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24D-070 (23) Massachusetts Depa-tr ent of ptibltC Safety Board of Bui#ding lReg ttattons and *,inwards (ro-ri3.E"13t z;ttfb a.1S7a rl Ysxr F' ran CS-003398 CHARLES L LAWPE 93 BARRIE ROAD East Ungmeadoa MA >e=usn,s; r3 r OV20/2016 CROCK-1 OP ID: PM DATE(MM/DD/YYYY) ,d►coRV CERTIFICATE OF LIABILITY INSURANCE `.,.,.►�" 09/04/2015 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 NAME: Patricia Mahoney PHILLIPS INSURANCE AGENCY INC PHONE FAX 413-592-8499 97 CENTER STREET A/C No Ext:413-594-5984 LAIC,No): CHICOPEE,MA 01013 E-MAIL att /,,� hilli sns Chris Rivers ADDRESS:p y @P iurance.com p _ INSURER(S)AFFORDING COVERAGE NAIC# _ INSURER A:The Hartford 29459 INSURED Crocker Building Company Inc INSURER B: 186 Stafford St Springfield,MA 01104 INSURERC: INSURER D: 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 TYPE OF INSURANCE ODL UBR POLICY NUMBER MM DI LTR DIIYYYY MM/ DIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY 08UUNQT9436 04101/2015 04/01/2016 PREMISES Ea occurrence $ 300,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X PRO LOC $JECT F_ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00 Ea accident $ A X ANY AUTO 08UENQT9437 04/01/2015 04/01/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS PER $ ACCIDENT — X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS-MADE 08RHUQT9439 04/01/2015 04/01/2016 AGGREGATE $ 10,000,000 DED X RETENTION$ 10000 $ WORKERS COMPENSATION WC STA IT OTH- AND EMPLOYERS'LIABILITY X T RY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N A 08WEQT9438 04/01/2015 04/01/2016 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 A Rented/Leased Equi 08UUNQT9436 04/01/2015 04/01/2016 Rented Eq 200,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) RE: project at 228 King St. Northampton, MA The Stop & Shop Supermarket Co, LLC and KeyPoint Partners, LLC are included as additional insured when required by written contract. CERTIFICATE HOLDER CANCELLATION THESTOP SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Stop 8r Shop Supermarket Co ACCORDANCE WITH THE POLICY PROVISIONS. 1385 Hancock Street Quincy,MA 02169 AUTHORIZED REPRESENTATIVE JLr� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UIP. Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): C RV, l+a� p✓►-( Address: I�L S4_AV f'-c Jz-n City/State/Zip:<cp'o_� �� .t 41 � Phone #: Aryl an employer? Check the appropriate box: Type of project(required): 1. m a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. + 72_ ma ling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �� JZ-t�z .P Policy#or Self-ins. Lic. L,,L; C-;T' cl '4 3 Expiration Date: Ld I I -Z-0 I Job Site Address: ��s' vK�,� S;t2 €=°-i City/State/Zip: �46 w VtiL 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 thepIA for insurance coverage verification. I do hereby c t' unde th p ns��rj�ury that the information provided above is true and correct. Si nature: Date: Phone#• L11 3 " —) �—7— ON 3 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#: Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional < for work per the 8t' edition of the �� Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Date: r` Property Address: Zf. � � 's C'_ c� > y, fj�j .A4 Project: Check one or both as applicable: `I New construction Existing Construction Project description: /air MA Registration Number: Expiration date:�t—�� , am a registered design professional, and I have prepared or directly supervised a preparation of all design plans, computations and specifications concerning: Architectural [ ] Structural [ ] Mechanical [ ] Fire Protection [ ] Electrical [ ] Other for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports (see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to t A a `Final Construction Control Document'. Enter in the space to the right a"wet"or electronic signature and seal: A ON, Phone number: `�9<ry of MN �av mail: Building Official Use Only Building Official Name: Permit No.: Date: Version 06 11 2013 r SECTION 9: PROPERTY OWNER AUTHORIZATION Name and.Address of Property Owner Tim 6rnP ----........ Name(Print) No.arid Street Cih,/Town Zip Property Owner Contact Information: f Title Telephone No.(business) Telephone No. (cell) e-marl address � If applicable,the property owner hereby authorizes: Crocker Building Company,Inc. 186 Stafford Street Springfield MA 01104 Name Street Address City/Town State Zip to apply for and art on the property owner's Behalf,in all niatters relative to work authorized by this building�ermit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 13. _Otherwise provide construction Control forms(see section 107 in the code)as required. 10.1 Iegistered Professional Responsible for Construction Control(the professional coordinating document submittalsL ---- Siegfried Porth 413-529-9434 siegfriedp25gmail.com 6634 Name(Registrant) Telephone No. e-mail address Registration Number 116 Pleasant ST Easthampton MA 01027 Architect 08/31/16 Street Address City/"Town State "Lip Discipline Expiration Date -- ----...— -------..__...............___--------- General Contractor Crocker Building Company Inc. Company Name. Charles Lawrence SCO03398 exp 01/20/16 Name of Person Responsible for Construction License No. and Type if Applicable 186 Stafford Street Springfield MA 01040 Street Address City/Town State 7jp 413-737-7803 413-530-6092 cliarliel@crockerbuilding.cont Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'CoAt FN5Ar10N_tNSURANC_.E_AFFIpAVIT jM.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the?VIA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes❑ No b SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE ---_.------._.—.__Item Estimated Costs:(La"or - and Materials) Total Construction Cost(from Item 6)=$—_--___— _1,Building :$107,800.00-----_— Building Permit Fee 5.60/sf X 1785 sf=$1071 2.Electrical — $ 15,000.00 3.Plumbing $ '13000,00 Note:\%lininium fee 5_.--_._....._._..(contact municipality) 4.Mechanical (1-IVAC) $ 6000.00 Enclose check payable to r -___._._-__ _..-----..---_...._..__...._._.............._.___....__...- 7.'Mechanical e_�Othr 7000.00 ( _ —_.._. =..._....._._.._-----.._................_.......__...__..._ (ca�ntact municipality}and write check number here 6.Total Cost $148,800.00 SI T'ION 13:SIGNATURE OF BUILDING PERMIT APPLICANT �- ._.__._.._.._.._ . .--------_...___........-_..—._-----.._.._..—__... By entering in}'Warne below I el,y a est d>r the pains and penalties of perjury that all of the information contained in this application is true and a r• to th es no.+-ledge and understanding. Charles L Lawrenc — - project Manager 413-737-7803 8/28/15 Please print and sig e Title Tele.plione,No. Date 186 Stafford St Springfield MA 0.11.04 charlielk?crockerbuilding,coni Street Address City/'Gown State Zip Email Address 1 Municipal Inspector to fill out this section upon application approval-, _._._......._--_----------._----- _-- Name ^— Date T he Commonwealth of Massachusetts Department of Public Safety ivlassachUSeLtS State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ................... (This Section For Official Use Only) $Ltildirig Permit Number: Date Applied: Building Official: -El SECTION 1:LOCATION .......... 8 King Street Northampton 01060 King's Gate Plaza .and Street City/Town Zip Code Name of Building(if applicable) essors Ma # 24D Block U2 SECTION 2:PROPOSED WORK tion of MA State Code used 8th If New Construction check here❑or check-all that apply in the two rows below Existing Building X Repair❑ Alteration Addition 0 Demolition ❑ (Please fill out and submit Appendix 2) Change of Use X I Change of Occupancy X ..........................Are building plans and/or construction documents being supplied as part of tIvis permit application? Yes X No F-1 Is an Independent Structural Engineering Peer Review required? Yes ❑ No X Brief Description of Proposed Work. Criterion Child Enrichment provides Early Intervention services to children from birth to three years of age who have delays in development or who are at-risk for delays. Early Intervention services at the site will include Child Group, Parent-Child Group and Parent Support Group services.Children and parents will be participating in groups focused on enhancing development in a social setting. Parents will also receive support separately in a group designed to address their roles as caregivers of children with delays in development.The site will also provide assessment services to identify what areas of development need intervention.Center-based individual services cony also be provided for children who may need to use specialized equipment or receive additional therapy services.The site will provide office space for general operations of its program employees. This is not a child care program.Children are here only short periods of the day(I hour to no more than 2.5 hours at a time)and they cannot receive any more than 2.5 hours of services in a child group per week.Children tinder 18 months must attend the groups with their parent,,and most attend groups with parents. t, The program requires a 1-4 and E Usage for the occupancy eerfilicate. ...................... SECTION 3:COMPLETETHIS SECTION[F-EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 C\-[R 34) Cl Existing Use Group(s): —------ I Proposed Use Group(s): 14 and E SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) story 46000 No ............. ....................................... ___ __ change I N a No Total Areft(sq.ft.)and Total Height(ft.) change 20'+/- change SECTION 5:USE GROUP(Check as_2ppli able) -A: Assembly A-1 Cl A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 13: Business ❑ E Educational X F: Factory....._F-1 ❑ F20 H: High Hazard 1-1-10 1-1-20 H-3 ❑ 1-1-40 1-1-50 — 7-- 1: Institutional I-1 D 1-2 13 1-3❑ 1-4 X M,. Mercantile❑ R: Residential R-1 11 R-2❑ R-3❑ R-4❑ .......... ....... ............ ............. S; Storage S-1❑ C-2❑ U: Utilit-Y.—D------Ji�_ecw Use❑and please describe below: -Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check is applicable) IA 0 IB 0 IIA El 1113X 1 IIIA 0 IIJB 0 IV ❑ VA 0 VB 0 SECTION 7;SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit- Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site X A trench will not be Public X Check if outside Flood Zone❑ Indicate.municipal X required X or trench or specify: Private.❑ or indentify Zone:.......................... or on site system❑l permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: NIA1 tistc.-ric Commission 1,eview Process: Not Applicable X Is Structure ivithin airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No X Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code:8th Use Group(s):1-4 and E Type of Construction:1113 Does the building contain an Sprinkler System?:Yes Special Stipulations: File#BP-2016-0344 APPLICANT/CONTACT PERSON CROCKER BUILDING CO INC ADDRESS/PHONE 186 STAFFORD ST SPRINGFIELD01104(413)737-7803 PROPERTY LOCATION 228 KING ST-SUPPORT GROUP SERVICES MAP 24D PARCEL 070 001 ZONE HB(100)/URA(0)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid I x n B Buildinp,Permit Filled out Idu Fee Paid Tyn of Construction: INTERIOR FIT OUT FOR SUPPORT GROUP SERVICES l ` x i c i ob f) f'J New Construction R 12l r)I? 7 v (P o�c�fi 1 5 >'<T 1 Q►J Non Structural interior renovations Addition to Existing Accessory Structure Buildin Plans Included: Owner/Statement or License 067805 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: f✓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 __6� ZZ Z J _ �l Signature of 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. 228 KING ST-SUPPORT GROUP SERVICES BP-2016-0344 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D-070 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2016-0344 Project# JS-2016-000553 Est.Cost: $148800.00 Fee: $1071.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CROCKER BUILDING CO INC 067805 Lot Size(sq. ft.): 330184.80 Owner: TARLIN LLOYD D&JACOB RABINOV ARTHUR L SHERIN&SIDNEY R RAB C/O STOP&SHOP SUPERMARK Zoning: HB(100)/URA(0)/ Applicant: CROCKER BUILDING CO INC AT. 228 KING ST - SUPPORT GROUP SERVICES Applicant Address: Phone: Insurance: 186 STAFFORD ST (413) 737-7803 Workers Compensation SPRINGFIELDMA01104 ISSUED ON.912112015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INTERIOR FIT OUT FOR SUPPORT GROUP SERVICES - FIRE PROTECTION DRAWINGS PRIOR TO ROUGH INSP 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 9/21/2015 0:00:00 $1071.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner