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38B-006 (49) INFORMATION PAGE Ifrrow Mutual Liabilifl) Irrsrrrarrc C e omprrrry Policy No. 171_HA, _ 1. Name of)nsured: Collins Electric Company, Inc. Renewal of 1689A Mailing Address: t'0 Box 3311, Springfield, MA 01 101 Other workplaces not shown above: i:.i Individual 1.1 Partnership X Corporation 1:1 Other 2. 1'hc Policy 1?criod is 11-0111 ,111) L,.1-Y L_,2013 to:hk1luary_1.,.20.14 .At the Insured's Mailing Address. 3. A. Workers Compensation Insurance: fart one of the policy applies to the Workers Compensation Law of the States listed here: Massachusetts B. linlployers 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 arc: Bodily hljury by Accident `b 1 ODU�000 _.._.____ Each Accident Bodily Injury by Disease $ icy Limit Bodily fijury by Disease � .l.,,OUO•,OOU..-,- —_ I ach Employee C'. Otltet• States Insurance: Pal•t three ()tips; policy applies to the States, if any, listed here: D.ThIS policy mCILI&S these endorsements and SChCdLdCS: Retrospective Premium FIndorsement, Endorsements 1, 2, 3,4 and Massachusetts Endorsement 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. CJ,ttitiificEtlinns PYCnllltEllllE151$ Rates _... — -------- .._._._...__... .... ".. . Estimated Code 17mirnated Total No. Amwal Rentuncratiult Per$100 ol- Annual Rcntoatcratiolt I'rcmiunts l'1ecil-ic Wiring within Bldgs& nt 5190 3,185,000 _-- 2.84 J� Massachusetts Department of Industrial Accidents AMessmem is 4.2`%, Terrorism Risk - ,03 Manual Premium Construction Credit ARA11 Su1-C1W1-ge - 1.05 Clerical C)titc.. 1 7 inlployce5 N (a.0 881(} 700,000 .09 Salesmen,Collectors or Messengers-outside 8742 l.x��erience Modification - 1.03 Standard Charge for Employers l..iability ("Overage 13 $1,000,000 Limit is 2 % 9812 l:xpensc C onstalit 0900 Minimum PI-Cmitltlt $ 500.00 'Total Esti►nated Annual Premium $ Dais of Issue 1.)rcemk� r_13,-20.12. C OLIniersigned by 1-� ✓ ---- ' Authorized ItCptwy I Wa i' The Commonwealth of Massachusetts Department of Industrial Accidents y Office of Investigations ' 600 Washington Street • Boston, MA 0211.1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/organization/lndividual):_ <-oc -l/vS C C. 2 LC^r o INC, Address: 5­3 566 v.vtb .4-1r6 . City/State/Zip: CNtCdp6 E 1".4 0/o�­o Phone Are you an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with -5-- 4. ❑ f am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' q ❑ Building addition [No workers' comp. insurance comp, insurance. required.] 5. 0 We are a corporation and its MR Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12,❑ Roof repairs insurance required.] t a 152, §1(4), and we have no employees. [No workers' 13.❑ Other _ comp, insurance required.] *Any applicant that checks box tt 1 must also fill out the section below showing their workers'compensation policy information. I 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-wntractors have employees,they must provide their workers'comp,policy number. I am an employer that isproviding workers'compensation insurance for my empl yees. .Below is the policy and job site information. Insurance Company Name: Co Policy #or Self-xLie.#:_ 171811 Expiration Date: °! Job Site Address: S/vl l rp cu cc C, l,✓E S i City/State/Zip: !mod 2 Tk(1P,,1 v1v j M9 0/11(a0 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 MiGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, a,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 D1A for insurance coverage verification. 1 do hereby certify under the pains anpd�penalties of perjury that the information provided above is true and correct Sigpature: x Dater APR 1 1 2013 Tq�6� r. Fv�c,�.0� ASjr, 7'2EPqJv2EK,. Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Per # 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 0 No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 (Mark Lemelin 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 under the pains_.and penalties,of perjury,, Mark Lemelin Print Name _. . 04/10/1013 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:`William A Collins w._.. _. License Number ee M a. 53 Second Ave. Chicopee, p 01020 � CS- aj,�11 3S Address Expiration Date !,(413) 598-1000 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 G) No Version1.7 Commercial Building Permit Mary 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): RDK Engineers Name Area of Responsibility 200 Brickstone Sq. Andover, Ma. 01810 Address Registration Number 078)296-6223 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 I Expiration Date 9.3 General Contractor °Collins Electric Co Not Applicable ❑ Company Name: William A Collins Responsible In Charge of Construction 53 Second Ave Chicopee,Ma 01020 Address —7- ,q ��� `.(413) 598-1000 Signature Telephone 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: - L:' R:. Rear Building Height " Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved arkin #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued:m C. Do any signs exist on the property? YES Q NO 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: 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 0 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❑ Other❑ Brief Description :Roof penetrations and supporting steel for the installation of a new generator. Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 [] 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 26 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 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: m.._.__ ....__._ 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) S 1 St St 1 2nd 2nd _ 3rd 3`d to f _.. ._ 4th 4 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 ❑ Private ❑ Zone Outside Flood Zone[] Municipal ❑ On site disposal system[] C - E301 S'� Versionl.7 Commercial Buildin Permit May 15,2000 Department use only, City of Northampton Status of Permit: uilding Department Curler Cutoriveway Permlt 212 Main Street Se' ewerlSeptic Availabtllty S�,ECS�o F.. oN�'3 o0 Room 100 WaE rNUelI Avaitabtt,#y p .OPMpM� Northampton, MA 01060 TVw6 SetsofStructural flans N phone 413-587-1240 Fax 413-587-1272 Plot/Slte Flans t�thet pe+aify . 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 Proaertv Address: This section to be completed by office iCoGeneration Plant Map Lot Unit' 126 West St. Northampton,Ma. 01063 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Smith College '126 West St Northampton, Ma Name(Print) Current Mailin g Address: ;(413) 585-2400 Signature Telephone 2.2 Authorized Anent: 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 ? (a)Building Pennit Fee $50,000.00 $6.001 2. Electrical (b)Estimated Total Cost of $50,000.00 Construction from 6 $ 3. Plumbing 0.00 Building Permit Fee : 4. Mechanical(HVAC) $95,000.00 $300.00: 5. Fire Protection ', 6. Total=0 +2+3+.4+5) Check Number This Section For Official Use Onl Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2013-0990 APPLICANT/CONTACT PERSON COLLINS ELECTRIC CO F ADDRESS/PHONE P O BOX 3311 SPRINGFIELD (413)592-9221 PROPERTY LOCATION 126 WEST ST-POWER PLANT � � £ti 6V'1 MAP 38B PARCEL 006 001 ZONE SI(100)/WP(6)/ 1° r� FaL P THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid T_rpeof Construction: ROOF PENETRATIONS&SUPPORTING STEEL FOR INSTALLATION OF NEW GENERATOR New Construction Non Structural interior renovations Addition to Existing Accesses Structure Building Plans Included: Owner/Statement or License 32235 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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.