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25A-190 (3) Client#: 134452 KURTZINC ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)9/10/2013 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 Nancy Matanes HUB International New England PHONE 508-235-2274 FAX 866-379-3254 (ANC,No,Ext): (A/C,No): 222 Milliken Blvd Wass: matanes hubinternational.com Fall River,MA 02722 ADDRESS: Y 508 235-2200 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Ins Co. INSURED INSURER B:Admiral Insurance Co Kurtz,Inc. P.O.Box 1597 INSURER C:Arbella Indemnity Insurance Corn Westfield, MA 01085 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 SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY X X 8500049917 01/28/2013 01/28/2014 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISESO(EaEo occurrence) $300,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $15,000 X PD Ded:250 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO T LOC JEC C AUTOMOBILE LIABILITY X X 1020013164 01/28/2013 01/28/2014 Ea COMacciBINdent) $1,000,000 ED SINGLE LIMIT ( ANY AUTO BODILY INJURY(Per person) $ ALL OWNED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) A x UMBRELLA LIAB X OCCUR X X 4600049918 01/28/2013 01/28/2014 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 _ DED X RETENTION$10000 $ A WORKERS COMPENSATION X 0054320112 01/28/2013 01/28/2014 X WC STATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? Y 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 B Pollution X X FEIECC1762300 09/05/2013 09/05/2014 $1,000,00043,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) **Workers Comp Information** Proprietors/Partners/Executive Officers/Members Excluded: Lori Kurtz,Treasurer Eugene Kurtz,President Certificate Holder is named as additional insured on all policies except Workers Compensation,when (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Informational Purposes SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD #S985508/M985506 NM001 ■ . • • R ,PLEX BUILDINGS WALL SYSTEMS }ACCESS SYSTEMS PACE ''WILL -JAM 'S r SOLUTIONS SCOTSMAN R E D I S P A C E S O L U T I O N S C O M P Redi-Plex Specifications QTY OF 1 PER EXTERIOR DOOR RECEPTS: .110 VOLT 20 AMP DUPLEX IVORY,QTY PER PLAN OPTIONS RECEPTS: 20 AMP 120 VOLT.LOCATED PER PLAN GFI AS REQUIRED RECEPTS: HEAT TAPE RECEPT(GFI PROTECTED) HEAT TAPE TO BE BY OTHERS _ 9WITCI-1Eq: 110 VOLT 15 MP _•" _• - _- IVORY,QTY AND LOCATIONS PER PLAN HOME RUN TO OCCUR FROM THE SWITCH FARTHEST FROM THE HITCH END DISTRIBUTION 4-11/16"BOX WITH 20 AMP DEDICATED CIRCUIT AND WALKER FLEX BOXES: COVER 0 SDJP04(QTY OF 4 PER MODULE) FIRE ALARM: ROUGH-TN ONLY(SYSTEM TO BE BY THE CUSTOMER AT SITE) LOCATIONS PER PLAN ALL BLANK BOXES HAVE IVORY COVER PLATES H.V..A.C. HEAT/COOL: BARD WALL HUNG 3-TON A/C W/ELEC.HEAT W'15 KW HEAT ON SIDEWALL UNITS W/10 KW HEAT ON CENTER UNITS G CONTROL MODULE SUPPLY DUCT: FIBERGLASS DUCT BOARD IN THE ROOF,TRANSTTTONED AND SIZED PER PLAN_ SUPPLY DIFF. 24"X24"LAY-IN W/ADJ.DAMPER,PERFORA'T'ED FACE STYLE RETURN DUCT: FTRFRGLASS DUCT BOARD IN THE ROOF RJA DIFF: 24"X24"LAY-IN(NO DAMPER),PERFORATED FACE STYLE THERMOSTAT: MANUAL CHANGEOVER HEAT AND COOL-HONEYWELL T8400C OR EQUAL CODES: STATE OH/MUKY/VAJNJ/MN/CT/NH/IL/NC/SC/TN REVIEW/SEALS: IN/MD/MA/M0/1A/WI/RI/AK/KS/WV,PA L&I COMPLIANT THIRD PARTY: THIRD PARTY CERTIFICATE • PLEX BUILDINGS WALL SYSTEM ACCESS SYSTEMS SOLUTIONS SCOTSMAN RED ! SPACE SOLUTiONS . COM Redi-Flex Specifications BLINDS: I"MINI ALUMINUM(ALABASTER) PLUMBING: (WITH RESTROOM OPTIONS ONLY) WTR CLST: CHINA TANK TYPE(HANDICAPPED,ELONGATED BOWL,FLOOR MTD.) QTY PER PLAN OPTIONS WTR CLST: CHINA TANK TYPE(ELONGATED BOWL,FLOOR MTD.) -QTY PER A?10P IONS- URINAL: CHINA WALL MOUNTED WITH FLUSH VALVE QTY PER PLAN OPTIONS LAVATORY: CHINA WALL HUNG(HANDICAPPED PER PLAN) W/SINGLE LEVER ADA FAUCET QTY PER PLAN OPTIONS WTR HTR ELECTRIC IN JANITOR CLOSET SIZED PER FIXTURE DEMAND BASED ON PLAN OPTIONS MOP SINK: 24"SQUARE FIBERGLASS WITH LEGS IN JANITOR CLOSET SI.JPPI Y: TYPE"L"COPPER DWV: SCHEDULE 40 PVC(CAST AS REQUIRED) GRAB BARS: 36"&42"STEEL, 1-1/4"O.D. MIRRORS: 18"X 30"FRAMED QTY PER PLAN OPTIONS T.P.HOLDER: SINGLE ROLL,WALL MOUNTED QTY PER PLAN OPTIONS MODESTY PART.: TAN METAL FLOOR MOUNTED OVERHEAD BRACED - - ._.__ ____..W- - _ _- QTY PER PLAN-OPTIONS _. _ _ -- _: . __. . :_ - _. ._ _ -..__:__ ._.-.__ •.:-- ELECTRICAL: LOADCENTER: CUTLER HAMMER 150 AMP ON SIDEWALL MODULES 100 AMP PER CENTER MODULE, 120/240 V. 1-PHASE 60 HZ,3-WIRE ALL BREAKERS TO BE BR TYPE WIRING: COPPER ROMEX(12-2 W/G MIN)TYPE NM-B EXPOSED WIRING IN CEILING TO BE INSTALLED IN CONDUIT PER NEC INT.LIGHTS: 24"X48"4-TUBE FLUOR.(LAY-IN) (RECESSED) AND STRAPPED TO TRUE CEILING FOR SHIPMENT, SITE INSTALLED BY WILLIAMS SCOTSMAN,LOW ENERGY BALLASTS DUAL SWITCHING WITH T-12,34W LAMPS QTY OF 10 PER MODULE EXT.LIGHTS 60 WATT(SEAGULL#4325) QTY OF 1 PER EXTERIOR DOOR EGRESS LIGHT EXIT/EMERGENCY LIGHT WITH BATTERY PACK AND REMOTE HEAD • • • • • Re PLEX BUILDINGS m -WALL SYSTEMS ACCESS SYSTEMS SPACE WILLIAMS SOLUTIONS SCOTSMAN REDI SPACE SOLUTIONS . COM Red i-Plex Specifications CEILING: SUSPENDED CEILING TO BE STANDARD CLASS A,2'X4'SYSTEM GRID ARMSTRONG#769 CORTEGA OR EQUAL FISSURED PATTERN ACOUSTICAL TILES,2'X4'. FINISHED CEILING HEIGHT OF 8'-0"TO TOP OF GRID. ADDITIONAL HANGERS TO BE PROVIDED AT ALL LIGHT CORNERS,DIFFUSERS AND GRID INTERSECTIONS. PROVIDE , 4 q NCrI RP.4(71^.Y1 'rip A'Mori" 171, 71T A TT A rHED rtErT CEILING PLANS FOR INDIVIDUAL GRID LAYOUTS. TRUE CEILING NYLON NET SCREEN TO UNDERSIDE OF RAFTERS INSULATION 1/2"UNFINISHED GYPSUM BOARD SHEATHING ',S"FR PLYWOOD(MULEHIDE) ROOFING: 45 MIL EPDM(BLACK-MULEHIDE) MANSARD: 5/8"DURATEMP WITH 1.5"PROJECTION ON ON THE SIDE WALLS AND 24"OVERHANG ON THE END WALLS (MANSARD FOLLOWS ROOF LINE,30"PEAK TO 26-1/4"AT MODULE ENDS),WHITE K SERIES MINI-GUTTER INSTALLED ON ALL SIDES AND ENDS OF EACH MODULE MATE LINE: SHIP LOOSE 1X6 SILVERPOINT FOR MATE LINE WALL SHIP LOOSE BOTTOM TRIM AND MATE LINE TRIMS TO MATCH MANSARD DOORS: INT DOOR: 36"X 80"PRE-FINISHED EMBOSSED WOODGRAIN SOLID CORE,JENN- WELD IMPERIAL OAK EMBOSSED HARDWARE: PASSAGE LEVERSETS;CLOSER ON RATED DOORS, - - - -- PUSH/PULL WITH CLOSER ON RESTROOMS OR PRIVACY SET AS REQUIRED BASED UPON PLAN ALL DOOR HARDWARE SHALL BE MASTER KEYED TO W/S MASTER KEY SYSIEM,TELL MANUFACTURING QTY PER PLAN OPTIONS EXT.DOOR: 36X80 18 GAUGE COMMERCIAL STL.WITH 16 GA.STL.JAMB 10"X10"VISION PANEL,SINGLE CLEAR SAI.ETY GLASS (WEATHERSEAL AT WINDOW AND CLOSER IN DOOR) WITH PANIC HARDWARE AND CLOSER EXTERIOR LEVERSET(NO PULL BAR/CYLINDER) QTY PER PLAN OPTIONS HIND°WS: SIZE: 32"WX60"H SINGLE HUNG"CAPITOL"OR EQUAL(MEANS OF EGRESS COMPLIANT) BRONZE FINISH THERMAL BREAK FRAMES GLAZING: D.I.G. TNT,TRIM: PRE-PAIN'LED.CV TAN QTY PER PLAN • • �° PLEX B WLClitiiES WALL SYSTEMS ACCESS SYSTEMS S RACE WILLIAMS SOLUTIONS SCOTSMAN I RED ! SPACE SOLJTIONS . COM Redi-Plex Specifications EXTERIOR WALLS STUDS: 2"X4"STUD GRADF @ 12"O.C. BOCAJUBC FRAMING WALL HGT: 8'-0"FINISFI CEILING HGT TO TOP OF T-GRID WALL HEIGHT PER SECTION TO ACCOMMODATE ROOF PITCH ON SIDEWALL UNITS,AND AS REQUIRED ON ENDWALLS PER MANSARD DETAILS COVERING: W'VINYL COVERED GYPSUM GROUP II COLOR: _. LOOMA BEIGE SHEATHLNG: TYVEK OR EQUAL ATR INFULTRATION BARRIER AS REQUIRED BY ENERGY CODE INSULATION: R-11 KRAFT FACED SIDING: 5/8"STIMSON LUMBER DURATEMP GROOVES 4"O.C. PAINT MIX CODE: SHERWIN WILLIAMS A100 GLOSS COLOR: SILVERPOINT SHERWIN WILLIAMS A100 GLOSS 1 GALLON FORMULA EXTRA WHITE BASE DEEP GOLD- 2;32 AND 1/128,RAW UMBER-5/32,BLACK- 7/32 AND 1/64 TRIM: 1X4 MDO STAINED, 1X6 MDO BOTTOM TRIM NO'Th: CORNERS AND MATE LINE BODY TRIM ARE SILVERPOINT COLOR: BAINBRIDGE GREEN SHERWIN WILLIAMS A100 GLOSS MIX CODE: 1 GALLON FORMULA ULTRA DEEP BASE WHITE- 26/32,BLACK-2 OZ.AND 5/32 DEEP GOLD- 2 OZ.AND 6132.NEW GREEN-2 OZ.AND 15/32 BLUE- 2 OZ.AND 27/32 INTERIOR WALLS PLENUM WALLS: PARTIAL WIDTH OF MODULE STUDS: 2".X4"STUD GRADE @ 16"O.C. BOCAIUBC FRAMING WALL HGT: 8,-0"FINISH CEILING HGT TO TOP OF T-GRID COVERING: . %2"VINYL COVERED GYPSUM GROUP II COLOR: LOOMA BEIGE ROOF: RAFTERS: 2X8 S.P.F.42 AT 16"O.C. TRANSVERSE RIDGE MATE BEAM: STEEL TRUSS(CLEAR SPAN PRE-ENGINEERED)MAX.SPAN OF 60' NO COLUMNS OR LOAD BEARING WALLS WITHIN EACH 60'SPAN CENTER PEAK,30"HIGH TO 26-1/4"HIGH AT ENDS, TRUSS WITH SLOTTED BOTTOM CHORD BEARING CONNECTION TO ALLOW FOR FIELD ADJUSTMENTS POSTS: POSTS CONCEALED IN ENDWALLS POSTS: NO EXPOSED POSTS • • • • •FLEX BUILDINGS -WALL SYSTEMS ACCESS-SYSTEMS IS PA C E WILLIAMS ffi SOLUTIONS SCOTSMAN c l E D I S P A C E S 0 L U T I 0 N S . C O M Red i-Plex Specifications UNITS: Left Sidewall(LSW) Right Sidewall(RSW) Center Unit(CS) 60'X 11'-9"BOX SIZE MODULES CODE/STATES/ OH/MI/KY/VA,NJ/MN/CT/NH/IL/SC/TN/NC SEALS: IN/MD/MA/MO/IA/WI/RI/AK/KS/WV,PA L&I COMPLIANT DESIGN LOADS: FLOOR LIVE LOAD: 100 PSF ROOF LIVE LOAD:- 60 PSF _. WIND LOAD: 120 MPH FRAME: TYPE: PERIMETER MAIN BEAM: 12X14#/FT ROT.T FD SHIP LOOSE BEAM CLAMPS(15'O.C.MAX)FOR MATE LINE CONNECTIONS X-MEMBER 8X6.5#/FT AT 48"O.C.FLUSH WITH TOP OF MAIN BEAM NOTE: COAT ALL BEAMS WITH RUST INHIBITIVE PAINT-100%BLACK COVERAGE,MIN.TWO COATS HITCH: BOLT ON AXLES: FIVE,TRIPLE AND TANDEM SPLIT-34"APART MULTI-LEAF SPRINGS,UNDFRSLUNG HEAVY DUTY HANGERS Tit DOWNS: SITE INSTALLED BY OTHERS(FRAME.TIE DOWNS/HOOKS) TIRES: 8:00X14.5 10 PLY NOTE: BLOCKING AND ANCHOR LOCATIONS SHALL BE PAINTED ON THE MODULE FRAME WITH AN ARROW DESIGNATION FLOOR: BTM BOARD: 30 GAUGE GALVANIZED INSULATION: R-19 UNFACED JOISTS: 2X6 S.P.F.#2 @ 16"O.C.LONGITUDINAL DECKING: SINGLE 5/8"T&G FLOOR DECKING,HELD BACK 2-1/4"AT MATE LINE. HOLD BACK TO BE CONTINUOUS ENTIRE I:FNGTH OF MATE LINE COVERING: 26 OZ.COMMERCIAL CARPET,SHAW AMBITION II,#57505 TOPAZ COVERING: 1/8"VINYL COMPOSITION TILT,ARMSTRONG FORTRESS WHITE IN RESTROOMS ON STANDARD LAYOUTS WITH RESTROOMS ONLY TILE AVAILABLE THROUGHOUT UPON REQUEST TRIM: 4"VINYL COVE BASE ON SITE BY WILLIAMS SCOTSMAN ARMSTRONG#68 PALE GRAY 6"VINYL COVE BASE IN RESTROOMS ONLY ARMSTRONG#68 PALE GRAY (#65 SOFT WHITE MAY BE SUBSTITTI I'ED FALL 2005 AS NEEDED) • • • • • • CONNECT StRAF BUILDING FRAME WITH HOOK �s B•LDZt�� SHIMS QUIR£D SGL 8" X B" X 16" DRYSTACK CONCRETE 1 1/a" WIDE X .035 BLOCK .\GALVANIZED HURRICANE STRAP ■ GRADE CROSS DRIVE ROCK ANCHOR ars LAM CWDYCA'APPROVAL Aa%[ fyenyl4��• SiCNI SCOTSMAN PIER DETAILS 'wJ° v. Ivy,0 4,A.,o ` .r ut.t ws raw>a-1x. A-1 OCT tOsmum sumo.. m1aa r MOM(WM • • ._ + Lt a to o 03 0 1%j tMNN * 0003 e. . • a- I 3 OAT a 2 ti 0 N M U h N tnNNN 1-*-*- O O .. 0 t4) •. L. O s11 r ' N N tO 4 d3 00 N 07 \ N 4ta .t n' to G1+n 03 0 0 Of O0 tot MN OON • 1 Q C O MtO•Lttn 4.05.00 o O 0 � 0 (��� n� .. N o �.i�.�._— L N 00 N f� O O SO I' IO�r ]c . a. NO)NM aam N4NMN OOM s * O co Y� tf) * i 0 4"N N N 4�'4t 4t I �; 0 I O �° 1 N . I le tn as Ir I_x 4.0 en 0 Nt 40 I CO I I N x N NJJ N ;, ��16 Y I QI xx;n_XxvniaX § i * COI 1 .• %D I,00 0 d' co s 1 6 I I I .-NN N O 1 I I x I o .Y I ni N co — ►_I° I o I-,1 A 7- *1 >c<a. I W a oa 1 JUIQ ce s O I IZ/Id 1 OI►_, �o�Y O N I _ 0 W��p • *I Q Z c.� m Al O mOQ I Y 1 I o o 0 al I m J 0 NJ La I* CO 1 CO *1 Q 0 Ir- O II W m 0 I O I- a J O — 1 1 I m O Z 1 2 O 1 N I I o ° m La 1 WR 0 I Y ( I _ O ° J a 1* o -- u, I -Y *I o ; n0 r WJQ14- i$ x I I > mOJd :d_ ito,I.,O 1 N Y I I J J 1 x iiii: i co -J03 0 gk Y I w u, ,,,,. II II c8 La° ..aL O ° X10il CC W $ w a` 1L Q 4,6-,LI YtL6 •►t 1 w x E .iL-.£Z i d' °a 2�•11 N /Lj t 0 _N O ;s o • U 1 aoN n Z / \ //i\ YEN C 1 / Hh: i Q p� El E o., re no li! W oovc Q- W O V . 2 C4 J - : V jz b 2 W IL N o l o • II 1-1--) 11 it - II 7 in 1, ,,,, 46 r1 .3 ss._____... 11 , ii :.• , 1 _ 11 _ II .1 1 t Z. < Q E u ¢. 0 0 0; s• m ) U du'• ,cx N 3 - c V II U _r M i..."/ E i€ LL LL ..-v 0 I.----.. a:IMINIMMININ.I --.I • ■ • 0 T x ti R I w :4 o to E ;-. 8til • - Q ..6-3 1 ..6-.14 '— g ..j 2..EZ _ J O N M ;t.i () w a p it ry :gytm c Tit ets.,utIms.A•totteili 44 H444‘41441444 vote Detmoitt,e44 SAO/ \fat fl y 044 A4041013 Liu 1301 gogist, 1444meto441# 02108-1618 P1444 Kf?)l7--3N fug (61) 727- 132 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 111.5 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: USA fea.Cy iauQvws (name of haul 5 The debris will be disposed of in : L !w, s'C es 1—P‘c .L • 1.. (name of facility) (address of facility) signature of permit applicant /0/7/AP date debnsaffdoc..... The Commonwealth of Massachusetts • r Department of Industrial Accidents F il yl=',-.. Office of Investigations =1...,%!1= _ 1 Congress Street, Suite 100 i • � '- Boston,M4 02114-2017 .. www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builder s/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly .-r.._ Name (Business/Organization/Individual): I.11...1—z p C_. Address: g' I 0 01,T LA N.. p+ON 12: City/State/Zip:u) es i f iEL D, I D l O SS' Phone#: •1113- S6 0636 • Are you an employer?Check the appropriate box: Type of project(required): 1.kJ I am a employer with i kI 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.Ill am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. 0 Demolition working for me in any capacity. employees and have workers' comp.insurance 9. ❑Building addition [No workers' comp. insurance p required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. officers have exercised their I am a homeowner doing all work 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' 13.0 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. tContractors 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: )11 ...G e.‘,1.A Fityz.i.QG+• 0 N a":L) s. a o • Policy#or Self-ins.Lic.#: ©0 s'y 3 a 0 1 / a Expiration Date: t✓ao//L. Job Site Address: _-.1--.-A\ a',;:m,b T C.ti M. 'W De - • City/State/Zip: (4-7, 9i js x"6.5 il4 0;' ‘0 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 aims and pe , •- , .- ry that the information provided above is tr e and correct.ce A3 Sig Date: ature: ��✓ __ Phone#: LI,1 3 - 6L.8 - O .3 6 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#: • 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 k SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN \ OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT — , .. Vv 1 s" as Owner of the subject property hereby authorize C-•6 e es SeR.eim k oI.T Z .TNc, to act on my behalf, in al) iciatters relative to work authorized by this building permit application. Signature of Owner '\5 ' Date C.L i es O ek.e.13/9 , as O er/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best o my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of• ,•-r/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Constructi(onn Supervisor: Not Applicable 0 Name of License Holder: `' eN 0- < QT Z 3 License Number Bra soyii-r,antviol) t b 13- cs 7reb /hf9 oio&c /atrt/A? Address Expiration Da e W13 - 668'. 6.636 Signature f _ Telephone SECTION 13-WORKERS'COMPENSATI NSURANCE 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 b ding permit. Signed Affidavit Attached Yes No 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 koRTZ IIJC.. Not Applicable ❑ Company Name: Glue, K Jk"i z Responsible In Charge of Construction RID Soo-FHA/4 m-aA) Ev) W6,5►"--; kb, 1)4 6/Oar Address _ q/3•tr6P• 66CA Signature Telephone VersionI.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 2. 2 S 2... 2. Y Frontage 3 6 °t Setbacks Front Side L: /S R: oZ L: I S R: Z O Rear Building Height 2' 2 Bldg.Square Footage /I,,/,y 0 % ry�►O Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces 3 Li G Li Fill: (volume&Location) A. Has a Special Permit/Variance/Findin• 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 Registry of Deeds? NO 0 DON'T KNOW 0 YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q 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 Q IF YES, describe size, type and location: Handicapped Parking 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 Q NO O 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❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use Q Other❑ Brief Description Pk.D l�1 P6 H E M P e120948/ © '- l's C C- I i L '` Of Proposed Work: a L1 CO 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 ❑ B Business 2A ❑ E Educational ❑ 2B X. F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑0 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 ❑ 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: i3 u 1/4 Proposed Use Group: 0 vA I Ness Existing Hazard Index 780 CMR 34): 2— Proposed Hazard Index 780 CMR 34): 2, SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Te., o12.Ay CDC- Floor Area per Floor(sf) T�;31-,2� 1st 1st l L/ LI O 2nd 2nd 3rd 3rd 4th 4th Total Area(sf) Total Proposed New Construction (sf) Total Height(ft) Total Height ft 7.Water,Supply(M.G.L.c�,§54) 7.1 Flood Zone Information: 7.3 Sewa•� •isposal System: . Public [ Private Zone Outside Flood Zone Municipal ►_4 On site disposal system❑ , Versionl.7 Commercial Building Permit May 15,2000 !r t Department use only City of Northampton Status of Permit: OC I 1 1 2013uiiding Department Curb Cut/Driveway Permit - 12 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Electric, Plumbing&Gas Inspe i Northampton, MA 01060 ampton, MA 01060 Two Sets of Structural Plans phone 413- 87-1240 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 5�l r t3ST Rib t. 1R►re Map dm Lot 14 Unit N 0 R.T H 9 iv OA M9 b l 06 O Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: PVT A zBoQ rr St. S a di-,y NA 01101 Name(Print) L' ` ct�-- 4 1 C . wt -s Current Mailing Address: 4I - ?3a - 62 / Signature J ?, ` °' " > Telephone 2.2 Authorized Agent: , Lt%jalQ3 SerzQoA eq W es;e;Z LO 1M4 Name(Print) Current Mailing Address: � lV a'S Lila. 566. 0636 Signature Telephone 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 (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 J I ) I #1701 b This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0436 APPLICANT/CONTACT PERSON KURTZ INCORPORATED ADDRESS/PHONE P 0 BOX 1597 WESTFIELD (413) 568-0636 PROPERTY LOCATION 54 INDUSTRIAL DR MAP 25A PARCEL 190 001 ZONE GI(111)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 4 1� *la() Fee Paid Typeof Construction: ERECT 24 X 60 TEMPORARY OFFICE TRAILER Mob 411.E f A Pc kW 0 R K A N 0 New Construction FO:A.YD/t Tto A iN S 'CCX to N PrLic(p- TO KT Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 036505 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN, FQRMATION 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 r 0sl ,3 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. 54 INDUSTRIAL DR BP-2014-0436 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A- 190 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: TRAILER BUILDING PERMIT Permit# BP-2014-0436 Project# JS-2014-000759 Est. Cost: Fee: $720.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KURTZ INCORPORATED 036505 Lot Size(sq. ft.): 98010.00 Owner: PIONEER VALLEY TRANSIT AUTHORITY Zoning: GI(111)/ Applicant: KURTZ INCORPORATED AT: 54 INDUSTRIAL DR Applicant Address: Phone: Insurance: P 0 BOX 1597 (413) 568-0636 Workers Compensation WESTFIELDMA01086 ISSUED ON:10/15/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:ERECT 24 X 60 TEMPORARY OFFICE TRAILER - (module paperwork & foundation inspection prior to set) 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 10/15/2013 0:00:00 $720.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner