22B-113 (2) _ Liberty
Workers Compensation And Employers Liability Insurance Policy Mutual-
INSURANCE
RENEWAL
Transaction Effective: 06/10/2014
Policy Number: WC 8681750 Policy Period: From 12:01 AM 06110/2014 To 12:01 AM 06/10/2015
Coverage Is Provided In PEERLESS INSURANCE COMPANY-A STOCK COMPANY NCCI Number:11355
Named Insured: Agent:
INGLEWOOD DEVELOPMENT CORP PHILLIPS INSURANCE AGENCY INC
AND INGLEWOOD REALTY TRUST
Agent Code: 2080901
Federal Employer ID Number: 043344946 Filing Number: 000082115
ENDORSEMENT SCHEDULE
Form Number Description
25-191 -0694 EXTENSION OF INFORMATION PAGE
25-193 -0694 ADDITIONAL WORKPLACES SCHEDULE
25-199 -1094 QUICK REFERENCE
25-217 -0304 MASSACHUSETTS CONSTRUCTON CLASSIFICATION
25-236 -0909 LETTER TO POLICYHOLDER-MA BENEFITS AND CLAIM AGG DED
FORM NC5000A0711 CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM
WCOOOOOOB -0711 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE
WC000114 -0114 NOTIFICATION END'T OF PENDING LAW CHNG TO TERRORISM
WC000403 -0484 EXPERIENCE RATING MODIFICATION FACTOR
WC000404 -0484 PENDING RATE CHANGE
WC000406 -0884 PREMIUM DISCOUNT
WC000406A -0895 PREMIUM DISCOUNT
WC000414 -0790 NOTIFICATION OF CHANGE IN OWNERSHIP
WC000419 -0101 PREMIUM DUE DATE ENDORSEMENT
WC000421 C -0908 CATASTROPHE OTHER THAN CERTIFIED ACTS OF TERR PREM ENDT
WC000422A -0908 TERRORISM RISK INS PROGRAM REAUTHORIZATION ACT DISCL EN
WC060301 -0484 CONNECTICUT APPLICATION OF WORKERS COMPENSATION INS
WC060303C -0711 CONNECTICUT WORKERS COMPENSATION FUNDS COVERAGE
WC200101 -0108 MA TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT
WC200102 -0114 MA NOTIFICATION END'T OF PENDING LAW CHNG TO TERRORISM
WC200301 -0484 MASSACHUSETTS LIMITS OF LIABILLITY ENDORSEMENT
WC200302A -0908 MASSACHUSETTS-ASSESSMENT CHARGE
WC200303D -0810 MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT
WC200306B -0613 MASSACHUSETTS LIMITED OTHER STATES BENEFIT ENDORSEMENT
WC200403 -0191 MASSACHUSETTS CONTRUCTION CLASS PREMIUM ADJUSTMENT
WC200405 -0601 MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT
WC200601A -0708 MASSACHUSETTS CANCELLATION ENDORSEMENT
WC310308 -0484 NEW YORK LIMIT OF LIABILITY
WC310319G -1013 NY CONSTRUCTION CLASSIFICATION PREMIUM ADJ PROGRAM EXP
Date Issued: 06109/2014
Copyright,1987 National Council on Compensation Insurance
25-194(06/94)(WC 00 00 01 A) INSURED COPY PGDM060D J12071 PEONLYST 00001107 Page 17
Workers Compensation And Employers Liability Insurance Policy
EXTENSION OF INFORMATION PAGE(continued)
Premium Basis Rate Per Estimated
Code Total Estimated $100 of Annual
Number Classifications Annual Remuneration Remuneration Premium
0063 State Premium Discount........................................................................................ $ -682.00
9740 Terrorism Risk Insurance Act of 2002 Coverage.................................................... $ 1 61 .00
0001 MA DIA Assessment 0.03400 ............................................................ $ 494.00
State Total Estimated Cost.................................................................................... $ 14,807.00
NY
5403 CARPENTRY NOC 21,854 15.6800 3,427.00
Sub-Total................................................................................................................ $ 3,427.00
9 812 Premium for Increased Limits Part Two ............................................................... $ 9 6.0 0
Sub-Total................................................................................................................ $ 3,523.00
9046 Contracting Class Credit-using factor 0.0000 0.00
...........................................
State Total Estimated Standard Premium ............................................................ $ 3,523.00
0063 State Premium Discount........................................................................................ $ -289.00
9740 Terrorism ............................................................................................ $ 11 .00
9741 Catastrophe(other than Certified Acts of Terrorism) ................................... $ 2.00
0932 New York State Assessment.................................................................................. $ 488.00
9749 NY WC Security Fund Surcharge $ 0.00
State Total Estimated Cost.................................................................................... $ 3,735.00
Date Issued: 06/09/2014
Copyright,1987 National Council on Compensation Insurance
25-191 (06/94)(WC 00 00 01 A) INSURED COPY PGDM060D J12071 PEONLYST 00001106 Page 16
'O�Libe
Workers Compensation And Employers Liability Insurance Policy Mutual,
INSURANCE
RENEWAL
Transaction Effective: 06/10/2014
Policy Number: WC 8681750 Policy Period: From 12:01 AM 06/10/2014 To 12:01 AM 06/10/2015
Coverage Is Provided In PEERLESS INSURANCE COMPANY-A STOCK COMPANY NCCI Number:11355
Named Insured: Agent:
INGLEWOOD DEVELOPMENT CORP PHILLIPS INSURANCE AGENCY INC
AND INGLEWOOD REALTY TRUST
Agent Code: 2080901
Federal Employer ID Number: 043344946 Filing Number: 000082115
EXTENSION OF INFORMATION PAGE
Premium Basis Rate Per Estimated
Code Total Estimated $100 of Annual
Number Classifications Annual Remuneration Remuneration Premium
CT
5403 CARPENTRY NOC 6,366 30.0500 1 ,913.00
Sub-Total................................................................................................................ $ 1 ,913.00
9 812 Premium for Increased Limits Part Two ....................... 21 .0 0
........................................
Sub-Total................................................................................................................ $ 1 ,934.00
State Total Estimated Standard Premium ............................................................ $ 1 ,934.00
0063 State Premium Discount.................................................................... -50.00
....................
9740 Terrorism ............................................................................................ $ 1 .00
9 741 Catastrophe(other than Certified Acts of Terrorism) ................................... $ 1 .0 0
0000 CT Second Injury Fund 2.750% ....................................................................... $ 61 .00
0000 CT Assessment Fund 1.700%........................................................................ $ 3 3.0 0
State Total Estimated Cost.................................................................................... $ 1 ,980.00
MA
5437 CARPENTRY-INSTALLATION OF CABINET 278,539 4.8 6 0 0 13,537.00
WORK OR INTERIOR TRIM
5606 CONTRACTOR--EXECUTIVE SUPERVISOR OR 57,200 1 .6 6 0 0 950.00
CONSTRUCTION SUPERINTENDENT
8810 CLERICAL OFFICE EMPLOYEES NOC 150,000 0.0 8 0 0 120.00
8742 SALESPERSONS, COLLECTORS OR MESSENGERS- 52,000 0.1 6 0 0 8 3.0 0
OUTSIDE
5403 CARPENTRY NOC IF ANY 9.8600 0.00
Sub-Total................................................................................................................ $ 14,690.00
9 812 Premium for Increased Limits Part Two ............................................................... $ 294.00
Sub-Total................................................................................................................ $ 14,984.00
9898 Experience Modification -using factor 0.99000 ................................. $ -150.00
State Total Estimated Standard Premium ............................................................ $ 14,834.00
Date Issued: 06/09/2014
Copyright,1987 National Council on Compensation Insurance
25-191 (06/94)(WC 00 00 01 A) INSURED COPY PGDM060D J12071 PEONLYST 00001105 Page 15
�: -• Liberty
Workers Compensation And Employers Liability Insurance Policy Mutual.
INSURANCE
RENEWAL
Transaction Effective: 06/10/2014 INFORMATION PAGE DIRECT BILL
Policy Number:WC 8681750 Prior Policy: 8681750 Date Issued: 06/09/2014
Coverage Is Provided In PEERLESS INSURANCE COMPANY-A STOCK COMPANY NCCI Number: 11355
1.Named Insured and Mailing Address: Agent:
INGLEWOOD DEVELOPMENT CORP PHILLIPS INSURANCE AGENCY INC
AND INGLEWOOD REALTY TRUST 97 CENTER ST
123 DWIGHT ROAD CHICOPEE MA 01013-1664 MA 0101
LONGMEADOW MA 01106
Agent Code: 2080901 Agent Phone: (413)-594-5984
Federal Employer ID Number: 043344946 Filing Number: 000082115 SIC Code: 1751
Other Workplaces not shown above: REFER TO ADDITIONAL WORKPLACES SCHEDULE
Entity of Insured-CORPORATION
2. Policy Period:
The Policy Period is from 06/10/2014 to 06/10/2015 , 12:01 AM Standard Time at the insured's mailing address.
3. A. Worker's Compensation Insurance:
Part One of the policy applies to Worker's Compensation Law of the states listed here:
CT, MA, NY
B. Employers Liability Insurance:
Part Two of the policy applies to work in each state listed in 3.A.The limits of liability under Part Two are:
Bodily Injury by Accident $ 1 ,0 0 0,0 0 0 each accident
Bodily Injury by Disease $ 1 ,0 0 0,0 0 0 policy limit
Bodily Injury by Disease $ 1 ,0 0 0,0 0 0 each employee
C. Other States Insurance:
Part Three of the policy applies to states, if any, listed here: All states except North Dakota,Ohio,Washington,
Wyoming and states designated in item 3.A.on the Information Page;
D. Endorsements and Schedules:
This policy includes these endorsements and schedules: See Extension of Information Page
4. Premium:
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.
Premium Basis Rate Per Estimated
Code Total Estimated $100 of Annual
Number Classifications Annual Remuneration Remuneration Premium
See Extension of Information Page
POLICY PREMIUM TOTALS
Total Estimated Standard Premium $ 20,467.00
0900 Expense Constant $ 338.00
Total Premium Discount $ -1 ,021 .00
Total Estimated Premium $ 19,784.00
Total Assessments/Funds/Surcharges $ 1 ,076.00
Total Estimated Cost $ 20,860.00
Minimum Premium $ 1 ,250-00 Deposit Premium $ 20,860.00 Adjustment Period: ANNUAL
Date: Countersigned by:
Authorized Signature
Copyright 1987 National Council on Compensation Insurance.
25-190(07108)(WC 00 00 01A) INSURED COPY PGDM060D J12071 PEONLYST 00001103 Page 13
The Commonwealth of Massachusetts
Department of Industrial Accidents
y Office of Investigations
I Congress Street, Suite 100
,W Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Inglewood Development Corporation
Address: 123 Dwight Road
City/State/Zip: Longmeadow, MA 01106 Phone#: (413)567-0069
Are you an employer? Check the appropriate box: Type of project(required):
1.X I am a employer with 12 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 g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.$
required.] 5. E] We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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 41 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.
lContructors 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 the policy and job site
information.
Insurance Company Name:Peerless Insurance Company
Policy#or Self-ins. Lic. #:WC 8681750 Expiration Date:06/10/15
Job Site Address: Florence Recreation Fields, Meadow St. City/State/Zip: Florence, MA 01062
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 certi&under the pains and penalties of perjury that the information provided ab ve is true and correct
Signature: Date:
Phone#: 413- 670069
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
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#:
Versiotil."Conunerciail 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
¢WNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
r j u
v
hereby authorize 731 lk wl( 41 Dn e`0'02—C 1 to
ae on^beha matflars relative to work authorized by this building permit application.
it /3
� J
Si u o(owner Date
as Owner/Authorized
Agent hereby declare that the statements and infomaation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed un a nd pen f penury. �-
Print Name
8ignatu 0wn'er,1Agent date
SECTION 12-CONSTRUCTION SERVIC
10,1 Licensed Construction SSupervisor* ' Not Applicable D
Name ofLicenseHolder: �ti/ kriS�Opyter E)wrgPX C-S_— C)5(354
License Number
is 3 L�� h�- ,ad , adoi rn o110(D o t o ao(tp
Address a Expiration
x{13-S69- oob9
Signature Telephone
l 1 Lti
SECTION 13-I OR ERS°c PENSATION SURANCE AFFIDAVIT(M.G.L.G,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
1'ersior l.? crrnrnereial Building Permit A.3ay 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 700 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable El
Nance(Registrant).
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Andress 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 Expiration Date
9.3 General Contractor
-t+LJ
0,1> Not Applicable CI
Company ame:
Resssble to Charge t Construction
A ra3
Signature Telephone
Versiotil.7 Commercial Building Permit May 15,2000
S. NORTH AMPTON ZONING I
Existing Proposed Required by Zoning
This Column to be filled in by
Building Department
Lot Size
Fronta,ze
Setbacks Front
Side L-_R: L R.,
Rear
Building Height
Bldg.Square Footage °110
Open Space Footage %
(Lot area mums Wig&paved
parking)
of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T 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 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
/—N
Needs to be obtained k_) Obtained 0 Date Issued.
C. Do any signs exist on the property? YES 0 NO 0
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
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 I acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Managem*pt Permit from the DPW is required.
Versioul.7 Conunercial Buildike Permit May 15,2000
SECTION 4.CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE I
Interior Alterations ❑ Existing Wall Signs ❑ Demolition[:] Repairs n Additions ❑ Accessory Building
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other
Brief Description Enter a brief description I
Of Proposed Work: Kak Z 4l:A/At;er2
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
.A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A F-1
A-4 p A-5 ❑ 1B ❑
8 Business ❑ 2A ❑
E Educational 1:1 2B ❑
F Factory ❑ F-1 p F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile 1:1 4 ❑
-R Residential ❑ R-1 0 R-2 ❑ R-3 El 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 58 ❑
U utility ❑ Specify:
M Mixed Use Specify: M vIV ~ S
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 I
BUILDING AREA EXISTING PROPOSED NE P CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
ist
2nd 2nd
3rd 3rd
4°h 41h
Total Area(sfj Total Proposed New Construction(sf)
Total Height(ft)
Total Height It
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 21 Private Zone Outside Flood Zone❑ Municipal C) On site disposal system 0
Versiot l.'7 Commercial Building Permit pia=15,2000
Department use only
("� M
fty of Northampton status of Permit:
1.J --' —_ ilding Department Curb Cut/Driveway Permit -
12 Main Street Sewer/Septic Availability
NOV 10 2014 11 Room 100 Waternllell Availability
ort iampton, MA 01060 Two Sets of Structural Plans
mil #,-, i3n, 7-1240 Fax 413-5137-1272 Plot/Site Plans''
_ Other Specify
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
'C&Ze.c.
Map � };�"` Lot 1 '. Unit
Zone a a Vj Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address
Signature Telephone
2.2 Authorized Agent: �r
�7
Name{Print} Currqrit Mailing Addr s
Ak ol�s6
Signature Telephone S6 Q®
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1, Building (a)Building Permit Fee
2. Electrical g0V (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. mechanical(HVAC) 161000 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 Commissionerlinspector of Buildings Date
File#BP-2015-0547
APPLICANT/CONTACT PERSON INGLEWOOD DEVELOPMENT CORP
ADDRESS/PHONE 123 DWIGHT ST LONGMEADOW (413)567-0069
PROPERTY LOCATION MEADOW ST
MAP 22B PARCEL 113 001 ZONE
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: CONSTRUCT PAVILION W/BATHROOMS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory,Structure
Building Plans Included:
Owner/Statement or License 051354
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
<I f 3
Signature o 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.
MEADOW ST BP-2015-0547
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22B- 113 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2015-0547
Project# JS-2015-001050
Est. Cost: $57900.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: INGLEWOOD DEVELOPMENT CORP 051354
Lot Size(sq. ft.): 1061121.60 Owner: CITY OF NORTHAMPTON
Zoning: Applicant. INGLEWOOD DEVELOPMENT CORP
AT. MEADOW ST
Applicant Address: Phone: Insurance:
123 DWIGHT ST (413) 567-0069 WC
LONGMEADOWMA01106 ISSUED ON.1111412014 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT PAVILION W/BATHROOMS
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 SiSnature:
FeeType: Date Paid: Amount:
Building 11/14/2014 0:00:00 $0.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner