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31B-168 30 HENSHAW - TILLY HALL
30 HENSHAW-TILLY HALL BP-2021-1189 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:31 B- 168 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF' BUILDING PERMIT Permit# BP-2021-1189 Project# JS-2021-001992 Est.Cost: $18250.00 Fee: $133.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MMC SPECIALTY ROOFING INC 076497 Lot Size(sq. ft.): 55756.80 Owner: SMITH COLLEGE OFFICE OF TREASURER Zoning: EU(100)/URC(I00)/ Applicant: MMC SPECIALTY ROOFING INC AT: 30 HENSHAW- TILLY HALL Applicant Address: Phone: Insurance: 89 MARSH HILL RD (413) 642-3842 O WC BRIMFIELDMA01010 ISSUED ON:4/16/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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 sir;narn CiPS/T FeeTvpe: Date Paid: Amount: Building 4/16/2021 0:00:00 $133.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 1 �� EIVE APR 1 5 202/ The Commonwealth of Massachusetts �F Suli � ' �'. Office of Public Safety and Inspections It' ' Massachusetts State Building Code(780 CMR) rmit Application for any Building other than a One-or Two-Family Dwelling mp;0 (This Section For Official Use Only) Building Permit Number&P-a a -Writ I Q9' Date Applied: Building Official: I h a cti A vLQ SECTION 1:LOCATION �� ,_ Nee tart otO6 3 T 1k VAG4.+se No.and Street City/" Zip Code Name of Building(if applicable) Assessors Map# Block(#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building PQ Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No Pi Is an Independent Structural Engineering Peer Review required? Yes 0 No Brief Description of Proposed Work: Q +O\I els;S zn EP t k and. ��sll ICJ i sNr. oLcv1S ( Poi .s0G�a "c-ac e ZDo'c ?Inst.)I a�i or, c3.An- r►€ ) •O D 4G.s-I4 ede Cbo/ . 2 200 Squc.,r•e_ 4'e.e4. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft)and Total Height(ft) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-ID R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA CI IB ❑ HA IIB ❑ IIIA ❑ IIIB ❑ IV 0 VA CI VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: A trench will not be Licensed Disposal Site 0 Public 0 Check if outside Flood Zone 0 Indicate municipal 0 required 0 or trench or specify: Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner SvInA-1•. CoIlese. Ste.} /lbc ,kw►P�o�n ©(04,3 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: MAA f Ste c:all Roo4; 17 G Ps'v a c4 _ 511'reek "l�d:O C c0wc-8- MA 0 x%51 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O Otherwise provide construction control forms see section 107 in the code as re•uired. 10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor M PAC, 0A-k� R , Company Name�+ CI I �� r1 c- C.S 0 7�o C'q Name of Person Responsible for Construction License No. and Type if Applicable $9 AALut51r 1‘-‘k\ Rom o1O 1O Street Address City/Town State Zip 4 -6't2 3S 4 Z 41_1_3__-47$- 6193 G1:c4 ammc5feact1+ mat, enon Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes g No 0 SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ Building Permit Fee=Tota •nstruc••• Cost x (Insert here 2.Electrical $ appropriate • niiral factor)= 3.Plumbing 3 4.Mechanical (HVAC) $ Note:Minim fee=$ •ntact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ `g 12.50 (contact municipality)and write check number here - SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. par% GJucs DJ/,/ e-vA- -5 737 $4175/ 10/2,1 Please print and sign name Title Telephone No. Date SC) Jolie V �et.� f Jr'. + c1C AAAoto$S 1,.o�•IYO 17& fe 1 .Cov.� Street Address i City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date City of Northampton ?oaY p. 5%5......"..S1C t : Massachusetts ��,f'.` �_ !<< 1...1 ;G y t{ DEPARTMENT OF BUILDING INSPECTIONS yl ;4 `'V : 212 Main Street • Municipal Building ,}� Ct, wa Northampton, MA 01060 -Pr), - j�'g� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: t/325 -can Kec \'‘r 4 (...)i lac-a.Nnavn i Mkt The debris will be transported by: Name of Hauler: Amtc-i co.r L,2r,.� � Signature of Applicant: Date: 1-17 721 .�......".N MMCSPEC-01 KAYLA I A CORD DATE(MMIDD/YYYY) �,-� CERTIFICATE OF LIABILITY INSURANCE 7/23/2020 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 poiicy(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 At AME: Kayla Marie Drinkwine Phillips insurance Agency,Inc. PHONE PiX 413 592.6499 97 Center Street (Alt,No,Ext►:(413)594-5984 I l Fac,N0):L ) Chicopee,MA 01013 Mtn;kayla©phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Cincinnati Insurance INSURED INSURER B:Selective Ins Co of South Caro 19259 MMC Specialty Roofing Inc INSURER C:National Union Fire Ins Co. 19445 50 Valley View Drive INSURER 0:A.I.M.Mutual Ins.Co. 33758 Westfield,MA 01085 INSURER E:Accident Fund Insurance Co of America 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 'AWL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR,WVD J,MMIDDIYYYYI (MMIDD/YYIn A X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCURCSU0147019 2/21/2020 2/21/2021 1 � X � ; DAMAGE TO RENTED I PREMISES(Ea occurrence) $ 100,000_ ny' MED EXP(Anyone person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY X jEC LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: S B AUTOMOBILE LIABILITY LCEO aBt:da�DD SINGLE LIMIT $ 1,000,000 X ANY AUTO A 9105249 7/17/2020 7/17/2021 BODILY INJURY(Per person) $ _ OWNED SCHEDULED AUTOS ONLY (Pe AUTOSU Bra dent)BRODILY INJURYD (Per accident) S ALA, AUT ONLY _ OSONLYY DAMAGE S $ C X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS UAB CLAIMS-MADE EBU048425395 2/21/2020 2/21/2021 AGGREGATE $ 2,000,000 DED RETENTION$ $ D WORKERS COMPENSATION X PERTUTE OT AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N AWC'400.7030594-2020A 6/7/2020 6/7I2021 EL EACH ACCIDENT $ 1'000'000 QFFICER/MEMg5R EXCLUDED? N N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ E Worker's Compensatio ARP12001591101 1/24/2020 1/24/2021 State of CT 1,000,000 I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,AddIdonal Remarks Schedule,may be attached if mom space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts r-_ Division of Professional Licensor: Board of Building Regulations and Standards Construction'Supe.rnsoi CS-076497 Expires:06/07/2021 CLIFTON FROST 89 MARSH HILL RD • BRIMFIELD MA 01010 rs Commissioner it y c, / � The Commonwealth of Massachusetts Department of Industrial Accidents ■1V '.ia 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. Applicant Information } Please Print Legibly Name (Business/Organization/Individual)'Pi\��tC,_�`Z < i l �! IZL� in tiC� Address: 0 )1E y • 73�} City/State/Zip: a< `IL (i)- Ie_ 1)\1Vl 1Z c'1`'Phone 4:1' 1..3 71_ Are you an employer?Check the appropriate box: Type of project(required): I.E I am a employer with t' employees(full and/or part-time).* 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 [] Building addition 4.0 I 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 1 1.Q 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 sub-contractors listed on the attached sheet. 13..Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other_ 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. 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: A 1 ✓ z"� �'NSI- `"'nc�L Policy#or Self-ins.Lie.#:ALA-%C,4�%�%C'3 S lc "201 ThiA Expiration Date: Ir 7 -"? Job Site Address:_ \2-` S A- City/State/Zip::IvD n _Y1 /-} p d(04;.3 Attach a copy of the workers' compensation policy declaration page(showing the policy nu t'ber and a piration 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 ern.),u ` ains and penalties of perjury that the information provided above is true and correct. Signature: Lam" ✓ -` Date: Phone#: "A; 3 'Z- � 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#: