25A-185 (45) TP DALEY INS Fax:4137392645 Dec 8 '04 9:58 P.02
INSURER'S AFFIDAVIT AS TO WORKERS' COMPENSATION INSURANCE
I,Jane Eitel,Commercial Service Rep.,T.P. Daley Insurance Agency,Inc., 1381
Westfield Street,West Springfield,MA 01089,authorized representative of Acadia
Insurance Companies,do hereby affirm that effective 04/01/04,Gomes Construction
Company,Inc., 112 Church Street,Ludlow,MA 01056 is insured by said insurance
company with Policy Number WDF130046212 for Workers' Compensation in
accordance with Massachusetts General Laws,Chapter 152,and Subsection 7.05A of the
Standard Specifications for Highways and Bridges of the Massachusetts Highway
Department. Any Discrepancies between the Massachusetts general Laws, Chapter 152
and Subsection 7.05A of the Statdard Specifications for Highways,Bridges of the
Massachusetts Highway Department shall be resolved in favor of M.G.L.A.c 152.
Signed , Q
Subscribed and Sworn to me this 8"'day of December,2004 at West Springfield,MA
(Nod Public}
Joanne F.Rocca
My Commision expires 04/15/05
TP DHLEY INS Fax:4137391645 Dec S `04 9:55 P.U1
Cliendt:13814 GOMCO
► �8D.- CERTIFICATE OF LIABILITY INSURANCE - DATE(NWDOlYYI
12/08104
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
T.P.Daley Insurance Agency,Inc ONLY AW CONFERS NO KWPKTS- UPON THE CERTIFICATE
`1381 Westfield St. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY NE POLICIES BELOW.
RO-BOX 1150 INSURERS AFFORDING COVERAGE
West Springfield,ILIA 15MOSOv [
INSURED INSURERa• Atadia+Insw�anc4Csw►palaies
Games Construction Company,Inc.
INSURER 8:
112 Church,Street
Ludlow,MA 01056 INSURER D,
COVERAGES
THE POLICIES OF INSURANCE LISTM RFI CTN HAVE BEEN ISSUED To THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT M WHIM TMIS CVMKICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSION3 AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS,
NTR TYPE Of INSURANCE POLICY NUMBER MMtD MM)D LIMITS
A GENERAL LIABILITY CPA005088715 04/01104 04/01105 EACH OCCURRENCE S1,000000
X COMMERCIAL GENERAL LIABILITY Fti?E' e&*) $250000
CLAIMS MADE O OCCUR MEP EXP(Any one peNon) $5,000
PER DNA"Aw kb4URY 31,000,000
GENERAL AGGREGATE s2.00.000
GEN'L AGGREGATE LIMLTAPPLIESPER. I PROOUCTS-OOMf-vor G E2 000 OQO
POLICY 171 PRG LM
A AuTe lAouas uAna my MAA130046115 04101104 04/01105 COMU NED SINGLE LIMIT
X ANY AUTO (ED ewaem! s
ALL OWNEO AUTOS
BODILY INJURY 51,000,000
SCHEDULED AUTOS tPrMne^1
X HIRED AUTOS .. ._._...
BODILY INJURY $1,000,000
X NON-OWNED ALFrOS 11'eT��U
PROPERTY DAMAGE $1.000,000
(Per boodentq
GARAGE LLAIRLM AUTO ONLY-EA ACCIDENT .S
ANY AUTO EA ACC %
PTAIC0.tNAN..
AUTO ONLY AGO S
A -UXCM LLASILM CUA006090215 04/01104 04!01/05 EA CH OCCURRENCE $5.000.000
X OCCUR U CLAIMS MADE I AGGREGATE 35,000,000
k�^
DEDUCTIBLE $$
RETENTIONr $
A WORKERS COMAEN.AYION AND WCATM45M {Q4�1� we 6TATU- OTH-
EMPLOYERS'LIABRITY 51.EACH EACH ACCIDENT $1,000000
E.t_.DL$EA49;EA EMPLOYEE $1,000,000
E.L.DISEASE.POLICY LIMR' 01 OOO OOO
OTHER
DESCRIPTION OF OPERATIONSILOCA710N:VVEmCL P&EXC W SIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Re:Bank Avenue Sanitary Sewer,Northampton.MA
CERTIFICATE HOLDER ADDfneNAtBisypEa xwuRERa.E�cTELt. CANCELLkTMX
BHOVLO ANYOrTNE MOW DESCRIBED rOLICIEBBECANCELLED BEFORE THE ElQ'IIRATION
City Of NOrt arWpt9R 1DA7f TNEREOF,THE WSUING N&URER WILL ENDEAVOR TONIALAO DAYSWRnn"
125 Locust Street NOTICETOT)IE CERTIFICATE MOLDERNNME570TNELEFT,BUTFAILURE TODOOOSMALL
Northampton,MA 01060 IMPOSE NOOBUGATIONORLIABILITYOFANYMNDUPONTHE INSURE R,ITS AGENTS OR
REPRESENTATIVES
AUTHORIZED E ATIVE
C
ACORO 26-S(7/97)1 of 2 VS4396WM42506 ACORD C ORATION 1968
Fz0 ��.�°ye �ri� ofNT>td llallt 10 11 ---_�
R E e3•rtrhnrctta'
u. o DEPARTMENT op fluiwo\lc fNSPEcrtolds
212 Train Street ' Municipal Budding
?Northampton, Mass. 01060
WORJCEIZ'S CONMENSA-MN, MSURA CF Al, A}Tj_
------- - - (liccoscJ- PCrmittcc)
(phone'')
(su�t/ci tylslalc/a p)
do hereby certify, under Lhe paint and penalties of perjury, :hat
( ) I am an employer providing the following �ti,orkers comoens-nDop covem,c for in),
emplovees working on dais job:
(Incur-,n= Conr.:_cY) (P06C-, NU-a i cr) (Expirtion Daft)
O I am a sole proprietor, geaeral contractor or homeowner (cu cie one) and hive hired
the co=actors Gstec+ below who hive the follokvmg worker's coc.2Den-,P-don policies:
(i+amc of con.'rnczor) (InS1]C' ncrz. Cotnpa iy/1 GUci �rt1n7 Q) (t_x)IiJ:iOn DaIC)
(Name of Cootraaor) (Insuranc:. Comoaa,,•/PoUc-r Numccr) (Emir,Lion Date)
(Name of Cootracto.) (Insufancz Compan}'/PoUq- Number) (Expir,-600 Dalc) I
1
(Name of Coanclor) (Insurancc Comcany/PoLicy Numkf) - (Expir-dtioo Date).
(ntuc�Ai:ioczl c-'>cct if nooc-u 1•to mc?u�wfonn-joa pertainiag to.lf cow-so:s)
O I am a sole proprietor and have no one woridog for me.
( ) I am.a home owner performing all Lbe work myself.
NOTE:plesc lx warc t5c .(Jc bom owom w-bo anplay pczi m w ¢ ^^ cis G o cr repair work oa c d,,,u-Z of
not moet th.a ttsr_>mtu is u'sieh tJx bomeown=rcaicSo Cr oo the Qoun zppurt.ensra tbeco co( w be
eutploy�=3 unr e the.. _�=Mp .-tim Au(GL.1 rpptuat600 by a bomco%-a fcr e bc=x or pam1h r=y e.idmcc Lb:c
I-fPJ naxuc of ea ea:Ployec coder tbo Workc(e Comq�omatioa Ad
1 undan.ad tb-4 a copy of thi.—mey be to the Depnctmmc of lndtrttid AcodO3&OfGoe of Irr---for the
oova,c vcti[mioa annd ami f IIL-C to sauce toovcrv,� under socxiorz 15A of T.iOL 152 can Icsd to the i=Poaifioo of mmiail pcnxw,=
ooasistmg of a rMc of up to S 1-500.00 enCfor 6nPri3oamcni orup to ooc year cad civil pcaaftio to Lc form ore stop Work Ord=and.
rim or S 100.00 z d_y a IjA tnc
For d p-n —vl u—only
Pcrtntt Number --
1,{ap« Lot
Sigztun of Li scrlpermittcc —�Ej e -- _.
Version 1.7 Commercial Building Permit May 15,2000
i
SECTION 10-STRUCTURALPEER REVIEW(780 CMR 1f0'11j r',
Independent Structural Engineering Structural Peer Review Required Yes 0 No Q
SECTION 11 -OWNER AUTHORIZATION, TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDIN'GPERMIT
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.
;
! 4
Signature of Owner Date
i
I. 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 penury.
Print Name
Signature of Owner/Agent Date
SECTION 12' CONSTRUCTION'.-SERVICES:
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: W"& Ae L
License Number
Address Expiration Date
g" 1 41-3_5Y7-,e,VSJ- -1
Signature Telephone
SECTION 13-WORKERS'£OMPENSATION'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
r
I '
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN:ANbCONSTRUCTIaN_SERVICES-FO°RBUI,tDINGSrANDSTRUCTURESSUBJECTTO
CONSTRUCTION CONTROL PURSUANT°TO!780 COR 116(CONTAINING MORE THAN 35,000 CY.:OF"&CWSEDSPACE)
9.1 Registered Architect
Not Applicable ❑
t
Name(Registrant):
ERegistration Number
Address
1 Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
� I
I
Signature Telephone Expiration Date
Name Area of Responsibility
r
Address Re ig stration_Number
Signature Telephone Expiration Date
Name Area of Responsibility
i
Address Registration Number
--1i
r
Signature Telephone Expiration Date
Name Area of Responsibility
1
Address Registration Number
�_- I
Signature Telephone Expiration Date
9.3 General Contractor
r, SSA Not Applicable❑
Company Name:
E 77-5o -tie r n go S
Responsible In Charge of Construction
Address
Si tur Telephone
ti
Version 1.7 Commercial Building Permit May 15,2000
° Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size E Cx t-c
„CSC>
Fronta e ---�
Setbacks Front
Side L:' R:= L:�SQOI�Rj_
lo-
Rear i001
�uttding Heiglif-- i -
Bldg.Square Footage % it
Open Space Footage %
(Lot area minus bldg&paved i
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 ® YES 0
IF YES, date issued: I
i 1
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 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO 0
IF YES, describe size, type and location: i
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
t 3
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
l
SECT10N:4-.CONSTRUCTION SERVLCES FOFTPROJECTS LESS THAN 35,000
CUBIC FEETOF;ENCLOSED'SPACE `
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ld
Brief Description ;Enter a brief description here.
Of Proposed Work:
I f '
'SECTION 5-USE GROUPAND 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 ❑
H Hi h Hazard ❑ 3A ❑
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 El Specify:
M Mixed Use Specify:I
S Special Use Specify: +
COMPLETE THIS SECTIONvfF EXISTING BUILDING UNDER601NG-RENOVATIONS,ADDITIONS AND10R CHANGE IN USE
. <_ .
Existing Use Group: 1 Proposed Use Group:
Existing Hazard Index 780 CMR 34): € Proposed Hazard Index 780 CMR 34): I
SECTION&BUILDING"HEIGHT-p►ND>AREA-
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
a
Floor Area per Floor(sf)
St
QD
1st 1 U
-�� nd
2nd 1 2
M �� a
3ro s ��
3rd
4th
4d' -
Total Area(so Total Proposed New Constructions
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 E]
Version 1.7 Commercial Building Permit May 15,2000
City off Northampton
J f t uildiny epartment
212 Ma Street
y�Roo '100
146rthampp on, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
,SEC?ION 1 =SITE INFORMATION
-Y1-Pronertv-Address This section to be completed uff L _
_.,.._.k �. �x .
C'Cx ck- &)&* L e4i Cct__ I map tot t
XA CIy1
,h.
'SECTtOM2-PROPERTY OWNERSHIP/AUTHORIZED AGENT -.- • '`
2.1 Owner of Record:
! ' j
Name(Print) Current Mailing Address:
i
i
Signature Telephone
2.2 Authorized Agent:
I
Name(Print) O 3-r), �' �o�,� Current Mailing Address:
i
i
Signature 41, a"� Telephone
SECTION 3-ESTIMATED CONSTRUCTION'COSTS
Item Estimated Cost(Dollars)to be Official Use�Only
com feted by ermit applicant
1. Building U ,(a)Building,Permit Fee
2. ElectricalUD O O 0 (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 r d ze
This Section For Official lase Onl`
Building,Perm t Number` Date rr
Issued=
r
Signature:
Building Commissionemnspectorof Buildings Date
File#BP-2005-0657 t
APPLICANT/CONTACT PERSON GOMEZ CONSTRUCTION CO INC
ADDRESS/PHONE 112 CHURCH ST LUDLOW (413)583-5259
PROPERTY LOCATION 45 INDUSTRIAL DR
MAP 25A PARCEL 185 001 ZONE GI
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid AX50—
Typeof Construction: ERECT 10 X 10 GUARD SHACK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 076982
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
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.
45 INDUSTRIAL DR BP-2005-0657
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Biock:25A- 185 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: shed BUILDING PERMIT
Permit# BP-2005-0657
Project# JS-2004-0979
Est.Cost: $6500.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GOMEZ CONSTRUCTION CO INC 076982
Lot Size(sa. ft.): 950914.80 Owner: COCA COLA COMPANY THE
Zoning:GI Applicant: GOMEZ CONSTRUCTION CO INC
AT: 45 INDUSTRIAL DR
Applicant Address: Phone: Insurance:
112 CHURCH ST (413) 583-5259 WC
LUDLOWMA01056 ISSUED ON:12110104 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 10 X 10 GUARD HOUSE
POST THIS CARD SO IT 1S VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: House# Foundation:
Driveway Final:
Final: t ��
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Sly— Final:
THIS PERMIT MAY BE ,"VOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AN G REGULATIONS.
Certificate of Occupancy' Signature:
FeeType: k L iht No: Date Paid: Check No: Amount:
Building 12/10/04 0:00:00 35406 $50.00
312 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo