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39A-023 (5) 441 PLEASANT ST BP-2016-1210 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 39A-023 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-2016-1210 Project# JS-2016-002079 Est. Cost: $25500.00 Fee: $179.00 PERMISSION IS HEREBY GRANTED TO: Const. Cuss: Contractor: License: Use Group: UNIQUE STRUCTURES & STONEWORK INC 023602 Lot Size(sq. ft.): 21344.40 Owner: COMMUNITY ENTERPRISES INC zonine: GB(100)/ Applicant: UNIQUE STRUCTURES & STONEWORK INC AT. 441 PLEASANT ST Applicant Address: Phone: Insurance: 67 POTASH HILL LANE (413)566-8920 WC HAMPDENMA01036 ISSUED ON:4/14/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.-PHASE PERMIT-NON-BEARING PARTITIONS ONLY PENDING FINAL ARCH PLANS & CONTROL CONSTRUCTION DOCUMENTS FOR THE BALANCE OF THE PROJECT 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 4/14/2016 0:00:00 $179.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner � s Version 1.7 Commercial Building Permit May 15,2000 Department use only r ity f Northampton Status of Permit: uI di g Department Curb Cut/Driveway Permit APR 142016 21 Main Street Sewer/Septic Availability oom 100 WaterNVell Availability 7 -# a pton, MA 01060 Two Sets of Structural Plans DDS T Ur r3U„. r,Un �r% n 240 Fax 413-587-1272 Plot/Site 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 Propertv Address: This section to be completed by office Map Lot Unit NQ Zone Overlay District 0 /07-5- _ Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Co mrvy ✓tit Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: . . .. Name(Print) Current Mailing Address: .......... Signature Telephone SECTION 3-ESTIMATED C NST CTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bV permit applicant 1. Building / g"pQ�CIU: O! a Building Permit Fee 2. Electrical (b) Estimated Total Cost of S �tQf Construction from 6 3. Plumbing ' ®pr��' Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 0., 6. Total=0 +2+3+4+5) �����©4Q® Check Number - - -- - _ This Section For Official Use Only Building Permit Number Date Issued Signature• Buil ommissioner/Inspe Cr of Buildings Date ►ase 4g m,(T ©l� Q�c� a,?c to� O A/ 416 N-be�(�� pq2 p/pptlS d/Vy ����• / ersionl.7 Commercial Building Permit May 15,2000 d'bcs+ CIAI s 2 7-h e b4 1-we 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 mg Change er❑ Brief Description Enter a pri f description he t'1' 'tai ► Q ��! 7`i°��S �a vt -p G� Oce�✓17-c? Of Proposed Work. . D T n SECTION 5-USE GROUP AND CONSTRUCTION TYPE q S e �QaV4 S E?"4' /e� 0'vM ere- USE rUSE GROUP(Check as applicable) CONSTR ION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 18 ❑ B Business 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I 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: _` l.N� 5 5 Proposed Use Group: ,•J i N C' S $ Existing Hazard Index 780 CMR 34):i. 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 2nd 2nd Q,d �...... 3rd 3rd 4m 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 ❑ Zone Outside Flood Zone❑ Municipal On site disposal system❑ Version 1.7 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): 1 Registration Number Addres Expiration Date Signatu 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 Not Applicable ❑ - Y --Company Name: — - — — -- — - — — ------- -- ---- ----- - Responsi In Charge of Constr ction Address6;p o r0.S i L CLKe E'�t ©ra3� Signature Telephone q v�R�J R RAY ® oTyv►ct , L ,c o vh i Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING 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 0 DON'T KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW � YES 0 IF YES: enter BookPage 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 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 NO _----- IF YES describe size,type and location': r 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. f f 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 0 No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I ( ( jCdlek as Owner of the subject property hereby authorize, .. .... . . to act on my behalf, in all m:01at..,,v,to work authorized by this building permit application. Signal f 0 n Date I, 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 of perjury,... .......-. _ Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder .'1_. � % A P � t� �j 60 C;Z,. . 6 � FQ 1--a SA I 1 L� 6--CL _ License Number fw Addr ! 1�7 <- � Expiration Date 91Y.17.... o ��G 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 No O ,. The Commonwealth of Massachusetts Department of Industrial Accidents r — Office of Investia ations -i��Fq —} - 600 Washing torn Street >: Boston, MA 02111 www.nnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Q S C �j Please Print LeKibl) Name (Business/Organization/Individual): aN 1 f/e C �y cTo �LJ 'J S �� �C���� � ' 1 Address: , raTIA ,54 /,/, LL `�'T /1 C C C5 City/State/Zip: ILlb- Lell 410 3,'� Phone #: 4113 9 Y(? —d� 6 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I ❑ employees (full and/or part-time).* have hired the sub-contractors 6. 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 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. F-1Buildingaddition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.[Ft,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 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. 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 nam 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: �^ @R� yl-y C-L _ r r2�— / . Policy#or Self-ins.Lic.#: i✓'���� 3 7a o°z✓ Expiration Date: �� Job Site Address: l �* �'� City/State/Zip: O Attach a copy of the workers' compensation policy declaration page(showingb 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 O"'VER 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 Offi ice of Investigations of the DIA for insurance coverage verification. I do hereby certify der the pains all enaltie of perjury tl at the information provided above is true and correct. Sienature: Date: Phone#: Of use only. Do not write in this area, to be completed by city or town offcciaL 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#: i �I 04/12/2016 04: 15 R i chard Green Insurance (FAX)413 566 0090 P.001/001 CGIF CERTIFICATE OF LIABILITY INSURANCEDATE(MWDDNM) 04/12/2016 THIS CERTIFICATE 18 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 pollcy(los)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 413-566-0026 413-566-0090 N M Richard R.Green Insurance Agen2y,Agency, Inc. Richard R.Green Insurance Agency, Inc. 8, - 0 Arc Net 413-566-0090 AX 32 Somers Fid jakss.richard reenina charter.net PRODUCER Hemoden, MA 01036 INSURER111 AFFORDING COVERAGE MAIC M INSURED INSURER I Mose-Underwriters Specialty Insuren Unique Structures&Stonework Inc. INSURERS:Liberty Mutual 67 Potash HILI Lane INBURERC: Hampden, MA 01036 INSURER INSURER E: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 7HE 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 CE11TIFICATE 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. INSRADDLINUORLTR TYPE OF{N6URANCB POLICYN MBIR POLICY[FP MM%OCIYYYY LIMITS GENERAL,LIABILITY EACH OCCURRENCE i A COMMERCIAL GENERAL LIABILITY DAMAGE EMI E REn 0 CLAIMS-MADE ©OCCUR MLDEXP one es9n S. MP0020002000211 1PJ28/2015 1212812015 PERSONAL A ADV INJURY 51,000,000 dENERALAGGREGATE 5 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP A(34 i POLICY PR M LOC y AUTOMOBILE LIABILITY COMBrNEDSINGLE LIMIT # (EA Occident) ANY LOWNE BoDILYINJURY(Per person) i ALL OWNED AUT06 BODILY INJURY(Per accident) _ SGHEDULfiDAU708 PROPERTY DAMAGE HIREDAUT06 (Persecldsnq 5 NON-TWNEdAUT09 6 UMBRELLA LIAM OCCUR EACH OCCURRENCE S EXCESS LIAn HCLAIMS-MADE AGGREGATE DEDUCTIBLE a RETENTION 11 WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY 7 Y r N B OFF(CER/MEMBER'"EXCLUOED7 SCurIVE NIA WC5-31 S-375961-025 04/28/2015 04/28/2018 &L,EACH ACCIDENT 1100,000 (Mandatary In NH) If es dSdnescribe under E.L.DI8EA8fi.EA EMPLDVE $100,000 OF E.LDISEASE-POLICY LIMIT 500,000 DESCRIPTION OF OPERATION /LOCATIONS r VIHICLIS(ANAch ACORD 101,Addldonal Remarks Schedule,If mon space Is required) Subject to policy terms and conditions. Officers of the corporation are excluded from coverage under the Workers Compensation policy. CERTIFICATE HOLDER Fax:413-587-1272CANCELLATION Town of Northampton SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Building department THE LXPIRATION DATE THEREOF, NOTICE WILL BE 13ELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Street Northampton, MA 01060 AUTHORIuoREPR439N E ®1988.2000 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD 14CN !% Got re �l5oartrs:�"�• r ; 1 -mac- Rest Rest Storage Rest Rocsm.` Room Room � � Office Rest AOA i Office I Closet �Ce ' Room Rece p ion i Downstairs Closet Conference 1 Office AreaRoom Closet Closet i • E Closet oil m !1 Stcafft N 3 Cody Lair i ' 1 Rest iRest 1 .�talfS _ . Room rJtrl I Room.. IrS ! Close# � I fit t?� �,�.. jt'�`r ,, Y O U ARE HERE Kitchen Furnace vacuatim, Map Exit - UVIce 1st AidKitFirst F tJe Fire Extinguishers Stairs I Office Office Electrical shut-offCloset" ll k Water shut-off