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17C-135 (8) t NOTICE , NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: AQUADRO & ASSOCIATES INSURANCE AGENCY INC NAME OF INSURANCE COMPANY PO BOX 357 NORTHAMPTON MA 01061 or 355 BRIDGE STREET - NORTHAMPTON MA 01061 ADDRESS OF INSURANCE COMPANY DT - CO 253J5963TCT00 12/31 /00 TO 12/31 /01 POLICY NUMBER EFFECTIVE DATES AQUADRO SAME AS ABOVE 413-584-0589 NAME OF INSURANCE AGENT ADDRESS PHONE AQUADRO & CERRUTI , INC TEXAS ROAD - NORTHAMPTON MA 01061 5/8/01 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 01996 G.Nell Companies,Inc. State and federal Employment Posters available directly from G.Nell Companies,P.O.Box 450939,Sunrise,FL 33345-0939 call toll he ao0-09a-a111 to reorder Workers'Compensation(Laminated(#R7E.MA20 (Non-Laminated)0117E-MA10 Required by.Mass.Gen.Laws Ch.152 Sec.21(tor all employers), �t tt/ut1 P�. O 0 Clif 7 of wart Ija11 ptiali 8 6 �xisxciinsctta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (licenste/permittee} with a principal place busine esidence at: � /�1CCe 5 T- � (poe )__ �Q- �l (&trees/city/s12&2J p) do hereby certify, under the pains and penalties of perjury, that: I am an employer providing the following worker's compensation coverage for my employees wo g on this job: PT Co aS37V 3T Id-31-01 / (Insurance Company) (Polio Number) (Expiration Daze) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date) If. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (arrach additioml shed ifnoariuy to include information pertaining to all codradm) ( ) I am a sole proprietor and have no line working for me. ( ) I am a home owner performing all the work myself. NOTE-pleaao be aware that while hcmeown=who employ persons w do nmiOtca „c,-,washvction or repair work oa a dwciling of not mono than throe traits in which the homeowner midca oc on the gccwnds appuctettaai therdo arc not gc=-ally maxi dered to be employ=under the wmd(cr's ooagcwAtioa Act(GL152,ss 1(5))�application by a homeowner for a i1ceme or p—ad may evid—the legal stshrs of an employer uoderthe Wodreez Compensation Ad. I understand tbat a copy of this ctatcmcat may be forwarded to the Dgwt.rni of In&itn l A=4=&Offs-of Insunaoo for the ooverage vcrificstioa and that failure to aocure coverage under section 25A of MGL 152 can Ind to tho imposition of criminal penalties oomist ca of a fine of up to S1,500.00 and/or imprison of tip to one ycar and civil pcn&Wcs in the form of a Stop Work Ord--acid a fim of 5100.00 a day against tier. For 61=tnental use only Permit Number —o gyp# Lot# FMi Slgnab=of censerlPermittee Law Version 1.7 Commercial Building Permit May 15,2000 3E` T �S RU: U A�* EER � 778 � 0, �1��_� �x� wMw !� m.Graw" ndependent Structural Engineering Structural Peer Review Required Yes......❑ No...... TEOS AGEN� OR�ONTRACTORTAPPL ESFaR�BI[D N'G P RMITp .drJk,:. .,#iii ro '}dG�GkM,'i" e ns / ys��` ��( ��5��✓��L as Owner of the subject property Hereby authorize TZ-V C� Z UT /�� to act on ny behalf, in all att rs relati work authorized by this building permit application. Sign u e of 0 Date ` `G,�'�L(d �� U/1 o'ac) ap1/r 1 as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my <nowledge and belief. ned under the pains and penaltiep of perjury.. Tint Name Signature of Own Agent Date �EC.TIOV1ONSTRI1CT10NxSERVICES 10.1 Licensed Construction Supervisor: Not Applicable 11 Name of License Holder: ,c a h AUJP-0- ^c 0 C - License Number �� /O�- 0 6� Address a�4�� Expirati n Date 3- L— Signature Telephone SE,.°. 0 3 VIIOFtICERS OMPENSATION IkkNS?'RA AFTFIDAVlWf G L c�52, 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...... ❑ Version 1.7 Commercial Building Permit May 15,2000 3 E�3ON 9=APR ,ESSIONAL DESIGN S I DD C[S. R' 1'° u u.< � . a 1C BULD G AID STU TU ES B�ErTOs P. �O1 ST C�1 IQt �CQNTROL PUR$UA (F. , ,0 R .R...iz O �, '_ Ga NTH,I I�r35 OOwM, OI�ENCLOSED�SPAC 3.1 Registered Architect: Not Applicable IV lame(Registrant): r Registration Number .ddress Expiration Date :ignature Telephone i2 Registered Professional Engineer(s): SO f !ame Area of Responsibility ddress Registration Nu er :ignature Telephone Expir 'on Date e' lame jr ' Area of Responsibility ddress �''f Registration Nu er 'ignature Telephone Expiration-Date lame Area of Responsibility ddress Registration N er ,ignature Telephone Expiration Date r lame Area of Responsibility ,ddress Registration tuber )ignature Telephone Expir,tion Date !.3 General Contractor 41Jgd 1 CF P RuT-r /� Not Applicable ❑ ,ompany Name: (kad r- - Zes onsible In Charge of Construction (/. IA4. address ©lv v 'A - d X02 )ignature Telephone T Version 1.7 Commercial Building Permit May 15,2000 7. Water pply(M.G.L. c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage D�posal System: Public Private ❑ Zone: Outside Flood Zone ❑ Municipal [�i"On site disposal system ❑ y 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size - 4/0 G ff 4 N (9 1-1 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 Perm iUVariance/Finding ever been issued for/on the site? NO DON'T KNOW _ YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES J 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 IF YES, describe size, type and location: D. r there any proposed changes to or additions of signs intended for the property ?YES_ No IF YES, describe size, type and location: • 1' A Version 1.7 Commercial Building Permit May 15,2000 �E T S R [CESWOA.114? ECTS LESS THAN 35'OOQ it Nat NE to S.',3.,„i,, .».+ ..:IkdffisF% G .�✓�asa,s�.r�!��M�.�:..;a.�?, a?x+,t a'F �,*,;�-'J w: ;,:. � nterior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ ❑ ❑ _xterior/}Iterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] �j Accessory Building Repairs �] 2 � ;ECTIQN 5 £ ,,»fit USE�+GOUP,AIVDIGONSTRt1CTION TYPE }.., USE GROUP(Check as applicable) CONSTRUCTION TYPE Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1 B ❑ Business ❑ 2A ❑ Educational ❑ 2B I ❑ Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1.3 ❑ 3B ❑ I Mercantile ❑ 4 ❑ Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ Utility ❑ ' Specify: I Mixed Use ❑ Specify: j�17` mil/ Special Use ❑ #q Specify: GqM,jLET ,THI SECT[ONtIF EX]STING„BUILDING''UNDERGOING;RENOVATIONS,ADDLTIONS AND/OR CHANGE tN USE d xisting Use Group: C� Proposed Use Group: G [_- dsting Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): >EGTION6 f3UILD1NG1H�EIGHTAND3AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION 0 S 0 I M'' door Area per Floor(sf) 15t St. �. !_- 2nd ,nd 3rd 3rd 4th 11 J` I14gd I m otal Area (sf) Total Proposed New Construction (sf) otal Height(ft) Total Height ft--•--•••-••--------- Version 1.7 Commercial Building Permit May 15,2000 City of Northampton Building Department 212 Main Street Room 100 Northampton, 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 "ECTION 1 SITE INFORMATION a. w `Thisxsect10 be co"m``feted b. a i ..1 Property Address: l�9 �GL✓�GLGt�C°�( .�� Zon: � era D�str' . !';, s r,c GB-D roc �r'r AK's• a w a", r3 - .. �EC'FION2 ' PROPERTY OWNERSHIPCAUTHOR.IZED�AGENT t c .!.� .',.i ?.1 Owner of Record: 73 ��e lame(Print) Current Mailing Address: y -44� �1 igna ure Telephone ?.2 Authorized Agent: Q Bc'X ,140 Ia A -D R -f CF R ,.TtiG. Jame(Print) Current Mailing Addre "–p- -D- A�� //3- s8y ~�aa signature Telephone �EON3EST[MATEDCONSTRUCTfON COSTS 0 tem Estimated Cost(Dollars)to be a,, Off�c�af Case Qnl �� com feted b ermit a licant ...�. 1. Building (a) Hulidrng Pe�m� e. Q 2. Electrical � Estrmattedota os of� xw Gonstcuctionfrom: , A:, 3. Plumbing Buildmg�Perm> e 1 . . � �... -' i 4. Mechanical (HVAC) , 5. Fire Protections '. r 6. Total =(1 + 2 + 3+4 + 5) DOQ @ti,cber MUM >This n For Official, sWeQe �a '" 1�,�e 3 .' e'er 5 Buxcfl I'er. mb�e'c ` � ,r Date 'ssued' 4 " Si Ila re,' M� rs ne e �e na 1099 dt Co� ui - WELL ST BP-2001-0952 G1S#: COMMONWEALTH OF MASSACHUSETTS tic_ 13 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0952 Project# JS-2001-1713 Est.Cost: $13000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Aquadro & Cerruti Inc 062358 Lot Size(sa.ft.): 56192.40 Owner: FLORENCE CASKET COMPANY Zoning: SI Applicant. Aquadro & Cerruti Inc AT: 16 BARDWELL ST Applicant Address: Phone: Insurance: P O Box 656 (413) 584-4022 Workers Compensation NORTHAMPTONMA01061 ISSUED ON:5122101 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR SIDING & ROTTED SILL PLATE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 5/22/010:00:00 47448,47449 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo