Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
39A-020
ii CITY T T Construction Debri Affidavit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work cover-ed=by a Building Permit shall be disposed of in a properly licensed disposal facility, as defined by M.G.L. c. 111 § 150A. Address of Work: [ l$ ec.),.► Secs Lkvei ,�, — --The-debris-wi_lI.be transported by: �,�l�a�a- �ic�•aS LLC The debris will be received at: Q� Signature of Permit Applicant • Date E_61a0/ Building Permit Number: • The Commonwealth of Massachusetts Department of Industrial Accidents =- "" Office of Investigations ar _::; 1 Congress Street, Suite 100 ::— ` Boston,MA 02114-2017 — t :. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Crocker Building Company, Inc. Address: 186 Stafford St City/State/Zip:Springfield MA 01104 Phone #:413-737-7803 Are you an employer? Check the appropriate box: Type of project(required): 1. ❑ I am a employer with 15 4. ❑ I am a general contractor and I 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 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. 1Contractors 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:AIM Mutual Insurance Policy#or Self-ins. Lic. #: ECC-600-4000510-2013A Expiration Date: 3/31/2014 Job Site Address: 118 ConZ St. City/State/Zip: Northampton, MA 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 and pe lties perjury that the information provided above is true and correct. Signature: G%v Date: August 5, 2013 Phone#: 413737-7803 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#: I rt flipt L4,) CO 0 r n ° � d ro a co c N �\ ♦♦ C H (1} N D -0 ■ L1 c N Su gX _ " cn N A7 i From:Monique Schetzel FaxID: Date:8/14/2013 09:26 AM Page: 1 of 1 CROCK-1 OP ID: MS AC°R° CERTIFICATE OF LIABILITY INSURANCE DATE 08114DIYYYY) 08/14/13 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 413-594-5984 AME: Patricia Mahoney PHILLIPS INSURANCE AGENCY INC 413-592 8499 PHO 413-594-5964 FAX 97 CENTER STREET (A/C,No.Ext): (A/c,No):413-592-8499 CHICOPEE,MA 01013 ADDRESS:IJ YAP p E-MAIL att hilli sinsurance.com Chris Rivers INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance 12572 _ INSURED Crocker Building Company Inc INSURERB:A.I.M.Mutual Ins.Co. 33758 186 Stafford St Springfield,MA 01104 INSURER C INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MMrDO/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY S1888087 04/01/13 04/01/14 PRMSES l ERcNTcErD e ne) $ 100,000 CLAIMS-MADE X OCCUR MED EXP Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $ 2,000,000 POLICY X j O- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) A ANY AUTO A9092137 04/01113 04101114 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per deaden() $ AUTOS AUTOS NON-OWtJED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE $1888087 04/01/13 04/01114 AGGREGATE $ 5,000,000 DEG X RETENTION$ 0 $ WORKERS COMPENSATION X WC STATU- AND EMPLOYERS'EMPLOYERS'LIABILITY TORY LIMITS ER Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE ECC60040005102013A 04/01/13 04/01114 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E .DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 A Rented/Leased Equi S1888087 04/01113 04101114 Rented Eq 200,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: Interior Demolition-118 Conz St. CERTIFICATE HOLDER CANCELLATION CITYOFN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept. 212 Main St.Room 100 AUTHORIZED REPRESENTATIVE / L�� ,,� Northampton,MA 01060 ,( M !'P- 4_`'' ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 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 114) SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT /7141/ �lGJs* ✓ _. � . . _ _ _ _�, as Owner of the subject property hereby authorize' LJ<///frm, P. G v 4• to act on my ehalf, in matt s relative to work authorized by this building permit application. Signature of Owner Date I,! Q-?`\\•.!:4-..- O 0-1- Lte,n , 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 p� penalties under pains and g u Print N e L-8"--),\\•12•,••• e_>��.N 'IQ e3/51/3 , Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:1 Val Av.,- b Cts - CS • (3� ._ License Number �. _m.Qx'•. � . .s.__.. L►..� so+,U.,.,. Mme,. otci,S. `l/19/dory Address / Expiration Date �i //3• ???-149Q3 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 the building permit. Signed Affidavit Attached Yes #:4 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 744.J1J .. Not Applicable ❑ Company Name: sr-% cYNcQe gyp_ Responsible In Charge of Construction i86 STiorzr,csa_. ..._ S — s t.3 M otta ( Address A�G� d 1 -?3?-?9413; Signature Telephone 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 rg Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description 'Enter a brief description here. — 1.Sel4.v2 'b2MoVTw..-. • ePKi .1 wZ Of Proposed Work: '. . t�1v t 01241.41 J S p,\ S.Qnl■S A i\vN. (.ec raa inqavdtC 'tjNIS. SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 El A-2 ❑ A-3 E:1 1A I ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business INI, 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 El 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 ❑ 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: z!*- °-S . Proposed Use Group: � ICI- Existing Hazard Index 780 CMR 34):' _ f�.1 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) N ) A 1J , 151 1st 114 � �. �, 2nd 2nd 3rd 3rd �_... ._.._. 4tr, 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: Public X Private ❑ Zone Outside Flood Zone Municipal jki On site disposal system 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: Rear Building Height Bldg. Square Footage Open Space Footage vo (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 to,.4 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW k4 YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES ka 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 t 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 Ca4 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit M y 15,2000 �p � P ttl 1°� Rep�rtme �� °! City of Northampton Status`of Permit , �_ gut' Building Department Curb CutlDriveway Permit ,�Atr� '1 x 1 AuU 14a1111 212 Main Street Seer/ eptic AVailabufty 41 -,,� " Room 100 W er/Well vailajbiltty; '4-„ M � h -- • , Northampton, MA 01060 TwoSets o SStructural Ply� 7 , , , h DEPT.OF BUILDING INSPECTIONS A NORTHAMPTON,MA 01060 4 rt y phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans h Other Specify:, �_ t , 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 _ _ ,w Property ._._e _.. ,. . I.<8 eb+.v2. S;:\ln-t Map Lot Unit l ' •\"1-.(7 OtV Mn . Zone Overlay District _.... Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: '.c1?0. E ‹ 'Si.. C •C o..n.w.,,AAaq_0,\LOt3 Signature ,4 / Telephone (y(?' 74(.•• $p0 2.2 Authorized Agent: !� •' . 10 Cit4a0St_ZoN .■,•, 2-,si ..u. Name(Print) , Current Mailing Address: x . ..51 P c. • , . Cir, ,R3,3` (VIA 111d1-1 Signature / Telephone (lt ) 737•28d`� SECTION 3-ESTIMA D CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee tS.ocoC 2. Electrical l (b)Estimated Total Cost of S•C:14w Construction from(6) f _ „. , ._._„.� _ a . _ 3. Plumbing i Building Permit Fee 3.tnr. 4. Mechanical(HVAC) , 5. Fire Protection I 2 . 0 0 �` ` '� 6. T l=(1 +2+3+4+5) RS.©pp Check Number 3 7/7) ,; / This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0184 APPLICANT/CONTACT PERSON CROCKER BUILDING CO INC ADDRESS/PHONE 186 STAFFORD ST SPRINGFIELD (413)737-7803 PROPERTY LOCATION 118 CONZ ST MAP 39A PARCEL 020 001 ZONE GB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 3741"? 0/NCO Fee Paid l 7 /l Typeof Construction: INTERIOR DEMOLITION TO PREPARE FOR ENV REMEDIATION (CONTAMINATED SOIL) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 067805 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQRMATION 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. 118 CONZ ST BP-2014-0184 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 39A-020 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-2014-0184 Project# JS-2014-000314 Est.Cost: $25000.00 Fee: $150.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CROCKER BUILDING CO INC 067805 Lot Size(sq. ft.): 20473.20 Owner: GRETNA GREEN DEVELOPMENT CORP Zoning: GB(100)/ Applicant: CROCKER BUILDING CO INC AT: 118 CONZ ST Applicant Address: Phone: Insurance: 186 STAFFORD ST (413) 737-7803 Workers Compensation SPRINGFIELDMA01104 ISSUED ON:8/23/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INTERIOR DEMOLITION TO PREPARE FOR ENV REMEDIATION (CONTAMINATED SOIL) 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 8/23/2013 0:00:00 $150.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner