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24D-121 (4) 1 0 DATE(MMIDD/YYW) A�° CERTIFICATE OF LIABILITY INSURANCE 9/29/2014 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 endomemen s). N PRODUCER - NA : T Rim Ly Risk Strategies Company PHONE . (781)986-4400 FAx .(781)963-4420 LAIC go_ 15 Pacella Park Drive MAIL .kly@risk-strategies.com ADDRESS Suite 240 INSURERS AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURERA.AmGuard 42390 INSURED INSURER B Dale W. Crane INSURER C: 70 Bourne St INSURER D: INSURER E: Three Rivers MA 01080 INSURER F: COVERAGES CERTIFICATE NUMBER:CL14 9 2 9 8 3 7 11 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. IN SR TYPE OF INSURANCE POLICY NUMBER DCY EFF MMIU �EX LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence CLAIMS-MADE F—I OCCUR -MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ ri POLICY PRO LOC $ AUTOMOBILE LIABILITY EaMBI n SINGLE LIMIT de ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Pera d $ UMBRELLALIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ �4DED I I RETENTION$ $ A WORKERS COMPENSATION ALE W CRANE IS X WC STATU- O R AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE ANY EXCLUDED E.L.EACHACCIDEN7 $ 100,000 OFFICER/MEMBER EXCLUDED? a NtA AWC446692 /29/2014 /29/2015 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) Evidence of insurance only. 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. Dale W Crane DBA Crane Exterior Design AUTHORIZED REPRESENTATIVE 70 Bourne Street Three Rivers, MA 01080 _ Michael Christian/lCIL ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. IN3025(201005).01 The ACORD name and logo are registered marks of ACORD City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined' by MGL c 111 , S 150A. Address of the work: 0��1 �''� ✓� The debris will be transported by: /-7454-4-7- The �. ? The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ® No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, V i F 2 GF'-Z 4*VT 5 as Owner of the subject property W �i Xr hereby authorize authorize ^I!.<= to act on7� ehalf, i all m rs relative to work authorized by this building permit application. Signat a of Ow Date 1, 0,4.— Cyr 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 un �ps an d penalti ?Of rjury. � r C�f- Print ' Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable t❑ Name of License Holder: `C✓f11 '� ��`!�� !U l� License Number A ess Expiration Date 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 0 No 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 Expiration Date 9.3 General Contractor )� 6 Not Applicable ❑ Company Name: �^ ' Responsible In Charge of Construction Addre Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONiRG7 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 Q DON'T KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES ® NO 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 1 acre? YES ® NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE .:t , Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration JO Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description Enter a brief description here. Of Proposed Work: ,4�5yq-z_ JE75KC SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 p A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 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 ❑ 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) 1St 1 St 2nd 2"d 3rd 3rd 4th 4th 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 ❑ I Zone Outside Flood Zone[] Municipal ❑ On site disposal system❑ Version 1.7 Commercial Building Permit May 15,2000 n, City of Northampton "Building Department 2 ��5 212 Main Street Room 100 LL—, bin -- rthampton, MA 01060 Two bf�Ci� k g&Gas Inspections Northam ton,MA a 41 -587-1240 Fax 413-587-1272 Ploys Iii{ Ins 4 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��oT`v'�i i` f V�/LTi� ,�'f"v Map Lot Unit � Zone Overlay District Elm St District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /'¢ M Name(Print) Current Mailing Address: in 2 Signature Telephone 2.2 Authorized A ent: _ ElJ3,#:- A0��ear'�� /�� i��ojq-e'/Op'e-> Name(Print) Current Mailing Address: ' 7 Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 1 k `�-3 (a)Building Permit Fee 2. Electrical v/ (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection / 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Onl Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0895 APPLICANT/CONTACT PERSON DALE W CRANE ADDRESS/PHONE 70 BOURNE ST THREE RIVERS01080(413)374-5917 PROPERTY LOCATION 200 KING ST MAP 24D PARCEL 121 001 ZONE HB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: INSTALL REPLACEMENT WINDOWS&VINYL SIDING New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included• Owner/Statement or License 102408 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO AMATION 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 Signa of i d O 1 1 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. 200 KING ST BP-2015-0895 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D- 121 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate og ry^replacementwindows/siding BUILDING PERMIT Permit# BP-2015-0895 Project# JS-2015-001732 Est. Cost: $15173.00 Fee: $90.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DALE W CRANE 102408 Lot Size(sq. ft.): 11586.96 Owner: VALLEY BUILDING COMPANY INC zoning: HB(100)/ Applicant: DALE W CRANE AT: 200 KING ST Applicant Address: Phone: Insurance: 70 BOURNE ST (413) 374-5917 WC THREE RIVERSMA01080 ISSUED ON:312612015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS &VINYL SIDING 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 3/26/2015 0:00:00 $90.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner