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23D-124 (12) Property Address: Contractor Name: Address: City, Stater Phone:°�L Property Owner Name: ------------ - ----Address------� __-- - ��`���� -------__------- - ----- -___,---- - City, State: contractor)attest and affirm that the building 1 intend to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date Q .•a�ua�i=,,, ran,u.ra<Il,urt Date:1/142015 1:10:26 PM Paoe:2 of 2 ^� URBA&SO-01 CMASCIADRELL CERTIFICATE OF LIABILITY INSURANCE DA T MMID INYYYY) 1//14/214!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: McClure Insurance Agency,Inc. PHONE FqX — 103 Van Deene Ave. Arc No E.1:(413)781-8711 ac Ne: (413)731-8548 West Springfield,MA 01089 E-MAIL — ADDRESS: INSURERS)AFFORDING COVERAGE NAIC At INSURER A:Acadia Insurance INSURED INSURER B:A.I.M. Mutual Insurance Co. Urban$Sons Insulation Co.,Inc. INSURER C: 385 Liberty St. INSURER D: Springfield,MA 01104 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 LTR TYPE OF INSURANCE POLICY NUMBER MMlDDNYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00( CLAIMS-MADE E�I OCCUR CPA0188079-18 ' 08/0112014 08101/2015 PREMISES Roccurrence S _ 250,00( MED EXP(Any one person) S 5,00( PERSONAL 8 ADV INJURY S 1,000,00( GE.N't.AGGREGATE LIMIT APPLIES PER: GENERA(.AGGREGATE $ 2,000,00( POLICY 1K PECOT- E-1 LOC PRODUCTS-COMP/OP AGG S 2,000,00( OTHER: S AUTOMOBILE LIABILITY Ea aB COMNED ent)SINGLE LIMIT $ 1,000,00( A ANY AUTO MAA0362971-14 08/01/2014 08/01/2015 BODILY INJURY(Per person) S ALL OWNED X AUTOS SCHEDULED AUUTOS S BODILY INJURY(Per accident) S 1,000,00( X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE S AUTOS Per accident S ----- X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 1,000,00( A EXCESS LIAB CLAIMS-MADE CUA0208447-18 08/01/2014 08/01/2015 AGGREGATE S 1,000,00( DED RETENTIONS g WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER B ANY PROPRIETOR/PARTNER/EXF-CUTIVE YI'��"� NIA WMZ80080055562015A : 01/0112015 01/01/2016 E.L.EACH ACCIDENT S _500,00( OFFICER/MEMBER EXCLUDED? U ------ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S 500,00( If yes.describe under ---- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,00( DESCRIPTION OF OPERATIONS r LOCATIONS f 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I I OWNER AUTHORIZATION FORM . s i I (Owner's Name) owner of the pcuperty located at (Property Address) La IQLC-K)C-e Lob (Property Address) hereby auttrorize (Subcontractor) an authortmd subcontractor for RISE Engineering,to act on my behalf to obtain a bulding perrn*and to perform work on my property. Owner's Signature _._.. Date r f� 0 U4L The Commonwealth of Massachusetts `` Department of Industrial Accidents Office of Investigations 600 Washington Street kv Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual):\�) �,it:%-" Address:7_-I'�s .5, � City/State/Zip: Phone#: ; Are you an employer?Check the appropriate box: 1�I am a employer with i'k 4. E] I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. E] 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. ❑ We are a corporation and its 10.0 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 1 12.F] Roof repai t c. 152 rs insurance required.] , § (4)�and we have no employees. [No workers' 13.JZ 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: \�1 \� �\V�� i1 Policy#or Self-ins. Lic.#:`VNl t-t�_-2_St QlnM°Qf ��\CC Expiration Date: Job Site Address: c Q �� ���� �� City/State/Zip T �'(�, 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby-certify under the pains an allies of er'ury that the information provided above is true and correct Si mature: Date: Phone#: r,-- Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations W r !`: 600 Washington Street -, Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1.El I am a employer with � 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors r.partner- listed on the attached sheet. 7. ❑ Remodeling ?.❑ I am a sole proprietor o ship and have no employees -- These sub-contractors have g. E]Demolition working for me in any capacity. employees and have workers' 9 E]Building addition [No workers' comp. insurance comp.insurance.$ 5. 7 We are a corporation and its 10.