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22B-051 199 PINE ST-PRO CORP BP-2007-0634 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22B-051 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2007-0634 Project# JS-2007-000959 Est. Cost: $6500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HAMPSHIRE CONSTRUCTION CO INC 017276 Lot Size(sq. ft.): 6272.64 Owner: PRO CORPORATION PMC Zoning: NB Applicant: HAMPSHIRE CONSTRUCTION CO INC AT. 199 PINE ST - PRO CORP Applicant Address: Phone: Insurance: P O BOX 327 (413) 247-5024 WC NORTH HATFIELDMA01066 ISSUED ON:12/15/2006 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 20 X 14 OVERHEAD DOOR IN EXISTING WALL OF METAL BLDG 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 12/15/2006 0:00:00 $50.004722 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo File#BP-2007-0634 APPLICANT/CONTACT PERSON HAMPSHIRE CONSTRUCTION CO INC ADDRESS/PHONE P O BOX 327 NORTH HATFIELD (413)247-5024 PROPERTY LOCATION 199 PINE ST-PRO CORP MAP 22B PARCEL 051 001 ZONE NB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvneof Construction:_INSTALL 20 X 14 OVERHEAD DOOR IN EXISTING WALL OF METAL BLDG New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/Statement or License 017276 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INtPRMATION 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 X _ �Z Signature of Building Official o 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. Version 1.7 Commercial Building Permit May 15,2000 .. ePa.. �. as ria.. nl rtha. pt yMO2r, s , Building Department Er)c CtlflDrtvewa $errrti s; 212 Main Street Sewer/S pug tlabl Room 100 WaerlWet vat ,b It 1 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 PlotfS`t1Pan Wiz' ..,- �' - APPLICATION TO CONSTRUCT, REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING `SECTIONSITEINEORMAT� ION -1 1-Property Address ,T Thts sectton;to be completed ay.o lice ;. • d ra St•t 1 I , ,„.-;V � 1 .ZZ, n0 [.� O F/ O C AJ C SOverlay Dtstn)cti [�. �/'1 v. rri �wt', �sTJ� .m tA'E +. 'y`F-4YSa d •�.F �`7.ir-bT k J , ' , gT`*'�'�`br^7..ru.g�i. >L:,ezt.�.-w••�:�°�F�i.t��k-r-^hh�9sN��..t�� �� R.a. SECTION 2.-PR( PERTY OWNERSHIP%AUTHORIZED`AGENT 2.1 Owner of Record: A)Z "ILL 1,40Lpl NCa S LLC. i iC210 1 Col'Z71GE LLI 5T. , FLOIZEWL12- i Name(Print) I' L— Current Mailing Address: Signature Telephone 2.2 Authorized ent: Name(Print)' t n ,�n�yQ.f^ e s f=��Cunent Mailing Address: Co� Signature Telephone 1</7 ` J 5_ SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official:;Use Only completed by permit applicant 1. Building LCA CHO-- (a)Building PetmitFee: 2. Electricalioo (b)�Estimated-Total,Cost of I . _ `Construction from. 6 �— 3. Plumbing i Bwlding Perrriit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total (1 +2+3+4+5) (_ Check.Number a :This Sectiori'For Official Use Only $uildtng,Permtt:�tunbeG`� _ . `';MDate �° Issued: r Signature: Building Commissionedlnspectorof:Buildings :`Date ` r Version 1.7 Commercial Building Permit May 15,2000 SECTION 4.�CONSTRUGTION SERVICES FORPROJECTS CESS_ FIAN:35,000 CUBIC-EEETOF'ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing El Change of Use❑ Other-* Brief Description Enter a brief description here. Of Proposed Work: /Al574LJ__ 0. L1,C;boX /A/ EXT 1,14LL. OF EX/`3' y&-7AL i3(J/LD/NG,,j 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 ❑ 113 ❑ ..__.. B Business ❑ 2A ❑ E Educational ❑ 213 I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C H Hi h Hazard ❑ 3A ❑ Institutional ❑ I-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 UtilityE] Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS.SEGTION;IF=EXISTING BUILDING UNDERG.OING;RENQVATIONS,.JADDM.ONS"AND/OR.CHANGE IN.USE Existing Use Group: I Proposed Use Group: _ -2- Existing Hazard Index 780 CMR 34):' Proposed Hazard Index 780 CMR 34): i SECTION"6 BUILDING"HEIGHTAND AREA; " BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION r � rtE Floor Area per Floor(so N(� "A N ea Est 1st +�c' 'r++ .F�r-n•'!n',y "nr^•r�.n A ..�Ft iys..:'�u nd 2nd ..,�^2;T"'st'�k�-+. N4` r t � "" '>, 2 rd I 4� , 4 ` y Total Area(so Total Proposed New Constructiongg s "' � '�'� �,,Fx.+'"-5 �k.+ n ply , i Tt+'"r• ,„�exh4�T '�`lv Rll x?�jv Total Height(ft) � _ ; �,{ Fob; � � z Total Height ft Rif 7.Wa er Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewa a sposal System: Public Private ❑ Zone! 1 Outside Flood Zone Municip On site disposal system❑ Version 1.7 Commercial Building Permit May 15,2000 ; ORTEic11ZONG t•• Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size I I Frontage ' t I Setbacks Front I I l Side L:= R:= L= R:i J Rear L--J ButTding Heigh-t`-- Bldg.Square Footage % r— �— Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: i volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW -1�5r YES 0 IF YES, date issued: j IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW AM– YES 0 IF YES: enter Book i Paged and/or Document#i B. Does the site contain a brook, body of water or wetlands? NOZ5, DONT KNOW O YES ! IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtainedQ Obtained , Date Issued: j C. Do any signs exist on the property? YES Q NO ®' IF YES, describe size, type and location: I D. Are there any proposed changes to or additions of signs intended for the property? YESQ NO IF YES, describe size, type and location: j 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 Q ' 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 9-PROFESSIONAL DESIGN.AND'CONS.T.RUCTiON SER ICES- i=0R BUiLDiua Ai3D aiRUi i Jr«� CT .T...v CONSTRUCTION CONTROL PURSUANT'TO.780-CMR 116(CONTAIN(NG MORE TH414:35 OOQ'C F OF':ENCLOSEDvSPACE) 9.1 Registered Architect: Not Applicable � I i Name(Registrant): Registration Number Address i Expiration Date I Signature Telephone 9.2 Registered Professional Engineer(s): ,. ---- i i I Name Area of Responsibility l ; f Address Registration Number � � I Signature Telephone Expiration Date Name Area of Responsibility Address II Registration Number ! I Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility i Address Registration Number � I � Signature Telephone I Expiration Date 9.3 General Contractor l ,yAM P5�11—pi5 06/ J67'R()G'7101J Gy. � � Not Applicable ❑ Company Name: I205CaT T PSA V-?LE=7-r Responsible In Charge of Construction 32'4 W E 57 STZEE7 1l/02714 1147,�/E/7� M4 o/a G(o Addre l Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 SEC-TION 10-S;r RUCTURALREER REVIEW.-(780 CMR 11011) Independent Structural Engineering Structural Peer Review Required Yes O SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED: WHEN OWNERS.AGENT.OR CONTRACTOR APPLIES FOR.BUILDING,PERMIT ►,...J as Owner of the subject property � I hereby authorize 'to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date (_.. �a as Owner/Aw#=Ar� 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 penury. Print Name Signature of Owner Date -SECTION 12-CON TRUCTION SERVICES 10.1 Licensed Construction Supervisor: �'' �7- I Not Applicable ❑ /,,, Name of License Holder:i ��� T / 7 1 xA� ( Z_E 7� 10 / 7 -2 7 `e i License Number F3 oX NtiI:!TN UA f F"l L:L :�, hA , a1 o uo �- Add r s � /� Expiration Date Signature Telephone SECTION 13-WORKERS",COMPENSATION:.INSURANCE"AFFIDAVIT',(M:G.L c 152,:;§ 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 b •Iding permit. Signed Affidavit Attached Yes No r i t� Z Uffice of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ler-ibly Name (Business/Organization/Individual): HAMPSHIRE CONSTRUCTION CO. , INC. Address: 327 West Street City/State/Zip: North Hatfield, MA 01066 - Phone #: 413 247-5024 Are you an employer? Check the,appropriate box: Type of project(required): 1.® I am a employer with 14_ , . 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. $ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ 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' 13.0 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 tContractors 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: General Casualty Policy#or Self-ins.Lic.#: CWC0396222 Expiration Date: 04/29/2007 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 cern nder the payrrs,ipn enalties of perjury that the information provided above is true and correct. R Signature: Phone#• 413 247-5024 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#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or panniers, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would Ilse to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations -600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia RD ' CERTIFICATE OF LIABILITY INSURANCE 1110712006' PRODUCER (413)527-5520 FAX (413)527-5970 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Finck & Perras Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Campus Lane ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. asthampton, MA 01027 INSURERS AFFORDING COVERAGE NAIC# INSURED Hampshire Construction Co Inc & INSURERA: General Casualty 24414 Evergreen Corporation INSURER Hatfield Equipment Co, Inc INSURER C: BOX 327 INSURER D: North Hatfield, MA 01066-0327 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLIE INSR DATE(MM/DDffYI DATE(MM/DDIYYI LIMITS GENERAL LIABILITY CCI0396222 07/01/2006 07/01/2007 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE ric PRE F,TO RENTED $ 100'000 CLAIMS MADE M OCCUR MED EXP(Any one person) $ 5,000 AT:: PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 29000,000 POLICYF_j PRO JECT LOC AUTOMOBILE LIABILITY CBA0396222 04/01/2006 04/01/2007 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ A X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ FRAUTO ONLY: AGC EXCESS/UMBRELLA LIABILITY CCU0396222 07/01/2006 07/01/2007 EACH OCCURRENCE $ 1,000,000 OCCUR a CLAIMS MADE AGGREGATE $ 1,000,000 A $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND CWC0396222 04/29/2006 04/29/2007 WC STATU- OTH- EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER CERTIFICATE HOLDER CANCELLATION 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF AN IND UPON THE INSURER,ITS AG NTS OR REPRESENTATIVES. AUT R PRE EN TIVE �J /A( J ACORD 25(2001/08) ©ACORD CORPORATION 1988 y? BOARD OF BUDDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 017276 t ` Birthdate: 10/2711948 ysb, +F i.L Expires: 10/27/2007 Tr. no: 6840.0 Restricted: 00 ROBERT T BARTLETT JR PO BOX 327 N HATFIELD, MA 01066 Commissioner