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25A-179 (23) Version 1.7 Commercial Buildimo Permit Mm 15-2000 (� Department use only City of Northampton Status of Permit: C Building Department Curb Cut/Driveway Permit ' 212 Main Street Sewer/Septic Availability ROOM 100 Water/Well Availability tJ„ Northampton, MA 01060 Two Sets of Structural Plans / phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION RECEIVED, /3 n- 10 - 9 'S > 1.1 Property Address: This section to be completed by office !29 Industrial Drive East MaOCT p ��'�' Lotr7q Unit `Northampton, MA 01060 on Overlay District DEPT.OF BUILDING INSPECTION NORTHAMPTON,MA 0106,0 m St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 29 Industrial Drive East LLP (Mark Benoit) 983 Page Boulevard, Springfield, MA 01104 Name(Print) Current Mailing Address: (413)244-9006 Signature,—PLII Telephone 2.2 Authorized Agent: D. P. Carney Construction, Inc. 34 Horseshoe Circle, Ware, MA 01082 Name(Print) Current Mailing Address: (413) 967-7124 Signature Telephone SECTION 3'-ESTI ATED CONSTRUCTIO COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $136,479.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection $136,479.00 J 6. Total = (1 +2+3+4+5) Check Number ( This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date 4w-ty-ul mc-sA � 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 El Change of Use❑ Other❑ Brief Description Re-roof Millitech Building - 29 Industrial Drive East, Northampton, MA 01060. Of Proposed Work: 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 ❑ I 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 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: 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) 1S St 2nd 2nd 3rd 3`� 4 t �.-- 4th Total Area (sf) 27,000 Total Proposed New Construction (sf) Total Height(ft) 18 Total Height ft 7.Water Supply(M.G.L. c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone : Municipal ❑ On site disposal system❑ Version 1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be tilled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height 18 Bldg. Square Footage 2708 % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DON'T KNOW Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW Q YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW e YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES ® NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO O 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 © NO O 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 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 El Name(Registrant): Registration Number Address 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 D. P. Carney Construction, Inc. Not Applicable ❑ Company Name: Daniel P. Carney Responsible In Charge of Construction 34 Horseshoe Circle, Ware, MA 01082 ss r (413) 543-3150 Sig a Telephone Version 1.7 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 O SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 29 Industrial Drive East LLP (Mark Benoit) as Owner of the subject property hereby authorize D. P. Carney Construction, Inc. to act on my behalf, in all matters re rk authorized by this building permit application. 10/08/2018 Signature of Owner Date D.P. Carney Construction, Inc. as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Joann Carney Print Name 10/08/2018 Sig ture of caner/Agent Date SECT 12 -CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Daniel P. Carney [CS-099798 License Number 34 Horseshoe Circle, Ware, MA 01082 ;08/19/2019 �ss Expiration Date (413) 543-3150 Sign ure 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 O No 0 The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aaalicant Information Please Print Lezibly Name (Business/Organization/Individual):D. P. Carney Construction, Inc. Address:34 Horseshoe Circle City/State/Zip:Ware, MA 01082 Phone #:413-976-7124 Are you an employer?Check the appropriate box: Type of project(required): l.E]I am a employer with 15 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]' ]0 ❑ Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance: ✓ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑✓ Other Roofing 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the 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:Granite State Insurance Company Policy#or Self-ins.Lic.#:WC009930624 Expiration Date: 11/15/2018 Job Site Address: 29 Industrial Drive East City/State/Zip:Northampton, MA 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$1,500.00 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify nder the pains and pe es of perjury that the information provided above is true and correct. Sip-nature: Date: 17 Phone#: 41 C967-7)24 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): Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 11. : 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 partners,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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 wwwmass.gov/dia 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: 29 Industrial Drive East, Northampton, MA The debris will be transported by: All Waste Removal Company, Hampden, MA United Material Management, Inc. The debris will be received by: 896 Main Street, Holyoke, MA Building permit number: Name of Permit Applicant D.P. Carney Construction, Inc. 10/8/2018 Date Signature of P �Applicant Commonwealth of Massachusetts Construction Supervisor Division of Professional Licensure Unrestricted-Buildings of any use group which contain ®s Board of Building Regulations and Standards less than 35.000 cubic feet(991 cubic meters)of enclosed Construction Supervisor space. CS-099798 E x p i res:08/1912019 DANIEL P CARNEY 34 HORSE SHOE CIRCLE WARE MA 01082 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Commissioner Call(617)727-3200 or visit www.mass.gov/dpi Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation 1178 D. P. CARNEY CONSTRUCTION, INC. Registration: 34 HORSESHOE CIRCLE Expiration: 044/1112/11/2 020 WARE,MA 01082 Update Address and Return Card. SCA 1 $ 20M-05117 %�r�tnntsnnriin�n�/�r, -'�fiianr�ns�//1 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 121178 04/11/2020 One Ashburton Place-Suite 1301 D.P.CARNEY CONSTRUCTION,INC. Boston,MA 02108 DANIEL P.CARNEY 34 HORSESHOE CIRCLE WARE,MA 01082 Undersecretary NOt Id R6=Utdure DPCARNE-01 ANGELA A�O�RO CERTIFICATE OF LIABILITY INSURANCE DATE 10/09/2018Y) 10/09/2018 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Angela DiAugustino Phillips Insurance Agency,Inc. PHONE Fax 97 Center Street (A/C,No,Et):(413)594-5984 (A/C,No):(413)592-8499 Chicopee,MA 01013 pp RL .angela@phillipsinsurance.com INSURERS AFFORDING COVERAGE NAIC 9 INSURER A:Kinsale Insurance Company INSURED INSURERS:SIDIOCUVO Ins Co Of Southeast D.P.Carney Construction,Inc. INSURER C:Granite State Ins Co 34 Horseshoe Circle INSURER D: Ware,MA 01082 INSURER E: 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR n M/ D A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 CLAIMS-MADE F—X] OCCUR 0100041217-2 08/01/2018 08/01/2019 DAMAGE REMISESTO ER�ENTEoccurDnce $ 100,000 MED EXP(Any one $ Excluded PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000 POLICY❑X JECT M— LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: BI/PD Deductibl 5,000 MBINED B AUTOMOBILE LIABILITY Ea accid.'SINGLE LIMIT $ 1,000,000 X ANY AUTO A9094953 08/01/2018 08/01/2019 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOSBODILYBRODILY INJURY Per accident $ AUT03 ONLY AU0TAMAGE 0-S ONLY PPerOacEcide tD $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5'000'000 EXCESS LIAB CLAIMS-MADE 0100054375-1 08/01/2018 08/01/2019 AGGREGATE $ 5,000,000 DED X RETENTION$ 0 C WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY Y/N X T ANY PROPRIETOR/PARTNER/EXECUTIVE C009930624 11/15/2017 11/15/2018 1,000,000 OFFICER/MEMggER EXCLUDED N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1'000'000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT B Installation S1985457 08/01/2018 08/01/2019 Limit 107,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:Re-Roof Millitech Building 29 Industrial Drive East Northampton,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Atlantic Capital Investors,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. Mark Benoit 983 Page Blvd Springfield,MA AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4,0 r City Of Louis Hasbrouck<Iasbrouck@northamptonma.gov> NwOw w0an 29 Industrial Drive Louis Hasbrouck<Hasbrouck@northamptonma.gov> Thu, Oct 11, 2018 at 12:32 PM Draft To: dpcarney45@gmail.com Daniel, The building at 29 Industrial Drive East might need construction control.The code has a number of specific requirements for different types of re-roofing. Please send more specifics;flat or pitched roof,strip or recover, amount of insulation, etc.The existing building code got complicated. I looked for the original plans but couldn't find her. Louis Hasbrouck Building Commissioner City of Northampton Town of Williamsburg (413)587-1240 office �� ) J� (413)587-1272 fax ' �J t.� cJ 4 ty 9 J-7 C9(11 oil\ �s ca��'