25C-251 (54) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803
(800)876-2765 NCCI NO 40959
POLICY NO. WCC 5004106012013
PRIOR NO. WCC 5004106012012
ITEM
1. The insured Hamp,Frank&Hamp Ag Soc dba Three County Fair
Mail Address: P 0 Box 305 Northampton MA 01061
Street No. Town or City County State Zip Code
FEIN xxxxx6394
❑Individual ❑Partnership OCorporation ['Joint Venture ['Association ®Other Non-Profit Corp.
Other workplaces not shown above:
2. The policy period is from 02/04/2013 to 02/04/2014 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident$ 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
•
Bodily Injury by Disease $ 1,000,000 each employee
C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules:SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 033851
SEE EXTENSION OF INFORMATION PAGE
Minimum premium$ 234.00 Total Estimated Annual Premium $ 2,844.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 2,943.00
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly
MA Assessment Chg.
$2,361.70 x 4.2000% $99.00
This policy, including all endorsements,is hereby countersigned by 12/18/2012
Authorized Signature Date
GOV GOV KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP
MA 9016 7 502
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
11/04/2013 10:39 14135871272 NTON BLD DEPT PAGE 03/06
Version l.7 Commercial Building Pcrmit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
1,0t Size
Frontage
Setbacks Front
SideL:.............. R:............. L:........,,,,,,,: R:'................
Rear
................
Building Height
Bldg. Square Footage %
Open Space Footage "/n ...............
(Lot arcs minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Spec' t Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW ® 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 er DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q
, Date Issued:
C. Do any signs exist on the property? YES 0 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 ® NO 0
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 a NO
IF YES,than a Northampton Storm Water Management Permit from the DPW is required.
11/04/2013 10:39 14135871272 NTON BLD DEPT PAGE 04/06
Versiont.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 Data
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Data
9.3 General Contractor
Not Applicable❑
Company Name:
Responsible In Charge of Construction
Address
Signature .._ Telephone
11/04/2013 10:39 14135871272 NTON BLD DEPT PAGE 05/06
Vcrsion1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) 1
Independent Structural Engineering Structural Peer Review Required Yes ® No Q
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
.. ........ .....
I ,as Owner of the subject property
hereby authorize_ to
act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
rl '
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, ...... .
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable El
Name of License Holder:.......QC J.....a..5,Z.A✓..c 4
License Number
G r) R s O v -- , nA ra 4M , p., ..,.,..... C.x........03:..7O a.A
Address Expiration Date
Air
gnature 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 0 No 0
11/04/2013 10:39 14135871272 NTON BLD DEPT PAGE 06/06
"•, The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k��� � 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant,Information Please Print Legibly
Name(Business/Organization/individual): /12/71,f/r7/z6, ()11-1114?(://' < 1-107-01141y 441-4 f i
Address: 1i/'1 f,r _
City/State/Zip: 04/7179wa"'_4 .Gfrf C>rai� Phone#: ,96)'
Are u an employer?Check the appropriate box: Type of project(required):
1. I am a employer with .s 4. 0 I am a general contractor. and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2,❑ I am a sole proprietor or partner )fisted on the attached sheet. 7. [] Remodeling
ship and have no employees These sub contractors have 8. 0 Demolition
working .for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp_insura.nce,t
required.] 5. ❑ We are a corporation and its l0.L j Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑ 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;q1 Other fZ r1o4'r m) n s / cl
comp.insurance required.] , d
'"Any applicant that cheeks box a*l 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 than hire outside contractors must submit a now affidavit indicating such.
3Contractors 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:_4STOC/,4Tr-n LP!IiG/✓}'G5J' /.�/S • Co
Policy#or Self-ins,Lie.#t: A/C4 5-61)V/06 d',)0/ ' Expiration Date:
Job Si �ti tc Address: /1 S/— 7 r'`'' City/State/Zip: • 1
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$I,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 penalties of perjury that the information provided above is true and correct.
i•natur : ,, _d e' � D.te:
Phone#: if/f 011—2277
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#:
11/04/2013 10:39 14135871272 NTON BLD DEPT PAGE 02/06
Vcrsion1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs 0 Demolition 0 RepairsV1 Additions 0 Accessory Building 0
Exterior Alteration El Existing Ground Sign 0 New SignsSip Roofing 0 Change of
...... .„ „
R p Pr.?. t J Use.0 „Other. 0 ...„........ ...
. . ..
Brief Description Enter a brief description bere— e . 'S il S — 6 7 0 114 4/ kkN°0 Xij 41”
Of Proposed Work: i R lo c- ( $;4%. It ■141.-- 4t. PQ-S4-C.., CT 14 1.9) B AVAAS
,. „,!..:..,................ ..... ,..„„ , ..„„ ,
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 0 A-2 0 A-3 0 1A I 0
El
A-4 0 A-5 0 1B 0
B Business d 2A CI
E Educational d 2B I 0
F Factory 0 F-1 0 F-2 0 2C 0
H High Hazard 0 3A 0
I Institutional 0 1-1 0 1-2 El 1-3 El 3B 0
M Mercantile 0 4 0
R Residential 0 R-1 0 R-2 El R-3 0 5A CI
S Storage El S-1 1:1 S-2 0 5B 0
. ....
U Utility El Specify:
M Mixed Use
1.% Specify: : Fe u L-tvr 0 ,P-e-Ns Fo
S Special Use 0 Specify:l :
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS ANC)/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) 4 3 D 0 CC■Cel
. 1''' . .•
e : Li$0 b. : .............. ...... . .
2nd . .. ' •
2"• . ... . . ..... ...
. . . .. „,.., ..., .,...........
3rd
4th • •
Total Area(sf) ... L.i ?trb Total Proposed New Constructibn(sf) _..„.
Tot2I Height(ft) .?...6
. . . ... .. . . . ,
Total Height ft .
.
7.Water upply(M.G.L.c.40,§54) 7.1 Flopd Zone Information: 7.3 Sewagepiiposal System:
Public Private 1=1 Zone i Outside Flood Zonep Municipal @al On site disposal systemp
11/04/2013 10:39 14135871272 NTON BLD DEPT PAGE 01/06
Vcraio411,7 Commercial Building Permit May 15,2000
• f3qiod'rv>ielAY�dlv •'i. ,
City of Northampton ttstiii,itf 'e>'1'>'1 t:" ..''i
�4 �`� -uitding Department �l�s-:Gwfllrl. y�,,ittit.. `h ;; ' {:;;,: ",:'
. '� ;o ti`O"S 212 Main Street t4w0.e/Sie0 48iliibtlltiy' :''
dSJ�
U t -,' U Room 100 W to/W Il.AAilibirlt : -. ,�
p\�iR`u tGr.,• ‘!'k MA Vg No
N��rGm` phone 4113-587-1240, Fax 413 587-1272 Pl t/Si a PI ns 'uraf�'Iirt3'`: '' :.'
Other Sp04': •
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 l
1.1 Property Address: this section to be completed by office
5 y V.j e. 'S j'RZt-r Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,1 Owner of Record: lip, bh ,n I...c...?A, i ,�11 . 4-
C e W V�1V'C..!...... .
Name(Print) Current Mailing Address:
,
Signature Telephone ) 6- j"y-a 7
- y 3 "
2.2 Authorized Anent:
Name(Print) Currant Mailing Address:
Signature _ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b .ermita••licant
1. Building
0. 0 0 O (a)Building Permit Fee
2. Electrical
(b)Estimated Total Cost of
Construction from 6 0- b u
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) • •..
5. Fire Protection ••• • •.
6, Total-(1 +2+3+4+5) Check Number /157 4'/ _6
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0592
APPLICANT/CONTACT PERSON JOSEPH JASINSKI
ADDRESS/PHONE 62 GILLBERT RD SOUTHAMPTON (413)527-7379 0
PROPERTY LOCATION FAIR ST-FAIRGROUNDS
MAP 25C PARCEL 251 001 ZONE SC(100)/URB(1)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 167191 /CIO
Fee Paid
Typeof Construction: REPAIR SILLS,SIDING,WINDOWS&ROOF ON POULTRY BARN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 057025
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INS FORMATION 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
/// (J ///!al,
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.
FAIR ST-FAIRGROUNDS BP-2014-0592
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-251 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-0592
Project# JS-2014-000993
Est.Cost: $20000.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH JASINSKI 057025
Lot Size(sq. ft.): Owner: HAMPSHIRE FRANKLIN&HAMPDEN AGRICULTURAL SOCIETY
Zoning: SC(100)/URB(1)/ Applicant: JOSEPH JASINSKI
AT: FAIR ST - FAIRGROUNDS
Applicant Address: Phone: Insurance:
62 GILLBERT RD (413) 527-7379 0
SOUTHAM PTONMA01073 ISSUED ON:11/19/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR SILLS,SIDING,WINDOWS & ROOF ON
POULTRY BARN
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 11/19/2013 0:00:00 $120.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner