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31B-051 (31)
135 KING ST BP-2017-1446 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:3113 -051 CITY OF NORTHAMPTON l.ot:-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-2017-1446 Project# JS-2017-002116 Est.Cost: $375000.00 Fee: $2625.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: INGLEWOOD DEVELOPMENT CORP 053550 Lot size(sq. ft.): 17554.68 Owner: GOLDBERG BARRY G&ANNETTE E Zoning: HB(901/GB(l0)/URC(0)/ Applicant: INGLEWOOD DEVELOPMENT CORP AT: 135 KING ST Applicant Address: Phone: Insurance: 123 DWIGHT ST (413) 567-0069 WC LON GM EADOW MA01106 ISSUED ON:6/23/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL FOR NEW FITNESS STUDIO 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 it 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 Occu.anc si•nature: FeeTvpe: Date Paid: Amount: Building 6/23/2017 0:00:00 $2625.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-1446 APPLICANT/CONTACT PERSON INGLEWOOD DEVELOPMENT CORP ADDRESS/PHONE 123 DWIGHT ST LONGMEADOW (413)567-0069 PROPERTY LOCATION 135 KING ST MAP 31B PARCEL 051 001 ZONE HB(90)/GB(10)/URC(0)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid ..[[ / },� Building Permit Filled out Jh �� (,k Fee Paid Typeof Construction: REMODEL FOR NEW FITNESS STUDIO New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 053550 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: 'Approved Additional permits required(see below) Y6°411'14p(,uv&ISt)-.l� Pc-free/WV/1 — 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 Sign re of Building Official Date x/( 5/1-2_. 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. Version1.7 Commercial Buildin_Pemit May 15, 2000 Department use only 0\� 9 City of Northampton Stems Af Perm1f 1. Building Department Ludt CuUDnveway Pe�fml( 212 Main Street Sewer/Septic Availabi ity ° Room 100 Wat'erh^leltAvadablllty /- Northampton, MA 01060 Two SetsotStrugturalPians phone 413-587-1240 Fax 413-587-1272 PlotlSiie Plans Omer Specify _ APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY� DWELLINGIN /� r SECTION 1 -SITE INFORMATION jJ f_ f 1 (aA,V)-- 1.1 Procell Address: This section to be completed by office /3S[ - S,. Map 3 C3 Lot Q6/ Unit /VireeA4 Hnp/cir/ . Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e / / 1 e*dSu/+n son /60 l64,lG k A7.1 SOMr/i4 p.]/YI nzA- Name(Print) Current Mailing Address: O/0 73 21/3— SSS-3S/ Signature Telephone 2.2 Authodzetl ent:! Jy,h/co Lee✓c/ope-'enh /23 t.7rv,9/r/ gel Le fly nlerio✓ 4 ✓11.9- Name(Print) Kvi 2tiar�iCL ��n Yn�� Current Mailing Address: //I 2 H/3 — S67 - oa6P � Signature DG��r'bL��O/l�✓a 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 2. Electrical (b)Estimated Total Cost of Construction from(6) 3 75'/ c 0 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection _. ` 6. Total=(1 +2+3+4+5) 37S 000 Check Number 1003 6tytSr This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED� SPACE L'JOS Interior Alterations Existing Wall Signs ❑ Demolition Repairs Additions ❑ Accessory Building Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description Enter a brief description here. Re rnocte ( -%r 4 .,ew j otnes.5 Slr.etb Of Proposed Work: I SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A AssemblyElA-1 0 A-2 ❑ A-3 Er 1A I El A-4 ❑ A-5 0 1B 0 B Business ❑ 2A 1r E Educational ❑ 2B I ❑ F Factory 0 F-i ❑ F-2 0 2C ❑ H High Hazard 0 3A ❑ I Institutional 0 I-1 0 1-2 ❑ 1-3 0 3B ❑ M Mercantile 0 4 ❑ R Residential 0 R-1 0 R-2 0 R-3 ❑ 5A 0 S Storage ❑ S-1 0 S-2 ❑ 5B 0 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: A 3 Proposed Use Group: //Sf3 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" 6r2 to 1" Sifn-cam 25° 2n0 3b .. 3`d 45' 4t Total Area(sf) : 60 ego Total Proposed New Construction(sf) Total Height(ft) 2 p e a.°Total Height fl 7.Water Supply(M.G.L-c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public [Lr Private 0 Zone'....... . .....'. Outside Flood Zone Municipal [ran site disposal system 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 MGL c 111 , S 150A. Address of the work: ,3C skiHyc 5f/ NorA'Lnip )tn The debris will be transported by: IL.SA. gate /1:7 The debris will be received by: Building permit number: Name of Permit Applicant I wo, ' e v-/o. Date 6, - ii---azo/7 Signature of Permit Applicant Version1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) /�,� Independent Structural Engineering Structural Peer Review Required Yes O No e 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 ,T✓y/t°w u". e %apmen4 Grp. _ _ to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Own I Date 1 /(r cfta nil A vn ea ihary /±, iC wOoK Eletee/b 3 reit,n I-: ,as 9awer/Aulhorized 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. tai 4<-en en Lerf Print Name agnature or 'eN !/ Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: �/ Not Applicable 0 Name of License Holder• /a hat ape / rrant4Atey C$ -O53 SS° License Number 20 r1'/azlecrci,><Ui. /3e7cdie.-chwbl .414. oreo7 (2-/7 - :..v/7 Address Ze, Expiration Date 45-S79-0o16 Signature Ttapnonu ' 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 build permit. Signed Affidavit Attached Yes tJ No 0 Version!.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 tri,37Sre. ) : Frontage So Setbacks Front " Side L: R: L: R: Rear /ab Building Height d0 Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces /b Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regis of Deeds? NO 0 DONT KNOW YES O IF YES: enter Book .. Page and/or Document It 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 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and Location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO eJ 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 er 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: p annq �G�( Not Applicable ❑ Name(Registrant): - - - svrsm7evons4/t /4e,//f3/et f//o//„Sburg / PA Registration Number Address 717_ 703-3770 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 Expiration Date 9.3 General Contractor xx�� ',...L n✓ �C weed ✓e Let' iow/en/ Corp Not Applicable ❑ Company� Name: /Y� iAxz . . /Yronen.6e.`rq C5 - o S3SSU Responsible In Charge of Construction /13 /7w/9hJL -Cony rntog1YI.Q. a//C Address 9!3 eS Signature Telephone City of Northampton .`.So 4 - Massachusetts c? 1- l e v"/ f DEFERMENT OF BUILDING INSPECTIONS in in 4 212 Main Street • M nac =Jit. ipal Building .'s` r:;i.y(�s.Ey Northampton, Mr 01060 •._.. P�C INSPECTOR Louis Hasbrouck Fax:413-587-1272 Chuck Miller Building Commissioner Phone:413-587-1240 Assistant Commissioner CONSTRUCTION CONTROL DOCUMENT (For professional Engines SJArtllitects responsible for Entre Project) Project Title: Anytime Fitness Date: 6-2-17 Project Location: 138 King Street, Northampton, MA Map: Parcel: Zone: Scope of Project: Interior renovation &fit-out of a 6,280 SF fitness dub In accordance with the Eighth edition Massachusetts State Building Code, 780 CMR Section 1076: I, Ryan S. Hannold, AIA, NCARB Mass Registration u 551103 , Being a registered professional Engineer/Architect hereby CERTIFIES that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: [X]ENTIRE PROJECT 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 arreptable 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 and shall be responsible for the following as specified in Section 10.7.6.2.2: 1. Review of shop drawings,samples and other submittals of the contractor as required by the construction documents as submitted for the building permit,and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials_ 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,in general, if the work is being performed In a matter consistent with the construction documents. I shall submit periodically,in a form acceptable to the building official,a progress report together with pertinent comments- Upon completion of the work, I shall submit to the building official a final report as to the satisfactory completion and readiness of the project for occupancy_ t AB P Signature and Seal of Registered Professional ice ' � c It , . se:ITI 2nd Day of June 2017 y. \tea / (sea) The Commonwealth of Massachusetts Print Form Department of Industrial Accidents t c=T]=; Office of Investigations LT =:" r. _ mg 3, 600 Washington Street ' 3 Tait - Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Inglewood Development Corporation Name(Business/Organization/Individual): Address:123 Dwight Road City/State/Zip:Longmeadow, MA 01106 phone #:(413) 567-0069 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 13 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ID New construction listed on the attached sheet. 7. Remodeling 2.❑ 1 am a sole proprietor or partner- ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. employees and have workers' coo insurance.. 9. ❑ Building addition [No workers' comp. insurance P 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 12❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.11I Other comp. insurance required.] *Any applicant that checks box b'1 must also fill out the section below showing theirworkers'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. k ontracturs that check this box mut 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: Peerless Insurance Group Policy#or Self-ins.Lie. #NIC 8681750 Expiration Date:06/10/17 Job Site Address: 138 King Street City/State/Zip:Northampton, 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 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 herebycertify nder the tins a d penalties of perjury that the information provided above is true and correct. Signature: if - Date:6/7/17 Phone#:(413) 567-0069 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#: T ` Liberty Mutual.Compensation And Employers LiabilityInsurance Policy RENEWAL Transaction Effective: 06/10/2016 INFORMATION PAGE DIRECT BILL Policy Number:WC 8681750 Prior Policy: 8681750 Date Issued:04/12/2016 Coverage Is Provided In PEERLESS INSURANCE COMPANY-A STOCK COMPANY NCCI Number: 11355 1.Named Insured and Mailing Address: Agent: INGLEWOOD DEVELOPMENT CORP PHILLIPS INSURANCE AGENCY INC AND INGLEWOOD REALTY TRUST 97 CENTER ST 123 DWIGHT ROAD CHICOPEE MA 01013-1664 MA 0101 LONGMEADOW MA 01106 Agent Code: 2080901 Agent Phone: (413)-594-5984 Federal Employer ID Number: 043344946 Filing Number: 913761197 SIC Code: 1751 Other Workplaces not shown above: REFER TO ADDITIONAL WORKPLACES SCHEDULE Entity of Insured-CORPORATION 2. Policy Period: The Policy Period is from 06/10/2016 to 06/10/2017, 12:01 AM Standard Time at the insured's mailing address. 3. A. Worker's Compensation Insurance: Part One of the policy applies to Worker's Compensation Law of the states listed here: CT, MA, NY B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in 3.A.The limits of liability under Part Two are: Bodily Injury by Accident $ 1 ,000,000 each accident Bodily Injury by Disease $ 1 ,000,000 policy limit Bodily Injury by Disease $ 1 ,000,000 each employee C. Other States Insurance: Part Three of the policy applies to states,if any, listed here: All states except North Dakota,Ohio,Washington, Wyoming and states designated in item 3.A.on the Information Page; D. Endorsements and Schedules: This policy includes these endorsements and schedules: See Extension of Information Page 4. Premium: The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans.All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Code Total Estimated $100 of Annual Number Classifications Annual Remuneration Remuneration Premium See Extension of Information Page POLICY PREMIUM TOTALS Total Estimated Standard Premium $ 15,813.00 0900 Expense Constant $ 338.00 Total Premium Discount $ -675.00 Total Estimated Premium $ 15,476.00 Total Assessments/Funds/Surcharges $ 1 ,1 79.00 Total Estimated Cost $ 16,655.00 Minimum Premium $ 1 ,250.00 Deposit Premium $ 16,655.00 Adjustment Period: ANNUAL Date: Countersigned by: Authorized Signature Copyright 1987 National Council on Compensation Insurance. 25-190(07/08)IWC 00 00 01A) INSURED COPY PGDMO6OD J24477 PEONLYST 00000876 Page 13 4. - Liberty Workers Compensation And Employers Liability Insurance Policy Mutual. INSURANCE RENEWAL Transaction Effective: 06/10/2016 Policy Number: WC 8681750 Policy Period: From 12:01 AM 06/10/2016 To 12:01 AM 06/10/2017 Coverage Is Provided In PEERLESS INSURANCE COMPANY-A STOCK COMPANY NCCI Number: 11355 Named Insured: Agent: INGLEWOOD DEVELOPMENT CORP PHILLIPS INSURANCE AGENCY INC AND INGLEWOOD REALTY TRUST Agent Code: 2080901 Federal Employer ID Number: 043344946 Filing Number: 913761197 EXTENSION OF INFORMATION PAGE Premium Basis Rate Per Estimated Code Total Estimated $100 of Annual Number Classifications Annual Remuneration Remuneration Premium CT 5403 CARPENTRY NOC 6,366 2 9.4 4 0 0 1 ,874.00 Sub-Total $ 1 ,874.00 9812 Premium for Increased Limits Part Two $ 21 .00 Sub-Total $ 1 ,895.00 9898 Experience Modification-using factor 0.87000 $ -246.00 State Total Estimated Standard Premium S 1 ,6 4 9.0 0 0063 State Premium Discount.. $ -40.00 9740 Terrorism $ 1 .00 9741 Catastrophe(other than Certified Acts of Terrorism) S 1 .o o 0000 CT Second Injury Fund 2.750% $ 5 4.0 0 0000 CT Assessment Fund 1.600% $ 2 6.0 0 State Total Estimated Cost $ 1 ,6 9 1 .0 0 MA 5431 CARPENTRY-INSTALLATION OF CABINET 133,286 4.8 6 0 0 6,478.00 WORK OR INTERIOR TRIM 5606 CONTRACTOR—EXECUTIVE SUPERVISOR OR 256,527 1 .6 6 0 0 4,258.00 CONSTRUCTION SUPERINTENDENT 8810 CLERICAL OFFICE EMPLOYEES NOC 150,000 0.0 8 0 0 1 2 0.0 0 8742 SALESPERSONS,COLLECTORS OR MESSENGERS- 52,000 0.1 6 0 0 8 3.0 0 OUTSIDE 5403 CARPENTRY NOC IF ANY 9.8 6 0 0 0.00 Sub-Total $ 10,939.00 9812 Premium for Increased Limits Part Two $ 2 1 9.0 0 Sub-Total $ 1 1 ,1 5 8.0 0 9898 Experience Modification -using factor 0.87000 $ -1 ,451 .00 Date Issued: 04/12/2016 Copyright,1987 National Council on Compensation Insurance 25-191 (06/94)(WC 00 00 01A) INSURED COPY PG01/51160D J24477 PEONLYST 00000878 Page 15 Workers Compensation And Employers Liability Insurance Policy EXTENSION OF INFORMATION PAGE(continued) Premium Basis Rate Per Estimated Code Total Estimated $100 of Annual Number Classifications Annual Remuneration Remuneration Premium State Total Estimated Standard Premium S 9,707.00 0063 State Premium Discount $ -320.00 9740 Terrorism Risk Insurance Act of 2002 Coverage $ 1 76.00 0001 MA DIA Assessment 0.05750 $ 547.00 State Total Estimated Cost $ 1 0,11 2.00 NY 5403 CARPENTRYNOC 21 ,854 18.9700 4,146.00 Sub-Total $ 4,146.00 9812 Premium for Increased Limits Part Two $ 116.00 Sub-Total $ 4,262.00 9046 Contracting Class Credit-using factor 0.0000 S 0.00 State Total Estimated Standard Premium $ 4,262.00 0063 State Premium Discount $ -31 5.00 9740 Terrorism S 13.00 9741 Catastrophe(other than Certified Acts of Terrorism) $ 2.00 0932 New York State Assessment $ 552.00 9749 NY WC Security Fund Surcharge $ 0.00 State Total Estimated Cost $ 4,514.00 Date Issued: 04/12/2016 Copyright,1987 National Council on Compensation Insurance 25-191 (06/94)(WC 00 00 01A) INSURED COPY PGDM0601) J24477 PEONLYST 00000679 Page 16 INGLE-2 OP ID:AD %COR o CERTIFICATE OF LIABILITY INSURANCE DATEmwDD Y, 06/07/2017 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 endorsemen(s). PRODUCER CONTACT NAME; Angela DiAugustino PHILLIPS INSURANCE AGENCY INC PHONE -- Fax -- -- 97 CENTER STREET IAIc No Em:413-594-5984 Wo No):413-592-8.499 CHICOPEE,MA 01013 ADDRESS:Angela@phillipsinsurance.com PHILLIPS INSURANCE AGENCY INC - - -- INSURER(S)AFFORDINGCOVERAGE _ NAIC# INSURER A.Peerless Insurance Company 24198 INSURED Inglewood Development Corp. INSURER B:Ohio Casualty24074 123 Dwight Rd _ - - - Longmeadow, MA 01106 INSURER c:West American Insurance Co. 44393 INSURER D. INSURERS: _ 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 IFDOL SUBR POLICY EFF I POLICY EXP - LTR -- TYPE OF INSURANCE 4NSD VNO POLICY NUMBER IMMIDDIYYYYI:I MMIDDIYYYYI LIMITS CX COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE FX I OCCUR BKW55765431 0811012016 06I1012017 °FMSSO acE (Eoccurrence) 300,000 MED EXP(Any one person) 15,000 I PERSONAL&ADV INJURY 1,000,000 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 2,000,000 X POLICY'r JEC [ I LOC PRODUCTS-COMP/OP AGG 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 IEE ecoaenn B ANY AUTO BAO53472672 06/10/2016 06/10/2017 BODILY INJURY Iver person) ALL OWNED z SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS X HIRED AUTOS X NNON-OWNED _ ;ROPERPer T DAMAGE INCLUDED X UMBRELLA LIAR ,J OCCUR EACH OCCURRENCE 1,000,000 B EXCESS LIAR i CLAIMS-MADE US055880458 06/1012016;06/10/2017 AGGREGATE 1,000,000 DED X RETENTIONS 10,000 WORKERS COMPENSAPON I X STATUTE X Er - AND EMPLOYERS'LIABILITY A OFANY ICERNMBEREXCLUDEDxECOTNE vrx WC 8661750 06/10/2016 06I10I2017 EL EACH ACCIDENT 1,000,000 daIn EREXCLUDED, N xlA es.Mandatorydesenb NH) LEL DISEASE-EA EMPLOYEE 1,000,000 DESCRIPTIOON OFF OPERATIONS below E.L.DISEASE•POLICY LIMIT 1,000,000 A Leased/Rented BKW55765431 06/10/2016 06/10/2017 Limit 50,000 • Equipment Deductibl 250 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,Additional Remarks Schedule.may be attached If more space Is required) RE:Anytime Fitness Build Out 138 King St.,Northampton,MA 01060 CERTIFICATE HOLDER CANCELLATION CITYNOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Northampton Dept of Building Inspections AUTH ORIZED REPRESENTATIVE 212 Northin ampton, ipal 01060 Building Vv - net „"' -706 Northampton,MA 01060 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD