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32C-169 (19) 228 PLEASANT ST BP-2020-0080 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C- 169 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-2020-0080 Project# JS-2020-000130 Est.Cost:$16611.00 Fee: $116.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RENAISSANCE BUILDERS 013302 Lot Size(sq. ft.): 10018.80 Owner: HAMPSHIRE EDUCATIONAL COLLABORATIVL INC Zoning:CB(100)/ Applicant. RENAISSANCE BUILDERS AT. 228 PLEASANT ST Applicant Address: Phone: Insurance: P O Box 272 (413) 863-8316 TURNERS FALLSMA01376 ISSUED ON:7/30/2019 0.00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE WALLS TO MAKE 8 ROOMS INTO 4, RELOCATE DOORS FROM EXISTING WALL TO EXPAND OPENINGS 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: FeeTyne: Date Paid: Amount: Building 7/30/2019 0:00:00 $116.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0080 APPLICANT/CONTACT PERSON RENAISSANCE BUILDERS ADDRESS/PHONE P O Box 272 TURNERS FALLS (413)863-8316 PROPERTY LOCATION 228 PLEASANT ST MAP 32C PARCEL 169 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TWeof Construction: REMOVE WALLS TO MAKE 8 ROOMS INTO 4, RELOCATE DOORS FROM EXISTING WALL TO EXPAND OPENINGS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 013302 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) 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 / Y-!!,-Ylt 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. Version 1.7 Commercial Building Permit Mati I�. 2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability_ Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans t rci APPLICATION TO CONSTRUCT,REPAIR,RENOVATE, WR THE USE OR OCCUPAN OR DEMOLISH ANY BUILDING OTHER THAN ATWO FAMILY DWELLING SECTION 1 -SITE INFORMATION J U L 1 9 osectio 2 Zc�, I 1.1 Property Address: ThcompIeted by office uric r'lumhing&GnMap MA Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: l/L - Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent Name(Print) Current Mailing Address: I CM Signature Telepho e 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 1 Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) LP� 5. Fire Protection 6. Total= (1 +2+3 +4 +5) Check Number 2 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date Version 1.7 Commercial Building Permit May 15,2000 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❑ Roofing❑ Change of Use❑ Other❑ Brief Description Enter a brief description here. 4N1(h.�-e- W�� -"o p ! Of Proposed Work: fO Q vrd b421 f� `1 i,'-I` 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 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational 2B I ❑ F Factory F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 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: ��its , ;1. - .,_; ;_ v: Proposed Use Group: 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) 1st LA&I 1st 2nd 2nd (— --� 3.d 3m 1 4 4th th Total Area(sf) Total Proposed New Construction(sf) _ L._W.._., _. 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❑ 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 11 0014 % Lot Size _.._.___..._ Frontage Setbacks Front Side L:= R:= L:= R:= Rear Building Height Bldg. Square Footage % O Open Space Footage % (Lot area minus bldg&paved I_J parking) #of Parking Spaces Fill: volume&Location) -- - --- 1�--- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOWYES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 O 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"A?f 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 O NO 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: Not Applicable —_ Name(Registrant): Registration Number Address L-------- - — 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 L_. F - Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable El Company Name: f Responsible In Charge of Construction Addre Signature Telephone Versionl.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 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize __ to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date I, as Owner/Authorized -------------- Ag_ent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Sined under the pains and penalties of perjury. i Prin N Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: /1 �, ,/ Not Applicable ❑ Name of License Holder< 3- Y� f� __�a.�(r / R wa, License Number Ad res Expiration Jate 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 H.E.C. Academy Revised Proposal Page ACCEPTANCE OF PROPOSAL: Agreement between: Collaborative for Educational Services Sherry Smith, 228 Pleasant Street, Northamptod, MA 01060 And Renaissance Builders, PO Box 272, Turners Falls, MA 01376 The prices, specifications, and conditions are satisfactory and are hereby accepted. Please send a contract for the following work, as specified in the Proposal dated May 20, 2019: Interior Renovations to H.E.C. Academy $ 16,6111.00 Please make the following changes or clarifications: Payment will be made as outlined below.- Deposit elow:Deposit on signed acceptance of Proposal: $ 500.00 Final payment due on substantial completion of project. I authorize you to apply for a building permit, if required, on my behalf. t�J(-k-- 0"-)� 11 1`j Authorized Representative Vate Please print legal name for Contract Documents All individuals listed as Owners of Record for a property are required to sign Contract Agreements. Please note any corrections to your name or address. Also, please give us your phone number(s) and the best times to reach you so we can keep you posted regarding our schedule. You may also provide an email address if that is a good way to contact you. Note: Please return only this signed acceptance sheet along with deposit Retain the Proposal for your records. Renaissance Builders, PO Box 272,Turners Falls, MA 01376 License#013302, Registration#106490 5/20/2019 City of Northampton Massachusetts �v?f' "•:c� DEPARTMENT OF BUILDING INSPECTIONS 7i 212 Main Street • Municipal Building 4 Northampton, MA 01060 �SY"`•3 LOUIS HASBROUCK BUILDING COMMISSIONER Effective July 1,2015 Phone: (413)587-1240 Fax: (413)587-1272 Commercial Building Permit Fees (Commercial is any Project other than one or two family residential) http://www.northamptonma.gov/702/Building-Department Fees for work not listed will be determined by the Building Department Any work beginning before a permit has been issued is subject to double fees and a stop work order removal fee Hours of operation are typically Monday thru Friday 8:30 to 4:30,Walk-In hours are closed at 12:00 pm Wednesday Permit Fees are paid to the CITY OF NORTHAMPTON CHECKS OR MONEY ORDERS ONLY: NO Cash or Credit Cards Checks or Money Orders Must Be Submitted with the Application or it will not be acted upon To Be Processed,Applications Must Be Complete and Include ALL Required Attachments All Applications Are Subject To Zoning Review. The Weekly Filing Deadline is 12:00 pm (noon) on Wednesday. Building applications-Require a plot plan,floor plans, elevations, structural and energy information as appropriate Sign applications- Require a photo of the existing elevation and a photo shopped placement of the proposed sign One hard copy and one electronic copy are required for all specifications and plans Applications may be subject to Central Business, and or Historic and Demolition Delay reviews It is the applicant's responsibility to verify property bounds and conservation issues COMPLETE DEMOLITION Accessory Structure-------------------------------------------------------------------------------- Principal Structure------------------------- ----- ----------------------------------------------$300.00 NEW CONSTRUCTION or Additions Greater than 30%of the floor area of the existing building Multi Family All Occupied Floors, per sf--------------------------------------------------------------------------$.60 '/2 Floors,Walk-In Attics, Basements, Garages, per sf---------------------------------$.20 Decks, Porches, Canopies, Porticos, per sf------------------------------------------------$.20 Other Commercial All Occupied Floors, per sf--------------------------------------------------------------------------$.60 '/2 Floors,Walk-In Attics, Basements, Garages, per sf - ----- - -------------------$.20 Decks, Porches, Canopies, Porticos, per sf------------------------------------------------$.20 Agricultural All buildings, per sf-------------------------------- - -- - --------------------------------------------$.20 NEW ACCESSORY STRUCTURE Up to 120 sf(zoning review)-----------------------------------------------------------------$30.00 Over 120 sf------------------------- ------------------ ---------------$.20 per sf, Minimum $35.00 Tent over 120 sf----------------------------------------------------------------------- $30.00 Swimming Pool------$7.00 per$1000 of estimated cost(rounded up)Minimum$200.00 REPAIRS, RENOVATION,ALTERATION, RELOCATION and ADDITIONS Less than 30%of the floor area of the existing buildin Includes roofing, siding,window$7 00 er$1000 of estimated cost(rounded(rte p_ ( unded u -- -----------------Minimum $100.00 SIGNS Wall Sign up to 10 sf---------------------------------------------------------------------------$60.00 Wall Sign over 10 sf--------------------------------------------------------------------------------$60.00 AwningSign---------------- - ------------------------------------------------------------------------$60.00 GroundSign------------------------------------------------------------------------------------------$100.00 SOLAR All projects use the commercial rate calculator available on our web site as an Excel file hftp://www.northamptonma.gov/702/Building-Department OTHER SERVICES Request For Zoning Determination---------------------------------------------------------'$30.00 Replacement Permit---------------------------------------------- --- --------------------------$30.00 Contractor or Owner Change-------------------------------------------------------------------$30.00 Temporary Certificate of Occupancy with inspection------------------------------$75.00 Additional or Requested Inspections------------ ----- ---------------- -----------------$75.00 All Other Services including stop work and condemnation orders------------$75.00 Sheet Metal-------$50.00 with building permit or$7 per$1000 Minimum$100.00 A I( Northampton, MA : Assessor Database: http://northampton.ias-clt.com/parcel.detaii.php?id=32C-169-00110 Northampton, MA : Assessor Database Property Search: Parcel ID: Owner Name: Street Number: Street Name: PLEASANT ST Search Reset Property Detail: Parcel ID: Card: Street Name: Street Number: Zoning: State Class: Acres: Plot: 32C-169-001 1 PLEASANT ST 228 Other Educational 0.23 Owner Information: Property Images: Owner Name: HAMPSHIRE EDUCATIONAL Picture: Owner 2 Name: COLLABORATIVE INC Owner 3 Name: Street 1: 97 HAWLEY ST f + City: NORTHAMPTON State: MA Zip: 01060 Building Information: Grade: C+ Structure Type: OFFICE BLDG L/R 1-4S Units: 0 Year Built: 1994 Building Number: 1 Identical Units: 1 Sketch: Valuation: Appraised Land: $220,000.00 Appraised Bldg: $1,585,800.00 Appraised Total: $1,805,800.00 1 of? 6/6/2019, 12:11 PM Northampton, MA : Assessor Database: http://northampton.ias-clt.com/parcel.detail.php?id=32C-169-00110 10 55 Descriptor/Are 24 1 aCB 40 A:1 OR 2 3168 sgft 43 35142 B:ANNEX 208 sgft 1 3719 C:1OR 19 D 14 3190 sgft jZ D:1 sBR 44 528 sqft E:1 sCB 3512 sgft 1sBR fi0 F:EFP Hi 85 3190 112 sgft :B 36 51 1 sBR 8 3168 F Out-Buildings: Code: Description: Units: Year Built: Sorel: Size2: Area: Grade: Condition: PAI 1 1994 0 0 14000 NORMAL(Comm) Building Interior/Exterior Information: Floor From: Floor To: Area: Use Type: Exterior Walls: Contruction Type: Heating: A/C: Plumbing: Functional Utility 01 01 10749 OFFICES FIRE RESISTANT HOT AIR CENTRAL NORMAL 4 01 01 1249 COVERED MALL FIRE RESISTANT HOT AIR CENTRAL NORMAL 4 The information delivered through this on-line database is provided in the spirit of open access to government information and is intended as an enhanc service and convenience for citizens of Northampton,MA. The providers of this database:Tyler CLT, Big Room Studios,and Northampton,MA assume no liability for any error or omission in the information provided here. Comments regarding this service should be directed to:jsarafin@northamptonassessor.us Thu.lune 6,2019 : 12:10 PM : 0.12s : lOmb �1 10G snxaos 2 of 2 6/6/2019, 12:l 1 PM Renaissance Builders PO Box 272, Turners Falls, MA 01376 Phone(413)863-8316; Fax(4 13)863-9712 www.renbuild.net May 20, 2019 Collaborative for Educational Services Sherry Smith 228 Pleasant Street Northampton, MA 01060 Work List for interior renovations for H.E.C. Academy at the above address. Revised from April 22, 2019 Scope to include: Relocation of doors. Removal of walls to combine 8 classrooms into four classrooms. Relocation of electrical devices as needed. All labor to be comply with Chapter 149 Prevailing wage rates. 1000 GENERAL CONDITIONS 1010 Plans & Specifications A. Supply drawings as required for building permit application. 1020 Permits A. Supply all building permits as required. 1300 Project Management A. Provide copy of current Construction Supervisor's license. B. Provide shop drawings, samples, color choices, and/or selection charts as needed for Owner's approval. C. Coordinate operations under different sections that are dependent upon each other for proper installation and operation. D. Notify Owner as necessary when scheduled work will impact occupied portions of the premises. 1310 Supervision A. Provide supervision at all phases of construction performed or subcontracted by Renaissance Builders. 1400 Warranty A. Supply certificate of liability (minimum $1 M) and Worker's Compensation insurance. B. All work performed or subcontracted by Renaissance Builders to be guaranteed for one year. 1520 Temporary Facilities A. Provide portable toilet for workers. 1530 Temporary Protection A. Provide floor and dust protection to work areas, and provide a walkway to and from work areas. H.E.C. Academy Revised Proposal Page 2 1730 Cleanup & Trash Disposal A. Clean up all debris and leave the job site broom clean at completion of all work. B. Legally dispose of all debris. 1950 Owner Responsibilities A. Cost of electricity and water during construction. B. All other phases not specifically outlined in this Proposal. 2000 SITE WORK 2225 Demolition, Interior A. Remove two (2) existing doors at Kelly's classroom and save for reuse. B. Cut four (4) openings between eight existing classrooms. C. Each new opening to leave approximately 1' of wall on each end of opening except for science room which stops at the sink. 5000 METALS 5160 Steel Studs A. Cap studs remaining at top of openings using 16 gauge steel track. 6000 WOOD & PLASTICS 6100 Rough Carpentry A. Install fire rated wood blocking around perimeter of each opening as needed for trim nailers. 6220 Casing & Base A. Case each opening with paint grade poplar jambs and 1" x 4" poplar casing. B. Trim vinyl base to fit at new casing. C. Install 6" x '/n" continuous aluminum threshold at each opening. 8000 DOORS & WINDOW 8200 Doors, Interior A. Rehang salvaged doors in existing openings to reverse swing. 9000 FINISHES 9920 Paint, Interior A. New standing and running trim, door and window casings, millwork, and interior doors each to receive a total of three coats of Benjamin Moore, Sherwin Williams or equivalent latex paint. 16000 ELECTRICAL 16100 Electrical Wiring A. Relocate all existing outlets in areas where walls are being removed. B. Disconnect all data lines in walls being removed and coil above ceiling. C. Relocate two (2) light switches. D. Assumes all electrical is fed from walls or ceilings, not from floor. END OF WORK LIST Renaissance Builders, PO Box 272, Turners Falls, MA 01376 License#013302, Registration#106490 6/5/2019 Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Musetts 02108 Home Improvem.Mas'Qtractor Registration _ Type: Individual z Registration: 106490 RENAISSANCE BUILDERS M r Expiration: 07/22/2020 P.O.BOX 272 , TURNERS FALL, MA 01376 H ' "a r v a oa time' �� esti Update Address and Return Card. SCA 1 Co 20M-05/17 - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only Rea S �C-,1Individual before the expiration date. If found return to: is r 1 Expiration Office of Consumer Affairs and Business Regulation f 07/22/2020 One Ashburton Place-Suite 1301 RENAISSANC Boston,MA 02108 STEPHEN J.GR 390 MAIN RD. GILL,MA 01354 eve Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrtaction Supervisor CS-013302 Expires: 08/17/2019 STEPHEN J GREENWALD f 390 MAIN RDS GILL MA 01354 1 y. Commissioner i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street - Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunibers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RENAISSANCE BUii.DERS Address: PO BOX 272 - City/State/Zip: TURNERS FALLS, MA 01376 Phone #: 413-863-8316 Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with 24 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. Building addition [No workers' comp. insurance comp. insurance. 1 ❑ required.] 5. [J We are a corporation and its 10.❑ Electrical repairs or additions 3.El I am a homeowner doing all work officers have exercised their I LE] 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' 1311 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 short 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: AIM MUTUAL INSURANCE CO Policy#or Self-ins. Lic.#: MCC20020004972019A Expiration Date: 01/01/2020 Job Site Address: �1_ 1 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 cePM under the pains and penalties of perjury t the information provided above is true and correct. Si nature: V;Q� Date: Phone#: 413-863-8316 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#: AFFIDAVIT FOR DISPOSAL OF DEMOLITION DEBRIS Supplement to Permit Application As a result of the provisions of MGL c. 40, s54, I acknowledge that as a condition of the issuance of a 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. I certify that debris resulting from this demolition will be disposed of as listed below: nn Job Site Location: 4: I Y/�V J 71 Name of Permit Applicant: Renaissance Builders Disposal Facility: F & G Recycling Address of Facility: 15 Mullen Rd., Enfield, Ct 06082 - - IF-SAID-FACILITY IS -OTHER THAN WI-IAT I-HAVE--LISTED I CERTIFY-THATi--- I WILL NOTIFY THE BUILDING OFFICIAL OF THE CORRECT LOCATION OF THE SOLID WASTE DISPOSAL FACILITY WITHIN TWO MONTHS OF THE DATE OF THIS APPLICATION. Signature of Applicant Date RENAISSANCE BUILDERS 3628 (413)863-8316 Ez sE AEoa. PO BOX 272 TURNERS FALLS,MA 01376 ./r l 1 53.7079/2118 Date P�dto o e' dr-q 6-F �KFP-&Mp-/-ZAJ -� $ _ I�Iiars e Greenfield Savings Bank 1-888-324-3191 For H,0036 2811' 1: 2 L L870799I: LE 00 0140 2q0 Renaissance Builders PO Box 272, Turners Falls, MA 01376 Phone(413)863-8316; Fax(413)863-9712 www.renbuild.net July 17, 2019 Louis Hasbrouck Building Commissioner City of Northampton Building Department 212 Main Street Northampton, MA 01060 Enclosed is the Building Permit application and a check in the amount of $116.00 for the permit fee on the property located at 228 Pleasant Street, Northampton. Hampshire Educational Collaberative owns the property. Please contact me at 413.863.8316 if you should have any questions in regard to this application. Thank you, Donna Flagg Enclosure