�Electrical repairs or additions required.] Cr officers have exercised their I LE]Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.0 insurance required.] t c. Roof repairs 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box III must also fill out the section below showing their workers'compensation policy information. r 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 narrr 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: — 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 perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use onh'. Do not write in this area, to be completed by city or town officiaL -- Permit/License# - —City or`Town: _. - - _ ._ - 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#: Version l.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 I, ..... .._ .... .._. ........ ....._.._.....,_ as Owner of the subject property hereby authorize __ _ __._. _a... ... _.. ---- .... 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 and penalties of penury w Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION.SERVICES 10.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Sig a ture Telephone SECTION 13 WORKERS.' 5V ( C(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 0 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 1-16(CONTAINING MORE THAN 35,000 C.F.OF EKLOSED SPACE) 9.1 Registered Architect: --------- Not Applicable ❑ Name(Registrant): __ .._ ._. __._ .n.,___,_._,_._____. ..................... _ .w,._...>_ .._._ ..... 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 I Expiration Date 9.3 General Contractor _. Not Applicable ❑ Company Name esponsi le In Char of Construction ...:...,..,..__ . .. . _. _. ..._._ .... Addr_e el Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning . This column t 0' filled in by Building Department Lot Size __.... ..:..__. _ _ _ ....... ____•.w._,..._ ...... w Frontage _.... _ _ ..._._ _. .... .__..__ , ....__._. . __......__...._ .. Setbacks Front Side L.: _.___ R.>.._ Rear Building Height "' ✓" Bldg. Square Footage __. °/U _. r Open Space Footage _ % — — (Lot area minus bldg&paved #of Parking Spaces I Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES Q IF.YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW } YES 0. ._, IF YES: enter Book ' Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 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. 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 0 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[I New Signs El Roofing F-1 Change of Use❑ Other� J 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 ❑ 2B 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: M Mixed Use ❑ Specify: S Special Use F-1 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 OFFICE USE ONLY BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) St 1 sr 2nd 2nd _...,. _ _...._._ _.....,. ...,.__._:. ......., 3rd 3rd _._._:_.._.m.._ ..__._._._.. _..,_... :....._._ m 4 4 t " Total Area (so 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 ❑ Zone „ Outside Flood Zone❑ Municipal ❑ On site disposal system E] i alol y� ,1000 -- `—` - Departure t use,only of Northampton status of t=ermit BWliding Department curb`Cuf/DrivewayPemlit" i� 20� �12 Main Street SewerJSeptiGAua�laGrilfy 1 U u4 "i i ROOM 100 WaterlWell Availability L_- t mpton, MA 01060 Two Sets of,Structure[Plans' Electric. F r. hOraA 1�Rb �_r� -5$ -1240 Fax 413-587-1272 Ploii8ite 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 Map Lot Unit Zone Overlay District -- _:. _..,_._._ __._ _._ _ _ , ... _,.�_.,. . _N 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 A ent Name(Print) Current Mailing Address Signature Telephone SECTION 3' ESTIMATED CONSTRUCTION C0 S 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 Construction from 6 __.__.. ._. ... 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection S. Total =(1 +2+3+4+5) Check Number eOC� This.Section For Official Use Only Building Permit Number Date Issued Si nature: . Building Commissionerllnspector of Buildings Date 176 FEDERAL ST BP-2016-0221 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D- 124 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-0221 Project# JS-2016-000377 Est. Cost: $3630.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: URBAN & SONS INSULATION CO INC 101877 Lot Size(sq.ft.): 20952.36 Owner: ALTER ANNA&BRUNO TRINDADE Zoning: URB(100)/ Applicant: URBAN & SONS INSULATION CO INC AT. 176 FEDERAL ST Applicant Address: Phone: Insurance: 385 LIBERTY ST (413) 732-3922 WC SPRINGFIELDMA01104 ISSUED ON.812412015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL WALL INSULATION 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 8/24/2015 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner