25A-185 (30) rr01T1:Kmy Narrow At:vnimPS insurance Agency,Inc FaxID: I o:Maureen Date:413U/2UUB UZ 3Z ISM F'age:9b of
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID I- DATE4/3 YY Y;�
MORRI-1 04/30/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PHILLIPS INSURANCE AGENCY INC HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
97 CENTER STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
CHICOPEE MA 01013
Phone: 413-594-5984 Fax:413-592-8499 INSURERS AFFORDING COVERAGE NAIC4
INSURED INSURER?:
Continental Casualty Company
INSURER B. Transportation Insurance Compa
Morris Roofing & Sheet Metal
Corporation IN>`uRERC.
142 Hancock Street INSURER
Springfield MA 01139
INSURER E
COVERAGES
THE POLICIES CF INSJPANCE L S-ED BELCAN HAVE BEEN ISSUE=TO TH--INSURED NAMED ABOVE FOR T-1E�GLICY PERIOD I\IDdCA-ED.NOTNITF-STAN--ING
ANN"P.E ILIREMENT,TERM OR CCND TION CF ANY CONTRACT OR 0-HER DOCUMENT Nti ITH RESPECT TO WHICH THIS CERTE CAT--MAY EE I83,ED OR
MAY PERTAIN.THE INSURAN--E AFFORDED BY THE ROL CIES DESCP,IEED HEREIN IS SUE'JECT TO ALL Tf-E TERMS,EXC_JSDONS AND CONDITIONS CF SUCH
POLICIES.Ark RFGATE LIMI-S SHU> WY HAVE BE=N REDUCED B"PAID CLAIMS
LTR NSR TYPE OF NSURANCE POLICY NUMBER DATE(MM/DDM) DATE(W410D)YY) LIMBS
GENERAL LIABLRY EAC-i 0.:CURRENC= $1,000,000
A X CCA1WRCAL GENERAL JABILITY 2048605564 05/01/08 05/01/09 FPEMIS=S;Eae« r=_ c=) $100,000
CLAIMS MACE X❑OCCUR HIED EXF,Any cre per=_cr) �$10'000
• XCU PER SCNAL s ADS/INJLP' $1,000,000
• Contractural Li ab GEN--FA AGGREGATE $2,D00,000
GEIdL AGGREGATE LIMIT APP ICS PER RP,ODUCTS-COWOP AG $2,DOO,000
POLICY X ,0 101-J-CT
AUTOMOBILE LIABILITY
coMEa�€D slncLE uMlr g 1,000,000
B ANYAJTO 2099461980 05/01/08 05/01/09 (Eaacci9 l:)
X ALL OWNED AUTOS BODIL"INJ1.P."
(Per person,
$
X SCPEDULED AUTOS
X HIRED AUTCS E•ODIL"INJL.P"
$
(Per accident)
X NON-C4VNED HUTOS
P'P,O�EP.T"DAMAGE $
(Per accident)
GARAGE LIABILITY ALTO ON_Y-E..ALCIDENT $
ANY AJrO OTHER-HAJ,, _'_C $
AU O ON-Y A"G $
EXCESSAIMBRELLALIABLIT! EAC1 OCCURRENCE s5,000,000
B OCCUR �CLAJMSMADE 2048605645 05/01/08 05/01/09 AGGREGATE $5,000,000
Retained $10,000
DEDUCTIBLE $
RET=NTICN $ Is
V6'ORK.ERS COMPENSATION AND TGP."LINITS X EP. —
B
EMPLOYERS'LIABILITY 248605600 05/01/08 05/01/09 E.-EACH ACCLEN- $1,000,000
ANY PROPR E-0�/P.AFTNER?E:<=CU-IVE
0F=ICEF7uEM3ER EXCUJDED? E._.CCSEASE-E.AENPLOfEE $1,000,000
If yes,describe under
SPECIAL PROVISIONS telow E_.CCASE-POLICY L M 7 $1,000,000
OTHER
A DISABILITY BENEFITS STATUTORY LIMITS
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES/EXCLLSM43 ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
TOPROV I SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
To Provide Proof of Coverage
REPRESENTATIVES.
AUTH ED REFIRE
TIVAE
ACORD 25(2001108) 0 ACORD CORPORATION 1988
loard of Building Regulations and Standards
Construction Supervisor License
License: CS 76497
Birthdate: 6G7/1967
Expiration: 617/2009 Tr# 15960
Restriction: 00
CLIFTON FROST
89 MARSH HILL RD
BRIMFIELD,MA 01010 Commissioner
.w
The Commonwealth of111assacliusetts
w_ Beparttnent of Industrial Accidents
Office of Investigations
600 TT ashington Street
_ Boston, MA 02111
www.mass., dia
«'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information i {� ! Please Print Leaibhv
Name (Business/Organization/Individual): i�l��f�\7 �(�0�
Address:
City/State/Zip: -\, 0 + I Q�1 Phone#: y 3' 3�(- a 3°7
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.� I am a employer with� ❑ 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5• ❑ We are a corporation and its 10.7 Electrical repairs or additions
3.❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
right of exemption per MGL
myself. [No workers' comp. 12. Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*.Any applicant that checks box#1 rn:st also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the nacre 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 isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information. �( {� f
Insurance Company Name: Li—►r � �1����A�C t �\C�I�(� �IAJ
Policy#or Self-ins.Lic. #: ,I `1,&6 O..6,6 o b \J Expiration Date:
Job Site Address: �(\)D(Aq 1 r.1 U1`+ City/State/Zip:k3 �nlQ p N
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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investi-ations of the DIA for insurance coverage verification.
I do hereby cer ' un r the s an en ies of perjury that the information provided above is true and correct.
CC �...__
Signature: Date:
Phone#•'I°2)' H T 5 '6q
Official use onlh. Do not write in this area,to be completed by city or town ojfcial
CAN,or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Version 1.7 Commercial Buildin,Permit May 1S,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) —7
Independent Structural Engineering Structural Peer Review Required Yes O No Q
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
i, �C�.t y_ . � .,....., t 1^ u�� 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.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder 4 / .
License Number
Addr Expir ion Da
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 No 0
e
1
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 I Expiration Date
9.3 General Contractor
._ �._. ..,. . _... r ..._. ....... .. ....... .: Not Applicable ❑
Company Name:
Responsible In Charge of Construction
SKIP-
Add ss
Signature Telephone
t
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
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW (Z) YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
a
NO 0 DONT KNOW Q YES
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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued.
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location: cwyTgv� $�� ��d N 6�� IV C
D. Are there any proposed changes to or additions of signs intended for the property ? S 0 NO
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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
w
Versionl.7 Commercial Buildin.-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 Enter a brief description here.::� �y
Of Proposed Work: \J
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 ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C I ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ I-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: 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)
St 1st
1
2nd 2 nd
3rd 3rd
...,, .,...., ._„,_.
4th
4t"
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❑
Version 1.7 Commercial Building Permit Mav 15.2000
Department use only
City of Northampton Status of Permit:
[�-pilding Department Curb'Cut/Driveway Permit -
I
14 _ �' !21`,2 Main Street Sewer/SepticAvailabi(ity
Room 100 Water/Well Availability
MAY _ 6 2C0�Nortlaa'mpton, MA 01060 Two Sets of Structural Plans
phone 113-,98,7'-1240 Fax 413-587-1272 Plot/Site Plans
�_.. .. j Other Specify
APPI-6*110 N TO ON$TRkJC ,REP R,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
--vTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map Lot Unit
A`ip�,, �+\ Zone Overlay District
....... Elm Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signatur Telephone
2.2 Authorized Agent:
Name(Print) 2T/v W Current Mailing Address:
Signature Telephone L/13' :!k,)-' Ir.i 53
L
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2008-0975
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:roofing BUILDING PERMIT
Permit# BP-2008-0975
Project# JS-2008-001170
Est. Cost: $180000.00
Fee: $900.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MORRIS ROOFING & SHEET METAL 076497
Lot Size(sq.ft.): 950914.80 Owner: COCA COLA COMPANY THE
Zoning: GI Applicant: MORRIS ROOFING & SHEET METAL
AT. 45 INDUSTRIAL DR
Applicant Address: Phone: Insurance:
P O BOX 90178 (413) 478-6943 () Workers
Compensation
SPRINGFIELDMA01139 ISSUED ON:51612008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL NEW EPDM ROOF SYSTEM
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 5/6/2008 0:00:00 $900.0011326
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo