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23B-008 (6) ACO® DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 7/20/2015 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). PRODUCER CONTACT NAME: Fe' Trudell Martin J Clayton Insurance Agency, Inc. AHCN No.EXI: (413)536-0804 q/C No: 1413)534-7074 1649 Northampton Street ADDRESS:ftrudell @mjclayton.com P. O. Box 989 INSURER(S)AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURER A:Harle sville Insurance Company INSURED INSURER B:Commerce Insurance Company Baystate Building Maintenance, Inc. INSURERC:Wesco Insurance Company 219 Burlingame Road INSURER D: INSURER E: Palmer MA 01069 INSURER F: COVERAGES CERTIFICATE NUMBER:2015 MASTER 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 ADDL UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE J=WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑ OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ SPP068028V 4/24/2015 4/24/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY PRO PRODUCTS-COMP/OP AGG $ JECT ❑LOC 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident B ANY AUTO BODILY INJURY(Per person) $ 50,000 ALL OWNED Ix SCHEDULED 14M�1BBI-M40 4/24/2015 4/24/2016 BODILYINJURY(Peraccident) $ 100 000 AUTOS AUTOS X HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ 100,000 AUTOS Per accident Uninsured motorist BI split limit $ 20,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 C OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) WWC3091202 6/15/2015 6/15/2016 E.L DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF NORTHAMPTON THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPT. ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel Sullivan/FMT ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) BAYSTATE BUILDING MAINTENANCE, INC. David Kachinski 219 Burlingame Road Palmer, MA 01069 Service 413-739-3800, Cell 413433-1715, Fax 413-284-0368 Allergy & Immunology July 17, 2015 Associates of New England Subject: Request for Waiver I request that you grant a modification to waive the requirement for control construction for the AIANE Office at 269 Locust St. in Northampton because the work is of a minor nature, 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. All work will be completed within the prescriptive requirements of 780 CMR. Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project" Respectfully, David Kachinski Baystate Building Maintenance, Inc. EXHIBIT A.-Premises MOOR UN Kra The mdec+ Etd certfom that Ih><pkn shows:the unit, 10,14, of the urn bete conveyec#;ow hWWdd4/ ad)**V:� and chat Ihey W and acaiat*depict Of the unri,'tts k afkxi,r+ita tend ckonaioi*ruin ontmme;md.him a cdni crl area f6"�f char+saeeeea.t*but IL CARLSON C u1Tj AR HTSM Chai*T.,.S�hMtt FLOOR PLAN OF: 2 WR Y. ir. Dl ti /' /E7S� i ;fanir�tt ,MA APPitbX AIWA:ia7 F b *r - 7C?'iAE SCAt.E: •. IIYII{�81ri1 .......... y or tx .• 17 EXHIBIT A P v I I I i I FIR5T FLOOR - UNIT R-I5 OF WT SCALE: 3/32` i'-0' KEY PLAN NTS The undersigned certtfles that this plan shows the unit designation of the unit being conveyed and iTSneciately adjoining unlit,and that they W and occurately depki the layout of the unit, tte location, area and dmensions,matn entrance, and hvnodate common area to which It has acc9sa as Wt CARLSON&SCHv9TT ARCI fTECTS,INC. Charles T. Sc mitt UM FLOOR PLAN OF itE-''RED q� R-19 THE SILK MILL s T a°mac► r o no.4060 DATE 7/23/09 FLOREFJCE.AAA u sQAWAW y APPROX AREA t90. FTJ o s a zo s+ � TOTAL: 3512 5.F. SCALE: o of M PAGE I l :^ The Commonwealth of Massachusetts Department of Industrial Accidents a — Office of Investigations a , 600 Washington Street Boston,MA 02111 4 y'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ' Please Print L eaibly Name(Business/Organization/Individual): ✓9 yt d K g 0l r 1)I Sk t Xq YS d9 47M eCX),J1 J Address: a/9 &/Y-hhsy­� /2e� City/State/Zip: k1) ew— G Phone#: y/�j Are you an employer?Check the appropriate box: Type of project(required): 1.9 ey1 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors _ 2.❑ I am a sole proprietor or_partrier- listed on the attached sheet. 7: Remodeling - _ - These sub-contractors have ship and have no employees 8. E]Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.1 -- required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions f oficers have exercised their 11. J.❑ I am a homeowner doing all work ❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.7 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 the policy and job site information. Insurance Company Name: pS CO' IiJ5 , Policy#or Self--ins.Lic.#: 1A_1, '- _T03 Z.222 Z Expiration Date:�� Job Site Address: a(05 l'OGd3 d' Sd- City/State/Zip: Z 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 perjury that the information provided above is true and correct. Sienature• /L,J�/�-� Date: Phone#. �.� �3.3 l7/ Of use 01111). Do not write in this area, to be completed by city or town official ---- —City-of 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#: Versionl.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 AUTHORIZATION­TO;BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR:BUILDING PERMIT ___ .w._ __ .,.. ..w........ _.< 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. Signature of Owner Date 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_ofperjury_ _ .__ _.. __... .,_._.._. Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: .1�./`G�l I Ic\4�'i�t 1 k License Number As _ � Expiration D to Sign at Telephone SECTION 13 WORKERS'COMPENSATION INSURANCE AFFIDAVIT;(M 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 0 Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIO.N.RZE I RVICES-FOR BUILD.INGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR.1,16(CONTAINING. .MORE THAN 35,000 C.F.OF ENSLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): ............ _.._.._.._.-.__._-.._..........._r_,_ Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility ...........- ......................... Address Registration Number Signature Telephone Expiration Date I 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 --—--- Not Applicable ❑ Company Name: Responsible In Charge of Construction Signature Telephone Versionl.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 Mµµ f i" Side L:° m R:__ Rear _� ' _�....... �l Building Height Bldg, Square Footage Open Space Footage %° . -- _ (Lot area minus bldg&paved #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: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES ..__ _ _. ..... __.._ 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 Q Obtained , 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,exca tion, 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.35,000 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 des ri tion here. CU4-• -A �' �o�' o )e d- 1'�5'4-�Iwy'UG"' Of Proposed Work r+�•-+e: O ��' T"�' �f 3 � �xGy`� 5��11�De Way�c s �-�'o•v►S 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 ❑ 2B f ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High 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 ❑ Specify:I t M Mixed Use L1 Specify: �/� O i1GGS , s)- S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOINGRENOVATIONS;ADDITIONSAND/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(so 5ry.. .........__, __.........._., 15t 2nd 2nd 3 .. 3rd rd 4 n ._..,.__,,___._ _ _— 4th Total Area(so Total Proposed New Construction sf)_ _.._. ,_.._..__ _ ....._... Total Height(ft) - ------- Total Height ft- r.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: 'ublic ❑ Private ❑ Zone` Outside Flood Zone❑ Municipal ❑ On site disposal system[] Version1.7 Commercial Building.Permit May 15,2000 Departure t use,only - of Northampton Stags oPermEt z ding Department Curb Cut/Dnveway Perm . . 2 9 2015 IJ� 2 Main Street _ Sewert8epfic Avajta6F[rfy Room 100 WaterlWepAvaifabl1itp Electric F u N ,r �-1 � .:J�!Pff mpton, MA 01060 Two Sets of StructuraF PIanS -1240 Fax 413-587-1272 Plot/Srte Plans Other Speefy r. 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' A A171 T section to be completed by office 1.1 Property Address: ' &9 Lae_ d—LS d-- Map Lot Unit Zone Overlay District Elm'St:District CB District 777 SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:GAO Name(Print) Current Mailing Address: _ Signature Telephone 2.2 Authorized Agent: ..m. .__.................. ...................__..........._----- _ Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED:CONSTRUCTION:COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant - 1. Building ��� ��, (a)Bulding Permit.,Fee 2. Electrical (b) Estimated Total Cost of Consfruction from(6) 3. Plumbing Q Building PermitFee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) 3�fOQ• a o Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File# BP-2016-0110 APPLICANT/CONTACT PERSON DAVID KACHINSKI ADDRESS/PHONE 219 BURLINGAME RD PALMER01069(413)433-1715 PROPERTY LOCATION 269 LOCUST ST-UNIT RIB- 1ST FLR ALLERGY&IMMUNOLOGY MAP 23B PARCEL 008 000 ZONE SI(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 1051 ft Fee Paid Typeof Construction: CONVERT TO ONE UNIT(RIB&R1E) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildine Plans Included: Owner/Statement or License 105709 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR ATION PRESENTED: pproved 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 D olition Delay Signa ure of Bui in 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. 269 LOCUST ST-UNIT RIB- 1ST FLR ALLERGY&IMMUNOLOGY BP-2016-0110 GIS#: COMMONWEALTH OF MASSACHUSETTS MapBlock: 23B-008 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2016-0110 Project# JS-2016-000200 Est. Cost: $3800.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID KACHINSKI 105709 Lot Size(sq. ft.): Owner: KACHINSKI DAVID Zoning: SI(100)/ Applicant: DAVID KACHINSKI AT. 269 LOCUST ST - UNIT R1 - 1ST FLR ALLERGY & IMMUNOLOGY Applicant Address: Phone: Insurance: 219 BURLINGAME RD (413) 433-1715 WC PALMERMA01069 ISSUED ON:712912015 0:00:00 TO PERFORM THE FOLLOWING WORK.CONVERT TO ONE UNIT (R1 B & R1 E) 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 Occupant Signature: FeeType• Date Paid: Amount: Building 7/29/2015 0:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner