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24D-185 (13)
7 ® DATE(MM/DD/YYYY) AC40R° CERTIFICATE OF LIABILITY INSURANCE F 7/11/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). cP CT PRODUCER NAMAME: Christine Sullivan Aquadro & Associates PHONE (413)586-7373 FAX , (413)584-0859 355 Bridge St. , P. 0. Box 357 E-MAIL INSURERS AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURERA:Main Street America Insurance 29939 INSURED INSURER B: COOLIDGE NORTHAMPTON LLC INSURER C: PO BOX 310 INSURER D: INSURER E: WHITE PLAINS NY 10605-0310 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1441405466 REVISION NUMBER: 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. INSR T5b7L9UBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER M M /Y EACH OCCURRENCE $ 2,000,000 GENERAL LIABILITY AMA GE TO RENTED 500 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE ❑X OCCUR BPF3111Y 12/21/2013 12/21/2014 MED EXP(Any one person) $ 10,000 PERSONAL&ADVINJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X PRODUCTS-COMPIOP AGG $ 4,000,000 POLICY PRO LOC $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED Per accident $ HIRED AUTOS AUTOS $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000 DED X RETENTION$ 10,000 UF3111Y 12/21/2013 12/21/2014 $ A WORKERS COMPENSATION I TWOCRYSTATU_ X 0TH- AND EMPLOYERS'LIABILITY Y 000 ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ 500 OFFICER/MEMBER EXCLUDED? NIA 12/21/2013 12/21/2014 (Mandatory in NH) CF3111Y E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATION ONLY AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) INS025(201005).01 The ACORD name and logo are registered marks of ACORD Coolidge Northampton DeLaurentis Management Corp. 43A Greenridge Avenue White Plains, NY 10605 June 25, 2014 Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA I request that you grant a modification to waive the requirement for construction control of the project at 243 King Street, Suite 249, Northampton, Massachusetts because the work is of a minor nature, it will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. Thank you for your consideration. Respectfully, Richard LaValley Manager for Coolidge Northampton r 4 kftfA aoa�crwp. sueon P '8�"s" PI�aYc Reslrooms 1 .......... Balcony-Common Use Egress CI / ITID, T lLL.LJ_ Open Open Below Below ON - tt N °z i 1 1 R R The Commonwealth of Massachusetts 'M Department of I ndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 tiu www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): _ Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction --- 2.❑ I am a sole proprietor or.partner- listed on the attached sheet. 7: ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. F-1 Building addition [No workers' comp. insurance comp.insurance.$ required.] 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L 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.❑ Other comp. insurance required.] *Any applicant that checks box#1 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 then hire outside contractors must submit a new affidavit indicating such. Contractors 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 thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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$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 pe►jury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town offnciaL - - —City 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 Building Permit May 15,2000 SECTION 10-,STRUCTURAL PEER REVIEW(786 CMIRA40.11)' Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 -OWNERAUTHORIZATION.-,TO:.,BE.COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES'FOR BUILDING:PERMIT .......... ............... .................. ----------- .................................. .......... ......................... .......... as Owner of the subject property hereby authorize............-........ .......... .......... ............. ............ act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date Y" as Owner/Authorized 0 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 rider. p..paiqs ancLpena(ties of pequry Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION:SERVICES 10.1 Licensed Construction Superviso Not Applicable ❑ Name of License Holde License Number Expiratio Date Ll CI Signature Telephone SECTION 13--WORKERS'COMPENSATION INSU RANCE'AFFIDAVIT.(MI.G L;b.152,i;;§;I25C(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 - Noo 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 EKLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address _..,. ......... ... Expiration Date Signature µTelephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number i Signature Telephone I Expiration Date F..... ........:_ ... ....._... Name Area of Responsibility i ,....... Address Registration Number I Z Signature Telephone Expiration Date 9.3 General Contractor __,.... , ......_.______._..._ .._ .,...._ Not Applicable ❑ Company Name: Responsible In Charge of Construction _._.__.. _....,__.. .. W _ ..__.__.. __ _.. ,,_ .__.�..,_..,.._..,_.,_.....____...ry 3 Address i Signature Telephone Version.1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to re filled in by Building Department Lot Size Frontage Setbacks Front Side R:�------i R- Rear Building Height Bldg. Square Footage 0/ Open Space Footage % F-7 (Lot area minus bldg&paved parking) #of Parking Spaces A Fill: (volume&Location) A. Has a Special Permit/Variance� ndLiirng ever been issued for/on the site? NO 0 DON7 KNOW YES 0 IFYIES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON7 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-10 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Date Issued: 0 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: 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. Version 1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,OOD 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. 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 ❑ 213 - r ❑ 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 ❑ 513 U Utility E] Specify. _.w:.. ._..,,, i M Mixed Used❑ Specify: S Special Use El Specify. COMPLETE THIS SECTION.IF.EXISTING'BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/ORCHANGE 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(so St St ,_W...... ..;..,_._...._.. 1 nd nd 2 2 _...... __... .. ..,_.._ . ... „.,,.., „„„_..,„....F..,�...�..... _ 3rd3 E�_...._...._.. ......_._........._..._... .�...._._._.._...T.._, _ th 4th Total Area(sf) Total Proposed New Construction(sf) Total Height(ft) Total Height ft 7.Water Supply(M.Gk.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Pubkc-2 Private Zone Outside Flood Zone❑ Municipaa On site disposal system Version 1.7 Commercial Building.Permit May 15,2000 _ . Departure t use,onlX - City of Northampton Status pf PerEnEt �- ---i ` Building Department it Guff DrrVeway Permit 212 Main Street Sewer/SepticAvarlabtftty JUL 2014 �„/ Room 100 watefN\16 Avaifab,il orthampton, MA 01060 Twot ets of SCructura['Plans lectri Pi�mbing 8�Gas 3-587-1240 Fax 413-587-1272 Plo't/Slte Plans Northampton,MA 01060 Other.'Specrfyr 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 Property Address: - This section to be completed by office U, Pf-P- 4 Li'l i Map Lot Unit `•� ,p } Zone Overlay District Elm St:District` CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Signature `V Telephone ri t L/ q Lf 61 2.2 Authorized Agent: re� 1,e, Name(Print) Current Mailing Address. va �•.. �ii� c gS °J )3� 1 Signature i Telephone SECTION 3-ESTIMAl ED 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 3 Construction from-(6)* _..._._ ..,__..._._.__ .,w..., .. 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection _ ...._ _..__.. 6. Total=(1 +2+3+4+5) r i Check Number This Section For'Official Use Only Building Permit Number Date issued Signature: Building Commissioner/Inspector.of Buildings Date File#BP-2015-0057 APPLICANT/CONTACT PERSON RICHARD LAVALLEY ADDRESS/PHONE 27 NORWOOD ST GREENFIELD (413)326-1950 Q PROPERTY LOCATION 243 KING ST-SUITE 249 MAP 24D PARCEL 185 001 ZONE HB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: CLOSE UP 2 EXISTING DOORWAYS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 054203 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: proved 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 §tMT-uireof<uildif Kg6fficial 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. 243 KING ST-SUITE 249 BP-2015-0057 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D- 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: Building BUILDING PERMIT Permit# BP-2015-0057 Project# JS-2015-000099 Est. Cost: $595.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD LAVALLEY 054203 Lot Size(sg ft.): 86248.80 Owner: COOLIDGE NORTHAMPTON LLC Zoning: HB Applicant: RICHARD LAVALLEY AT: 243 KING ST - SUITE 249 Applicant Address: Phone: Insurance: 27 NORWOOD ST (413)326-1950 O Workers Compensation GREENFIELDMA01301 ISSUED ON.711512014 0:00:00 TO PERFORM THE FOLLOWING WORK.CLOSE UP 2 EXISTING DOORWAYS 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 Denartment 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 Sisnature: FeeType: Date Paid: Amount: Building 7/15/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner