25A-127 (4) ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY)
10/05/05
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Aon Risk Services of Texas, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
301 Commerce Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Suite 2101 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Fort worth TX 76102 COMPANIES AFFORDING COVERAGE
COMPANY ACE American Insurance Company
PHONE- (866) 283-7124 FAX- (866) 430-1035 A
INSURED COMPANY Illinois National Insurance Co
InStar Services Group, Inc.
InStar Services Group, L.P.
dba Action Fire InStar Services Group COMPANY
C
30 Haynes Circle x°
Chicopee MA 01020 USA COMPANY
D
SIR May Apply
COVERAGES
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.
CO POLICY EFFECTIVE POLICY EXPIRATION LIMITS
I.TR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/VV) DATE(MM/DD/YY)
po
00
A GENERAL LIABILITY HDOG21722285 10/01/05 10/01/06 GENERAL AGGREGATE $10,000,000
rn
General Liability PRODUCTS-COMP/OP AGG $2,000,000 rn
X COMMERCIAL GENERAL LIABILITY N
PERSONAL&ADV INJURY
$1,000,000
CLAIMS MADE X❑OCCUR O
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $l,000,000
u,
FIRE DAMAGE(Anv one fire) $100,000
MED EXP(Anv one person) $5,000 'Z
v
A AUTOMOBILE LIABILITY ISA HO 80 16 27 6 10/01/05 10/01/06 COMBINED SINGLE LIMIT $1,000,000 C
X ANY AUTO Business Auto E
ALL OWNED AUTOS BODILY INJURY
V
(Per person)
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY
(Per accident)
NON-OWNED AUTOS
PROPERTY DAMAGE
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
B EXCESS LIABILITY BE7227230 10/01/05 10/01/06 EACH OCCURRENCE $5,000,00
X UMBRELLA FORM umbrella Liability AGGREGATE $S,000,00
OTHER THAN UMBRELLA FORM Retained Limit Amoun $10100
WC STATU- OTH-
A WORKER'S COMPENSATION AND WLRC44188314 10/01/05 10/01/06 X TORY LIMITS FIR
EMPLOYERS'LIABILITY workers' compensation EL EACH ACCIDENT 1,000,000
THE PROPRIETOR/ X INCL EL DISEASE-POLICY LIMIT $1,000,000
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $1,000,000_
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESISPECIAL ITEMS
CERTIFICATE HOLDER, CAtNCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE
a1
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVORTO MAIL
city of Springfield
71 Colton street 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 5"
Springfield MA 01104 USA BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
i�
AUTHORIZED REPRESENTATIVE
ACORD 264(M) M
BOARD OF BUILDIN REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 0�416>✓
Birthdate: 09/18/195-6
dft
f
Expires: 09/18/2006 Tr.no: 5844.0 J
Resiricted: 00' 1
GARY W BRUNELLE
125 CREST LN
GRANVILLE, MA 01034
Commissioner j
� �� Pte, �✓l?,a�oa�l�.�.,tr .
Board of Building Regulations and Standards ;
HOME IMPROVEMENT CONTRACTOR
lug Registration: 146480 I
Expiration: 4/2712007
Type:, DBA
ACTION FIRE INSTAR SERVICES
DIANE SWAYGER
30 HAYNES CIRCLE GG '�
CHICOPEE,MA 01020 Administrator
i t.rilC.Vt'tt,MA uluzu Administrator ;I
I
SECTION 8-_CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable l�❑
Name of License Holder: C� _t . V- A-, 0—7
License Number
L 2-5- C, -t-st- AA 4, a3 9hl� 1)6
Add r s Expiration Date
�3 .3sT
Sign ure J Telephone
'3:'R+e" steredlorrieliri'rliie°irie&Contractou^� �" "� Not Applicable ❑
�`f6 `60
Company Name c Registration Num er -"--
/-rUTu A lie, '-(/2'7 72-
Address 1 Expiration Date
�On¢,S �y�?cq�t, �A Telephone `�'J` '� d
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.
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....... No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(l) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
- as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
i
a ,
J.
SECTION 5-DESCRIPTION OF PROPOSED (checkall applicable)
New House Addition ❑. Replacement Windows Alterations) ❑ Roofing
Or Doors M
Accessory Bldg. ❑ Demolition ❑ New Signs [C]] Decks [p Siding[p] Other ]
Brief Description of Proposed n
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes JC No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa EfmC�e ''Iracrse=ancccitQ�oe>�rsn. as�n .carte Ee %PA
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
t
e. Number of stories? t 14,'-1
f. Method of heating? V I1 A Fireplaces or Woodstoves _Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction .X l
I. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No 4
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION Ta-OWNER AUTHORIZATION-70,-BE-COMPLETED WHEN
OWNERS AGENT OR''CONTRACTORAPPLIES FOR'BUILDING PERMIT
h A �' �^ I �I as Owner of the subject
property I l
hereby authorize yk-1/Oy1 c ' ,y—
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner J Date
aval1iioeer/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.
Print Name
Signature of O ner/Ag t Date
' ^ '
` .
* '
Section 4. ZONING All Informatio'n Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage % F—;
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
'
A. Hus a Special Perm it/Vahanca/Findi ng ever been issued for/on the site?
NO 0 DON7KNOVV 0 YES 0 �
IF YES, date issued:.
IF YES: Was the permit recorded utthe Registry of Deeds?
NO v����
DON'T ".""." 0 .^S
IF YES: enter Book Page: and/or Document#
�� ��
B. Does the site contain a brook, body ofxvuterurwetlands? NO v���� DON7KNOVV �_/ YES x��
IF YES, has permit been or need tu ba obtained from the Conservation Commission?
'
Needs tobmohta[uad x~�` Obta�nad �~� Date
�
x�� v_� '
C. Do any signs exist un the pruporty �� ��� YES v�� NO «�/
IF YES, describe size, type and location:
D. Arethere any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E Will the construction activity disturb grading, or filling)over 1acre or isdpart ofo common plan
thowW|dismrbmm,1oore? YES r NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
a �
e, toul\v
rIt Nort, ton �
Department era
�1�`;Main Street Seure
1 ^ 2�Oc, ,� OOm 100 f � «
OC �IVortham ton MA 01060 e "' Ni�t phone 413--587-1 41.3=587-1 40 Fax 413-587-1272 F'C� Ia �
1<_ A"-UGATt0 CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
' This secUort>to be comPletedbyo�ce °��
1.1 Property Address:
�5 4Tt✓$ 5"T Maps Clot R ..�UQFt
0 2T!! kv--p 4-C>1
Zoc�e Ouerla} D�stric
Elm Sf w Distract "cB Qistnct ..
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDAGENT-
2.1 Owner of Record:
Name(PHM Current Mailing Address:
J13 - 1123
Telephone
Signature IV
2.2 Authorized Agent: //
tV r4� 5 G' 't C�i r� wtA • 61
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-"ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ��U (a)Building Permit Fee
2. Electrical 0-0 (b)Estimated Total Cost of
d Construction from 6
3. Plumbing So C) Building Permit Fee
4. Mechanical(riVAC)
5. Fire Protection 4 50 lobb
6. Total=(1 +2+3+4+5) 000 I Check Number
This.Secton For Official:Use Only
Date
Building Permit Number. tssaedc
Signature:
,
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0405
APPLICANT/CONTACT PERSON ACTION FIRE-INSTAR SERVICES GROUP LP
ADDRESS/PHONE 30 HAYNES CIRC CHICOPEE (413)594-7800
PROPERTY LOCATION 25 BATES ST
MAP 25A PARCEL 127 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid o
Typeof Construction: REPAIR FIRE DAMAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 074416
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
lNFOJMATION PRESENTED:
pproved 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 Co 'ssion
/(//X
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.
R
25 BATES ST BP-2006-0405
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A- 127 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0405
Project# JS-2006-0587
Est. Cost: $42000.00
Fee: $210.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ACTION FIRE-INSTAR SERVICES GROUP LP 074416
Lot Size(sq. ft.): 11979.00 Owner: HILL ARTHUR B JR&AGATHA N
Zoning:URB Applicant: ACTION FIRE-INSTAR SERVICES GROUP LP
AT. 25 BATES ST
Applicant Address: Phone: Insurance:
30 HAYNES CIRC (413) 594-7800 Workers
Compensation
CHICOPEEMA01020 ISSUED ON.1012 712005 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR FIRE DAMAGE
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 10/27/2005 0:00:00 $210.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
ILA,
25 BATES ST BP-2006-0405
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A- 127 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinq
Category: BUILDING PERMIT
Permit# BP-2006-0405
Project# JS-2006-0587
Est. Cost: $42000.00
Fee: $210.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ACTION FIRE-INSTAR SERVICES GROUP LP 074416
Lot Size(sq. ft.): 11979.00 Owner: HILL ARTHUR B JR&AGATHA N
Zonine:URR Applicant: ACTION FIRE-INSTAR SERVICES GROUP LP
AT: 25 ELATES S
Applicant Address: Phone: Insurance:
30 HAYNES CIRC (413) 594-7800 Workers
Compensation
CHICOPEEMA01020 ISSUED ON:1012712005 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR FIRE DAMAGE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
f.l t
f 8 OS��WiA Footings:
Rough. % '' Rough: ( � � � House# Foundation:
�JKZ .r
Driveway Final:
J � Rough Frame:
r
Gas: Fire Department Fireplace/Chimney:
r
Rough:
psi.• ...:,t�...,.
Final:/-/ =x'11) Smoke: Final: r7 i�
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIO NS.
,1
Certificate of Occupancy i' Si nature:
FeeTyue: `Date Paid: Amount:
Building 10/27/2005 0:00:00 $210.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo