE AFFORDS) BYSiE POLE DESCRIBED HEREIN IE 01283E.CT 70 ALL ME /ERNS EXCLOSIOt13AND CONUIiONS OFMCN POLICES. AGORB3A1E MIS SHORN MAY RAVE SEEN RED BY PAiD CLANS. # 1 R .f' 1� - DDLlC1f -.,;+- IOMPEXPRUI • • MOS GEREPA1_LIAEMJTY SAM OCCUrCE S 1, 000,000 TMpA 0E70REHM Q coSWERova. GENERAL LAWRY ispemsageemmo It 300,000 A. 1111111cuammukrX1occuR SEMMI00093 5/6/2010 5/6/2011 rrtEasoa rmolopenar) $ 10,000 FERSoNAL AAOY BOisY $ 2,000,600 cLAA7E $ 2,000.000 GERI. ARGREGRIE LTTA SFM PFSEMICTS - aowPmPNo S 2,000,000 X ' F( fl WC ADDSOBSE nanny Caillualn SWAUTB ma snaa MST 9 H Au. OVeilie AUTOS - .21467 6/2/2010 6/2/2011 ammywujity X =MUM Amen P S 250,000 BOa1.YINJURY $ 500, 000 X HIRED AUTOS fl RONDOIRED AUTOS (Par aseddnnq al . PROPERTY DAME. (Par accidona = 100,000 GARAGE L5 JIV AUTO ONLY -EA ACCOEEIr S ANY AUf0 EAACC $ A UTOOR.Y: AUG S saw r 110BREuA uABRm • MO( OCCURRENCE I 0=1.18 ! _t CL.ASIDSSE A•FE s . 1 DEDUCTIBLE ._ _ C SDIDteRB .eiSATION $ i i7%i*EY T! Mt * AND IRMOVERIYLIABIUTY Y B.L EJDiACCIOE T $ 1,000,000 psederay in OS 6/8/20/0 6/5/20:!1 EL 0mam E- EASrArme s 1,050.000 s w ,• mww EL on i1E -PoucI Lear s 1 000 . 00 OPER PEEicRinioaOF emonstun man t venues, solausona AIIDEDIff elPORSISIENTISPEGIALPROMONS Props' of Coverage CERTIFICATE HOLDER CANE I AJ11ON 8I1001-6ANYaFiIEAEe11EAsen FOOce3EEf 1EmeroRE7NEESrmAl10M DAM 7IRIREDF, mum PIWRERMi. ENLEAYOR tit IIAa. Min =IMO - ND7CEIDME CERTIFICATE ROLMiMENDTO DIE LEFT, aOTFY LIM MOO WWII mom Ito OBUGATi0II OR Mayo o . ar ARY IOW UPON ME 116 1, OS AG11OS OR ANTonamo RE1RIMERiATNE Judi Mabee /JO ACORD 25 (2009/01) © 1$S 8-209 ACORD CORPORA11001_ AN Tights mseesd. INSOGninion Tile ACORD name and logo am registered marks of ACORD The Commonwealth of Massachusetts "f Department of Industrial Accidents - - O ffice of Investigations �.. 600 Washington Street Boston, MA 02111 _.... 1 , _,.- www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /Individual): C C ` ST " OA d t °, C° u SA rt., C4-c' a Address: 3 $ A - - City /State /Zip: Ea S+ Loti u.-tet io cv 0 t 6 4 4 Phone #: t l? SE'S 1 >.?5 Are you an employer? Check the appropriate box: l l 4. I am a general contractor and I Type of project (required): 1. am a employer with ❑ g employees (full and/or part- time).* have hired the sub - contractors 6. ❑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' g Y P h 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 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' 13.2 Otlters< r-ed 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. R Insurance Company Name: 5c�1 -s ? rc�aAr� -,-- CC s 1 `T"`y Policy # or Self -ins. Lic. #: W C 0 O0 'as-?-7 Expiration Date: — '`0 l I Job Site Address: C°LAZ SA - i Le `"*°t" ' City /State /Zip: k 06 6 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains penalties of perjury that the information provided above is true and correct Signature: Date: l ,0 Phone #: L i/i - c. ( Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Version 1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No3D SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN ERS A ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 92,a; Qir , as Owner of the subject property her: . orize . re utn�� to a c t • behalf, in a I m. ' - ._ elan a to work authorized by this building permit application. 4' ' '� ,,J R - ?- t 0 Signature of Owner 1 : Date I --O reeL t[ Q utk:e4' , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. 7 v CQ pC-. N- 6 t4t.P Pri t Name ...,k, 410111 1 ^ — 1 0 Sig 1 ure of • er /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : 'O S2, k, twtn� ?i7 £ SS O I lk, License Number L$ s4 s+ Eioury AU tkc. oc ooh ? - ).1- '3 a I Address Expiration Date 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 j er No 0 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: 6 u E 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 CI. 0.N '- C tAIL Aeo t� Not Applicable ❑ Company Name: / 6 (- - ■ ( 0(t y Responsible In Charge of Construction 1 3 40• SS 4 ST C�cA 't.“ Q l 0 a Address Alp HR 6 x1.7376 Ji nature 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 /Finding 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 Regis of 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 er DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES j5 NO Q IF YES, describe size, type and location: o; 1 -ovKL us,-6 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO RI 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. 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 X 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: l ol E• P o'Y� t � S ( Ik I P t cc 41,t1 6a u...a 1 _; . (u cv' tl i S4- S 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 I ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C I ❑ 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 I ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B [ ❑ 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 Si 1 2nd 2nd 3 rd 3 rd 4 4th 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: Publicnr Private ❑ Zone Outside Flood Zone Municipal( On site disposal system❑ Version1.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability 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 ,_.''L SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office C 01-AZ SA- Map Lot Unit v f c.4. %Afire N V"` ct Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ta.r L CAL o r pr• t,t +\ kt�ss . . Pt.( of oar Nam (Print) Current Mailing Address: �.r��rr L i/ 5%)5"- 173 Signature - Mk s ' . �� Telephone 2.2 Authorized Agent: A tr t,k tA.o y I g t7r - or- S� �b a u_ st., l e 1� �. C'r C,oq Name (Print) Current Mailing Address: Y/3 - 6 ?- 7?7 Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS I ir l 0 , C 0 0 Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (0 00 0 (a) Building Permit Fee 2. Electrical N. ©t.) G (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection M 0 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 32 } 3 This Section For Official Use Only Building Permit Number Date Issued Signature: i t/ b I v B rring Commissioner /Inspector of Buildings Date P 1_ Dour -we.� C z.C9.0 (r t -ps BP- 2011 -0435 GIS #: COMMONWEALTH OF MASSACHUSETTS "' 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 -0435 Project # JS- 2011- 000711 Est. Cost: $10000.00 Fee: $55.00 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 Applicant Address: Phone: Insurance: 38 HARKNESS AVE (413) 525 -1735 () Workers Compensation EAST LONGMEADOWMA01028 ISSUED ON:11/9/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE ROTTED SILL PLATES & DAMAGED FLOOR JOISTS 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 11/9/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner