31B-114 (2) 10/24/2012 14:06 3 PAGE 02/02
ACORD" CERTIFICATE OF LIABILITY INSURANCE_ DATE IMMIDD/YYYYI
,' 10/24/2012
PRODUCER ., THIS CERTIFICATE 18 ISSUED AS A MATTER OF INI:ORMATION
GAMBLE INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
65 BROAD STREET ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW.
P,O. BOX 399
WESTFIELD, MA 01086 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A ATLANTIC CASUALTY INSURANCE CO
NEW ENGLAND PLUMBING & HEATING, INC. INSURER B: ASSOCIATED EMPLOYERS INSURANCE CO
59 BENNETT ROAD INSURER C:
WILBRAHAM, MA INSURER D:
1 ' INSURER E. —
COVERAGES ,
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INOICATW, 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. 7 Ly�q
LTR AVM TYPE OF INSURANCE POLICY NUMBER D. x (r �7_�i�11F'f ?ij%f%1��l LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
NI COMMERCIAL GENERAL LIABILITY UAMALit 10 KCN I hi) I=FMISF,$ (Em oecureeoe) S _ _ _ _ 100,000
B El CLAIMS MADE 0 OCCUR L081000930 02/17/2012 02/17/2013 MED EXP (Any ono parson) $ 5.000
• _ PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER; PROOUCTS - COMP /OP AGG , $ 2,000,000
POLICY 1� 1 PROJECT 7 LOG
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
il ANY AUTO (Ea accident)
• ALL OWNED AUTOS BODILY INJURY
• SCHEDULED AUTOS (Per person) $ __...
MI HIRED AUTOS BODILY INJURY
1. NON•OWNEDAUTOS (Pere6cident) $
- PROPERTY DAMAGE 3
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S
• ANY AUTO OTHER THAN
EA ACC 5
AUTO ONLY. qGG $ _
EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $
• OCCUR fl CLAIMS MADE AGGREGATE $
$
• DEDUCTIBLE
• RETENTION $ $
—
WORKERS COMPENSATION AND TOR; I - •
EMPLOYERS' LIABILITY 7 TORY LIMITS • n ER
B ANY PROPRIETOR /PARTNER /EXECUTIVE WCC 5011378012012 09/27/2012 09/27/2013 E.L. EACH ACCIDENT S 100,000
OFFICER/MEMBEREXCLUDED7
El, NEW -EA EMPLOYEE $ 100,000
I yas AL Ptlba iS(O E.L. DISEASE - POLICY LIMIT $
S PEL t IAI PROVISIONS below 500,000
OTHER
1 - ' • • , . .- - r. • • - • • • • " - - r : • - „ , 'le -- • •-•, • •'
PLUMBING CONTRACTOR:
CERTIFICATE HOLDER CANCELLATION _
CITY OF NORTHAMPTON SHOULD ANY OF THE ABOVE DE$CRII3ED POLICIES BE CANCELLED BEFORE THE EXPIRATION
A1TN: BUILDING DEPT DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
BUILDING COMMISSIONERS OFFICE NOTICE TO THE CERTIFICATE HOLDER NARK THE LEFT, BUT FAILURE TO 00 30 SHALL
212 MAIN STREET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
NORTHAMPTON, MA 01060 V REPRESENTATIVES,
AUTHORIZED REPRE - ' TATIVE
ACORD 25 (2001108) — / I1 ACORD CORPORATION 1988
,f
ALLIED WASTE
October 24, 2012
To whom it may concern,'
Please be advised that Allied Waste Services of Springfield disposes of MSW /Demo at
our transfer station, McNamara. McNamara then trucks the waste to Western Recycling where
the material is sorted and the recyclables are removed and disposed of properly.
The addresses of these disposal sites are:
McNamara
44 Rose St
Springfield, Ma
413- 781 -0425
Western Recycling
120 Old Boston Rd
Wilbraham, Ma 01095
413- 596 -4928
Sincerely,
Allied Waste Services
845 Burnett Road
Chicopee, MA 01020
413.557.6730 / FAX 413.557.6789
www.republicservices.com
Scott Bousquet- 413.596.9566
59 Bennet Rd, Wilbraham, ma 01095
Demolition Request
10/23/2012
Job site: 126 King St. Northampton, MA
Remove all existing old dry wall /plaster, knob and tubes, plumbing, rubbish, moldings up to the rough
framing.
Framing / walls to the stud will remain until structural professional's approval. Framed walls will not be
removed till a professional engineer determines what can be taken off. Load bearing walls will be
determined then.
All construction debris will be disposed by ALLIED WASTES MANAGEMENT- Republic Services Inc.
McNamara Transfer Station
44 Rose St. Springfield, Ma
413 - 781 -0425 - Manager -Gary Bousquet
., The Commonwealth of Massachusetts
-;x Department of Industrial Accidents
P , Z. t , ..j- Office of Investigations
P
r,.;a: 600 Washington Street
Boston, MA 02111
WWW.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
' Applicant Information • Please Print Legibly
Nanne ( Business /Organization/Individual): i V F c,/v . p r (///, 44, . `-- 1 "1 c-/-
.P
Address: 9 6 N tit' (7' K d l/li l I 2� 1 / / , /ice C.) S
City /State /Zip: Phone #: i--1 ( 3 / 6
Are you an employer? Check the appropriate box: Type of project (required): I
1. ❑ I am a employer with 4. M,_I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
listed on the attached sheet. 7. Remodeling
2. ❑ 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' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5• ❑ We are a corporation and its 10. cers have exercised their 11 10.11] Electrical repairs or additions
❑ q ] offi hised thei Plumbing repairs or additions
3. I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13. ❑ Other
employees. [No workers'
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:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/State /Zip:
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 D = for insurance coverage verification.
I do hereby ce • zfy un •r the pains and penalties of peat the information provided above is true and correct.
Signature: - ' d'e 6 _ Date: /) y / .)-----
Phone #:
Official use only. Do not write in this area, to be completed by city or town officiaL
Ci ty or Town: Permit/License #
Is suing 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 #:
• .
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 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE. COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,_ _ . . , . , S Owner of the subject property
,
hereby authorize ' ik.) to
act on my behalf, in all matters relative to work authorized by this building per applicatiort.___
rS1)\,__
Signature o Owner ate
1
1, r Li't . r 'S 1..sg.Z\-„ d _fiv,.4.,.1:1 ..c.___. ,„ _ _ .
I , 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 and_penal ties ofizerty, . _
c.- ,_ --
Print Name
Signature of Owner/Agent
Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construc , Not Applicable
/ i
Name of License Holder • ,
License Number
C Address
. Expiration Date
._,..
_
___ 7
Signature _ ,
Telephone
. -- — ... __
SECTI• 13 -VVORKERS' COMPENSA t IciN INSURANCE ArrlwavIT (lvt.t..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 Ja No 0
, 1
Versionl.7 Commercial Building Permit May 15, 2000
4 .
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTIONSEBVICES -FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROLPURSIJANt ID 780 CMR 116(CONTAINING IVIDRETHAN 35,000 C.F. OF EWLOSEDSPACE)
9.1 Registered Architect: .
Isl ot Applicable 0
TH ow%
Name (Reg o istrant): 1 e l 4 1 -7
1 6 1 6 pLe/a 5 A-r T 5 1 NO le:Til try) P TorNi i Registration Number '
Address ,
11 0 4 4 Expiration Date
$ 91/ 5 1 i
•
Signature . Telephone
9.2 Registered Professional Engineer(s):
, 1 ,
Name Area of Responsibility
.... - _
i
Address Registration Number
Signature Telephone Expiration Date
= . i
Name Area of Responsibility
1 1
Address Re9istration Number --
i = 1
. .
Signature Telephone Expiration Date
I i
Name Area of Responsibility
1 1
- I '
Address - Number
. ,
i ' 1
1 1 _
Signature Telephone Expiration Date
i r ----,
I I
< ,____ ___
Name Area of Responsibility
1
I 1 ... .
Address Registration Number
i I _ -____
Signature Telephone Expiration Date
- - -
9.3 General Contractor _
itil,. i .
--
-_-_--, "ft. ,.... , Not Applica. - ea
Company Name: .,,
Responsible In Charge of Construction '""' llillirna II .44
--- — i - , -4 '1W/111•111 , —...0101
-- p ar 'ma, arAiwoWtor. . t : .722r a .1%.1%; t - i.• g ....- —
--- .........._ -- , - --_,
Address , ,,,......ar -- Fo
i __ i 4 7 4 0 -
....■ .. _ ..-
t 4 I_OAIIIIIIIII Telephone 11111.110.-.
11 ,
•
Version1.7 Commercial Building Permit May 15, 2000
SECTION 9- Architect:
PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR116:.(CONTAINING MORE THAN 35,000 C.F. OFEKLOSED SPACE)
9
Not Applicable 0
kf T.
3 Name (Registrant):
Registration Number
Address \
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
, ..„
Name Area of Responsibility
-\-- _ ,
Address \ Registration Number
11 14 _
‘
Signature Telephone \ Expiration Date
Name • ea of Responsibility
Address
ISs--
Registra . •n Nu, •er
Signature Telephone Expirati• Date
Name V \ Area of Responsibility
. _
,---- \-,.--
, • _ , , ______, _ ___ _ -
Address Registration Number
Signature Tel- . one Expiration Date
Name Area of Responsibility
Address Registration Number
- ,
Signature Telephone Expiration Date
9.3 General Contractor
Company Name:
(
Not Applicable 0 •
..,,.„,
Responsible In Charge of Construct'',
Address
Signature Telephone ,
. ~
Version 1.7 Commercial Building Permit May 15, 2000
8. .. .
Lot Size
. Bxiadug Proposed , Required
by Zoning ,
�
This column mre filled in by
Buildin Department
Frontage
N '
Open Space ~~— � -__ J ' /
# of Parking Spaces \
Fill:
(volume — Location)
/ \
A. Has a Special Permit/Variance/Finding eve? issued for/on the site?
IF YES, date issued: /
IF YES: Was the permit recorded at the Registry of 1:2,eds?
-- NO 0
IF YES: enter Brick ' Pages \ , and/or Document #
B. Does the site contain a brook, body of water or wetlands? INIO 0 DONT KNOW 0 YES 0
IF YES, has as6rmit been or need to be obtained from the Commission?
Needs to by/obtained (3 Obtained
C. Do any signs exist on the property? YES 0 NO \ 0
IF Yet, describe size, type and location: ' \
D. Are there any proposed changes to or additions of signs intended foithe property 0
IF YES, describe size, type and location:
E. VN|| the . ns1mcLionactivdYdietudz(de hnO.g�ding.excovaUon.or�Uin0)ovo acre or is it part of a common plan
that wilt 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 ❑ Demolitior>N Repairs ❑ 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: " 5- 4 na bs p-- "DE M-CLI 1 to N
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 0 1A ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory 0 F-1 0 F-2 0 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 36 ❑
M Mercantile ❑ 4 ❑
R Residential frel R-1 ❑ R -2 [ R -3 0 5A ❑
S Storage ❑ S -1 0 S -2 0 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 7$3,CMR 34): ..,_,_ _________ Proposed Hazard Index 780 CMR 34): .. , ,
SECTION 6 BUILDING HEIG}+T AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf) , '
1
2nd 2" d
__
_
3rd _.. ..._. _
�-�,__... ., �.,,_._, .__ ..._. .. .., 3 rd
[ otal Area (s1,)-
s Total Proposed New Construction s
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 El Private ❑ Zone __,_____ Outside Flood Zone❑ Municipal ❑ On site disposal system
•
Version1.7 Commercial Building Permit May 5, 2000
a Departure t use only
City of Northampton Satu g t • Pe ri � r air ,
Building Department urbleuttDnve ua `e,7ntt. - ` 1 '
`' '� 212 Main Street 4ve'rJS'eptcAvaifabtttty
Q
na o Room 100 U1fa i6
be \ ' L orthampton, MA 01060 "Fwo S eis of trrxe�tuct Pl
• • , 41 -587 -1240 Fax 413 - 587 -1272 Piot/ Flan
Pt G F BUILDINTON � G INS' Other Specify .
ION • • p10� RENOVATE, • - OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE • - TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
1.1 Property Address:
i Map Lot Unit
\7-( 1(111 S
Zone Overlay District
e
-- .- -��- f � - �—�.- ---. - ------ ----, ' Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
j . T ....._ . _ . .�� ._... ... .
Name (Print) 4 Current Mailing Address
Signature Telephone
2.2 Authorized Agent:
Name (Print) Current Mailing Addresses a
Signature Telephone
1 SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ( (a) Building Permit Fee
2. Electrical - -._.. ----- __ .._-___ a (b) Estimated Total Cost of
Construction from (6) _. _._ -_ _._....v
3. Plumbing i Building Permit Fee
4. Mechanical (HVAC) _......___..._.... ._, -
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) Check Number 1 -7 ? _ t s6
This Section For Official Use Only
Building Permit Number Date
Issued
Signature
/ L -' l^--`
/ 0 /P- 3/ --&
Building Commissioner /Inspector of Buildings Date
126 KING ST BP- 2013 -0488
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 114 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit # BP- 2013 -0488
Project # JS- 2013- 000774
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NEW ENGLAND PLBG & HTG INC_
Lot Size(sq. ft.): 6577.56 Owner: SUN TEH -JING & FENG -CHIN SUN & TEH -JIIN CHAO
Zoning: CB(100)/ Applicant: NEW ENGLAND PLBG & HTG INC
AT: 126 KING ST
Applicant Address: Phone: Insurance:
59 BENNETT RD (413) 596 -9566
WI LBRAHAMMA01095 ISSUED ON:10/24/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INTERIOR DEMOLITION
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 10/24/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner