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24B-067 (16)
263 KING ST- KIA BP-2016-1419 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24B-067 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2016-1419 Project JS-2016-002441 Est.Cost: $1060000.00 Fee: $4238.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: FORISH CONSTRUCTION CO INC 027190 Lot Size(su, ft.): 93218.40 Owner: 293 NORTHAMPTON REALTY LLC C/O WILLIAM LIA Zoning: HB(99)/GI(1)/ Applicant: FORISH CONSTRUCTION CO INC AT: 263 KING ST - KIA Applicant Address: Phone: _ Insurance: P 0 BOX358 (413) 568-8624 Workers Compensation W ESTF I ELD MA01086 ISSUED ON:7/6/2076 0:00:00 TO PERFORM THE FOLLOWING WORK:6,000 SF ADDITION TO THE EXISTING FACILITY AND 1,064 SF ADDITION TO THE SERVICE DRIVE 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/4 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 7/6/2016 0:00:00 $4238.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1419 , � APPLICANT/CONTACT PERSON FORISH CONSTRUCTION CO INC - . C„LADDRESS/PHONE P 0 BOX358 WESTFIELD (413)568-8624 PROPERTY LOCATION 263 KING ST-KIAQ�5-11� MAP 24B PARCEL 067 001 ZONE HB(99)/GI(I)/ 6 6'I THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Cat-n- eon 0€, #40763 Building Permit Filled out Fee Paid TvoeofConstruction: 6,000 SF ADDITION TO THE EXISTING FACILITY AND 1,064 SF ADDITION TO THE SERVICE DRIVE New Construction y Non Structural interior renovations ,r ( -, f I Addition to Existing (4/ Accessory Structure n /� 9} ,t Building Plans Included: J,/ (/ t Owned Statement or License 027190 �J,L�1k 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF. QRMATION 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 Permit DPW Storm Water Management Demolition Delay c /1--/C— P y/Sits 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. Versionl.7 Commercial Buildin• Permit May 15,2000 Department use only ity of Northampton Status of Permit: RECEIVED :uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability in. Room 100 WaterANell Availability_ N•rthampton, MA 01060 Two Sets of Structural Plans DEPT Of BUILDING INS -+:e- 41 ;-587-1240 Fax 413-587-1272 Plot/Site Plans NOATRNv!iON MA 0/060 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 263 King St, Northampton, MA 01060 Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 293 Northampton Realty, LLC C/O William Lia PO Box 5789, Albany, NY 12205 Name(Print) Current Mailing Address: 518-489-2111 Signature Telephone 2.2 Authorized Agent: Eric J. Forish 21 Mainline Drive, Westfield, MA 01086 Name(Print) Current Mailing Address: 413-568-8624 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee $1,060,000 2. Electrical (b)Estimated Total Cost of Construction from(6) _ 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 0 6. Total=(1 +2+3+4+5) Check Number bq,50 G y as 1.oa This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date a ne TOR5l1 Lc ettj ICN . Co,^11 Versionl7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE —Q Interior Alterations ❑ Existing Wall Signs 0 Demolition El Repairs❑ Additions 1� Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing 0 Change of Use El Other 0 Brief Description The project includes a 6,000 SF addition to the existing facility, and a 1,064 SF Of Proposed Work: addition to the service drive. SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A I 0 A-4 ❑ A-5 0 IB ❑ B Business it 2A 1 ❑ E Educational ❑ 28 I ❑ F Factory 0 F-1 ❑ F-2 0 2C I ElH High Hazard 0 3A ❑ I Institutional ❑ I-1 0 1-2 ❑ I-3 ❑ 3B 11 M Mercantile 0 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage 0 S-1 ❑ S-2 ❑ 5B I ❑ 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: B Proposed Use Group: B 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(sf) 1" 13,880 1„ 7,900 2 2°' ^' 3° 3rd 4th 4u Total Area(sf) 13,880 Total Proposed New Construction(sf) 7,900 Total Height(ft) 22 Total Height ft 22 7.Water pply(M.G.L.C.40,§54) 7.1 Flood Zone Information: 7.3 Sewage posal System: Public Private 0 Zone Outside Flood Zone MunicipalOn site disposal system❑ Forish Construction Company TRANSMITTAL 21 Mainline Drive No. 00003 R)Box 358 Phone: 413-568-8624 Westfield,MA 01086 Fax: 413-562-7136 PROJECT: Lia Chrysler-Building Additions DATE: 6/1/2016 TO: NORTHAMPTON BUILDING DEPARTMENT REF: City of Northampton Building Department Northampton, MA 01060 ATTN: WE ARE SENDING: SUBMITTED FOR: ACTION TAKEN: ❑ Shop Drawings ❑ Approval 0 Approved as Submitted ❑ Letter 0 Your Use 0 Approved as Noted ❑ Prints RI As Requested 0 Returned After Loan ❑ Change Order 0 Review and Comment 0 Resubmit ❑ Plans 0 Submit ❑ sampl=e SENT VIA: 0 Returned ❑ Specifications 0 Attached 0 Returned for Corrections rir OtherCheck No.69866 0 Separate Cot cc Via: ❑ Due Date: ITEM PACKAGE SUBMITTAL DRAWING REV. ITEM NO. COPIES DATE DESCRIPTION STATUS 1 6/1/2016 Check No.69866 AAN Remarks: Louis, Please refer to the atttached check for the building permit for Lia Chrysler at 263 King St. Feel free to call if you have any questions. Thanks, Dan Ryan Perish C CC: Signed: ( --_ Dan Ryan wane 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 118,820 SF 118,820 SF Frontage 260' 280' Setbacks Front 324.10' 75.50' Side L: 68' R: 23' L: 72' R: 23' Rear 84' 84 Building Height 22' 22' Bldg.Square Footage 13,880 % 7,900 Open Space Footage (Lot area minus bldg&paved Parking) #of Parking Spaces 162 139 Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW O YES IF YES, date issued: 7/a//dor . IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O YES 0 IF YES: enter Book j j oil Page X75 and/or Document# ,2 2 %a 7 B. Does the site contain a brook, body of water or wetlands? NOQiie) DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES xXC NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES fo"?) NO O IF YES, describe size, type and location: rag Xd4 Fvlfip� 't r-c.\ r 4& 3 ooh^ d8t2, E. Will the construction activity disturb(clearing, grading, excavation,or filling)over 1 acre oris it part of a common plan that will disturb over 1 acre? YES O NO cg IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 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 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: 5 /2/ /6/ 222 Not Applicable ❑ Name(-,.strait: /C ) ab3f / y-Frf /-0- �j�� 1y� ,�jJ� Registration Number Add= I C,!'J W�/ � a _ Expiration • Ae Ctors Telephone 9.2 R` tered 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 Forish Construction Co., Inc. Not applicable ❑ Company Name: Eric J. Forish Responsible In Charge of Construction 21 Mainline Drive, Westfield, MA 01086 Address rte" 413-568-8624 Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(730 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes © No Cl„ SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, Eric J Forish act on my behalf,in all m= = relative to work authorized by this building permit application Signature of Owner Date 1, __ EricJ__Forish as Owner/Authorized Agent hereby declare that the statements and information on the foregoing applicator are true and accurate,to the best of my knowledge and belief. Signed under thensinsa.N¢p/enable s u . Print Name �/ �. ...__... t—Oitt r 1 I ��s--- --� Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 licensed Construction Supervisor Not Applicable ❑ Name of License Holder Eric J. Fonsh _CS_027190 ......_.J License Number ,_ 21 Mainline Onve,Westfi�'{t`1', MA01086 . 1/3/2018 3 Address 1 ._._ Expiration Date v 413-568.8624 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 b tiding permit Signed Affidavit Attached Yes j{J N0 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGLcc 111, S 150k Y Address of the work: d 63 "c- .S� /0y�'�c.,.v17/0r /IA The debris will be transported by: 11 )Sec4J j rock,c The debris will be received by: \Ja\g2.7 \CC1dt ad, 9 R21,41,-,‘ fit/ 4(4 Building permit number: Name of Permit Applicant �CiC,,j. }-cr.S(n Date Signature of Permit Applicant CITY OF NORTHAMPTON,MASSACHUSETTS '� DEPARTMENT 125Locust OF PUBLICStreet WORKS be* 11 � '�pNorthampton, MA 01060 413-587-1570 Fax 413-587-1576 Letter of Transmittal To: Jeff Casey From: Doug McDonald Date: 5/12/2016 Re: Stormwater Management Operation, Maintenance and Inspection Agreement Amendment for Lia Chrysler Attached you will find the following items: I original signature copy of the Stormwater Management Operation, Maintenance, and Inspection Agreement Amendment for Lia Chrysler. They are transmitted as checked below: ❑ For approval ❑ Approved as submitted ❑ For your use = Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comments ❑ Revise and resubmit ❑ For your signature ❑ Other: O&M Agreement Amendment to be signed by the property owner and Recorded Remarks: Per requirements of the Northampton Stormwater Management Ordinance, please file the executed Stormwater Management Operation, Maintenance, and Inspection Agreement Amendment in the land records of the Hampshire County Registry of Deeds and provide a receipt certifying this action to myself at the DPW. I can be reached at 413-587-1582 or dmcdonald@nnoamptonma.gov with any questions. Signed: 1((��JJ Pg.1/1,M'.1Stommwater Permitsll Stormwater Permits InternalPermit Forms\OBM Agreement Transmittal to Record doc Initial Construction Control Document d? g i To be submitted with the building permit application by a Vt144 ) Registered Design Professional jfor work per the 8'"edition of the It I Massachusetts Slate Building Code, 780 CMR, Section 107 Project Title: 2-/4 oy‘c5✓G,j/%L" ,r / Date: �� Property Address: _ _1 lir/ _2 Ncre�ztae-,%. A14- Project: Check one or both as applicable: )&New construction )CExisting Construction 7 Project description: 7 /Q /os/ 7/c,//[/ 70_7-77c - iCk/ 77 ,9_ji c ,,//P IE/`�C/� � � MA Registration Number �p� Expiration date a�// , am a e. regisvere design professional, and I have prepared or directly supervised the neparation of all design plans, computations and specifications concerning: • (Architectural [ ] Structural [ ) Mechanical [ I Fire Protection [ ] Electrical [ I 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: I. 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, 1 shall su . \.. &IH .•`Hp ,, official a 'Final Construction Control Document'. G C I - Q�^ ito co Enter in the space to the ri hta"wet' • �\ �. = electronic signature and sea gp�ja- al a4 id �h S Phone number: 2JH, pe�� Email: Building Official Use Only Building Official Name. ___ Permit Nn: Dir Version 06_11,2.013 City of Northampton pro ` .} Massachusetts oe 2etis.- i e dsti +. Is DEPARTMENTOF BOIMiG INSPECTIONS 212 wain Street Municipal 0nitding Northampton, ,a 01060 INSPECTOR Louis Hasbrouck Fax: 413-587-1272 Chuck Miller Building Commissioner Phone:413-587-1240 Assistant Commissioner SECONDARY CONSTRUCTION CONTROL DOCUMENT (For professional Engineers/Architects responsible for a mope of a controlled project) Project Title: Lia Chrysler Additions Date: 5/19/16 Project Location: 263 King Street,Northampton MA Map:248 Parcel:067.001 Zone:uwoi Scope of Project: (2) Pre-Engineered/Pre-Manufactured Steel Building Additions to Existing Building In accordance with the Eighth edition Massachusetts State Building Code, 780 CMR Section 107 6: I, Michael Schafer Mass. Registration# 36891 being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: [ ] Fire Protection [ (Architectural [ ]Structural [ Il Mechanical ( (Electrical N Other(specify) Foundation Design for the above named project and that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable Laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that the above mentioned portions of the work proceed in accordance with the documents approved for the building permit. Upon completion of the work. I shal(.submit to the building official a final report as to the satisfactory CompletionayfMntioned work. Sig (.a . o g'. : >. Professional A '` rD 20 d6 (seal) City of Northampton rPf Massachusetts Ka i.. C fa 1• v tcc 8 ® DEPARTMENT OF BUILDING INSPECTIONS S. z. 212 Moan Street a Municipal auildtag Northampton, !A 01060 son° INS PECTOR Louis Hasbrouck Fax: 413-587.1272 Chuck Miller Building Commissioner Phone:413-587-1240 Assistant Commissioner SECONDARY CONSTRUCTION CONTROL DOCUMENT /Per professional Engineers/Architects responsible for a Rortion of a controlled project) Project Title: Lia Chrysler Additions Date: 5/19/16 Project Location: 263 King Street,Northampton MA Map:249 Parce1:067001 2one:HB/fa Scope of Project: (2) Pre-Engineered/Pre-Manufactured Steel Building Additions to Existing Building In accordance with the Eighth edition Massachusetts State Building Code, 780 CMR Section 107.6: I, Michael Schafer Mass. Registration n 36891 , being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: [ ]Fire Protection [ ]Architectural [ j Structural [ 1 Mechanical [ ] Electrical NI Other(specify) Foundation Design ... for the above named project and that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code,all acceptable engineering practices and all applicable Laws for the proposed project. Furthermore,I understand and AGREE that I shall perform the necessary professional services to determine that the above mentioned portions of the work proceed in accordance with the documents approved for the building permit. Upon completion of e work I shall submit to the building official a final report as to the satisfactory Completion of pA i* d wo*. i.: 4rr-'Slgn 'M e .g ••'rofessionai I Day of 'y,.- 20 16 (seal) The Commonwealth of Massachusetts Department of IndustrialAccidents esaelm 1 Congress Street, Suite 100 �1it$t,g Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant information Please Print Legibly Name(Business/Organization/Individual):FORISH CONSTRUCTION COMPANY, INC. Address:21 MAINLINE DRIVE, PO BOX 358 City/State/Zip:WESTFIELD, MA 01086 Phone#:413-568-8624 Are you as employer?Check the appropriate NE Type of project(required): LQ I am a employer with 20 employees(full andtorpan-time)." 7. ❑New construction 20 I um a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.(No workers'comp.insurance required.) 3.0Iam a homeowner doing all work myself(No workers'comp.insurance required.] 4- 111 Demolition 4.0 I am a homeowner and willbe hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all centre:tem either have workers'compensation insurance or are sok lin Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the subconnactms listed on the attached sheet, i3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance: 6 5e,rt(ac,rpdtion and les officers have their right of exemption per MGL e. 14.j7JGdter Comm'I Construction ❑ pour _Came we have no employees.No workers'temp.insurance required.) 'Any applicant that checks box el must also fill out the section below showing their workers'compensation policy information. Ho ..owners 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 subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'camp,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:ABC Massachusetts Workers Compensation Self Insurance Group Policy#or Self-ins.Lie.#:ABC MA 005010-16 Expiration Date: 1/1/2017 Job site Address:Lia Chrysler, 263 King Street City/State/Zip:NOrtflamptOf , MA 01060 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,509.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.09 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification, I do hereby certify under the p ns and penalties of perjury that the information provided above is true and correct eta e: -- z �7 Date: Q/j.Y/)-c 1 b Phone it: 413-568-8624 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License N Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/fawn Clerk 4.Electrical Inspector 5.Plumbing Inspector O.Other Contact Person: Phone#: INSURER'S AFFIDAVIT AS TO WORKERS' COMPENSATION INSURANCE L i . �� .&�/ l2 4Prs4: ^..O ',�a1Spf,/�g1> ( 'A - ) /'t/ amu Address]am: annauthprized representative of r l I , 9 Ae , a iii i=w .e isurance Company .SSCe L 1Su int C e. &,c' o;.fon_/ISCompany Name] (a producers in the voluntary market)* D an authorized agent of . Insurance Company(an agent [Company Name] in the voluntary market,authorized to sign on behalf of a producer)' ❑ an authorized signatory of the ,the Prime Contractor (Company Name) (an insured of a producer in the involuntary market pool)t ❑ an authorized signatory of ,the Sub-Contractor(an insured of [Company Name] a producer in the involuntary market poo/l,gi roup, or otherwise insured)$ / Cond do hereby aver that effective$d'do6r.7rt/r/r 774,7 [bare], riufalc72 ✓! [x° Sly//LG�c O W4 /i'i C [the Prime or Sub-Contractor], is insured for Workers' Compensation insurance with C// CSizritr SPik,(1104/5 Insurance Company under Policy No[s]. A,�}C,l11/Ql7,5`n/n/y, m'e rftuabt4PO fYle ai�tac�tveT er fii "ate otl'nsurance,and in accordance with Massachusetts General Laws, Chapter 152 and Subsection 7,05A of/he Standard Specifications for Highways and Bridges of the Highway Division of the Massachusetts Department of Transportation. it- Signature / Title COMMONWEALTH OF MASSACHUSETTS On t is u day o. cif 4 .: '- ,2041 before me,the undersigned notary public,personally appeared jade. :a a it♦' _document signer],proved to me through satisfactory evidence of identification,which was/were �w . ` ♦ ,to be the person who signed the preceding or attached document in my presence,and who swore or a fumed to me that the contents of the document are truthful and accurate to the best of their knowled9gge and belief. 11 G /idle it; .�-fi tactwitL,Notary at cc ( 4 ( _ C. LI, . .IPrinteA Name] a a MARIA C. SULLIVAN ']{ Notary Public 0 -ruCOI1 ttratirtiatiath OFM1IASSACHaSERS My Commission Expires 'A producer is an insurance company that provides insurance policies Edirecttlyynnota n irriM19NELif+' e ' 'For Prime or Sub-Contractor companies insured through the voluntary Inc etk ttus"Atftidat7it must be completed by the insurer or an authorized agent of the insurer. t lithe Prime or Sub-Contractor is insured through the involuntary insurance market,a pool,such as the Worker's Compensation Inspection and Rating Bureau,or is otherwise insured they may provide a Certificate of Insurance and this Affidavit which may be signed by an authorized signatory(company officer)of the Prime or the Sub-Contractor. Effective 10-May-I0