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16B-003 100 BRIDGE RD-JFK BP-2022-0013 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16B-003 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY'FUND (MGL c.142A) Category: REPAIR ' BUILDING PERMIT Permit# BP-2022-0013 Project# JS-2022-000017 Est.Cost: $42000.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: REBUILDEX OF PLYMOUTH COUNTY LLC 042906 Lot Size(sq.ft.): 963547.20 Owner: NORTHAMPTON CITY OF J F KENNEDY SCHOOL Zoning: URA(100)/RI(81)/WSP(44)/SR(0)/ Applicant: REBUILDEX OF PLYMOUTH COUNTY LLC AT: 100 BRIDGE RD - JFK Applicant Address: Phone: I (Insurance: 6 COMMERCE WAY (508) 866-3500', WC CarverMA02330 ISSUED ON:7/19/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE LOADING DOCK 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: • I THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. IT Certificate of Occupancy Signature: I ' r ` FeeType: Date Paid: Amount: Building 7/19/2021 0:00:00 $0.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner '1 he *ImilyRECEI M,ssachusetts I`I f; �� t . i g d ��spections ,._. _ -_ Massa Iti 1&1130113iing Co.• (780 CMR) Building Permit Application for any Building o • an a One-or Two-Family Dwelling (This Section For Official Use Only) Building;PermitNumbe6 2.Z43 Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) i 6 6 -0 03-00% t o® Iltzadle 0 t 0(,0 �f' k4e./1 z01,� Lt o oI-- 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 0 RepairX Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other ❑ Specify: / Are building plans and/or construction documents being supplied as part of this permit application? Yes l No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No C� Brief Description f Proposed Work: M e- '1' Lo Attly. 06G� p14As d z zi /149 ce-iL 7 ,(-9c3 'y141-1- 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) 0 Existing Use Group(s): S'top L Proposed Use Group(s): S c3.1od 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 Ef 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-10 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 CI IIB ❑ IHAO HIE CI IV CI VA CI VB 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: / Public Check if outside Flood Zone 0 Indicate municipal 31 A trench w�' not be Licensed Disposal Site Pr Private CIor indentify Zone: or on site system 0 required Of or trench or specify: permit is enclosed❑ Railroad right-of-war.- Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable LEI Is Structure within airport ap oach area? Is their review complet ? or Consent to Build enclosed 0 Yes 0 or No I' Yes 0 No t SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: rr Special tipulations: Design Occupant Load per Floor and Assembly space: D WIC- T221h{Q Al— SECTION 9:;PROPERTY OWNER AUTHORIZATION } . Name and Address of Property Owner Ci-6o. - NvC ( 990 n AA* 21 hnA- ST 0 t 0 6 0 Name(P t) No.and Street City/Town Zip Property Owner Contact Information: U.S IV 7€(Z - - — - k<<U S pii 2Tz P, NorA ►/•yo +-I4./z.vs Title Telephone No.(business) Telephone No. (cell) e-mail address If 4pllicable,the property owner hereby authorizes: V; r.-0 Ik• 1 a-iwki ii (o (titveu- CAA i GA1)-V'?/+— v F 0 2-17 0 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 0. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)! Sef w b S rv,;t -Ni L cri- -3 lig 1 `17q 3 o Iaine(Registrant) Tel one No e-mail address Re tration Number J /� C ore�i-es Rate- S ee c$e1cA (v�� 013 13 crab �/3� Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 'c2.03kri Ids oA- T liy co 4 1.1. e. Can �, I ymYName A-V0r►D PtPk jp_ CS - ocitoio �1 ,5 7,3 Name of Person Responsible for Construction License No. and Type if Applicable U Com0Aritte. LAM-1 CA l' L A40 o 7.1?0 Street Address City/Town State Zip 5 -$1e6—%So41) 1(?)l_q'S3- cf-9I- ebOz-QJ(ebvi Id.e)6. G4w4 Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Acddents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the uance of the building pemut. Is a signed Affidavit submitted with this application? Yes No D SECTION 12:CONSTRUCTION,COSTS AND PERMIT FEE (, Estimated Costs:(Labor (,�Z Item and Materials) Total Construction Cost(from Item 6)_$ 1 ,00o 1.Building $ 121 0 06 • Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 41 2'000 (contact municipality)and write check number here SECTION 13:SLGNATURE 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 f owledge and understanding. /I2I 2 Please print and sign name Title Telephone No. Date GoMMxeue, viNti CAt-Ve/— j4t*- 07/330 Tr- arebU,Ide.y.coh. Street Address City/Town State Zip Email Address I t� ' Municipal Inspector to fill out this section upon application approval: s` 6 ' ` 7 1 (a/al . .. , Name r i Date. City of Northampton d + .-0a��.' Massachusetts1,1510.4 wi3 DEPARTMENT OF BUILDING INSPECTIONS +r'+fit f 212 Main Street • Municipal Building V � a�� �' Northampton, MA 01060 'r '� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of BuildEing 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: A 1.-2(2. el NorcRAi-1(4-01X11-"' The debris will be transported by: Name of Hauler: AuxAT.At I 3 - z LI -3 0-- Signature of Applicant: Date: (-7-)-?-( II Initial Construction Control Docent t Y } To be submitted with the building permit application by a f Registered Design Professional tt , r for work per the ninth edition of the Massachusetts State Building Code,780 CMR,Section 107 oject Title: Date: ? IZ h- opedy Address: Project: Check(x)one or both as applicable: New construction (fisting Construction Project al .o ', ion: C$, -J(�l `�colc,i (�$ NS I Registration Number: Expiration date: ,am a regsstera�ter testa professional,oral,and I have prepared or directly supervised the preparation of all design plans,computations and specifications conc 1ingt: Architectmmral Structural Mechanical Fire Protection ec cal Other: for the above named project and that to the best of my knowledge, infos nation, 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 urnderstand 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: 1_ Review, for conformance to this code and e design concept, shop drawings, samples end 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,I shall submit to the building official a'Fianal Construction Control Document'_ Enter in the space to the right a'wet'or electronic si and seal: 3-RC.0\40 S 4.-\4 Phone mu er: 1 Pinata- BuildingOfficial I/se Only Building Chad Name: Penult No. Date: Note L T wTirgta with an`?project dew plies nsy computations and specifications that you pr ed or directly supervised If`other'is chosen,proride a description_ Version 01 01 2018 Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural ✓ 4 Fire Suppression ✓ 5 Fire Alarm(may require repeaters) 'f 6 HVAC 7 Electrical ✓t 8 Plumbing(include local connections) v — 9 Gas(Natural,Propane,Medical or other) 10 Surveyed Site Plan(Utilities,Wetland,etc.) 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review(521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information 30rke. P2 Milers i'1ega-JaSSoC akS .cowl • 'cc)b 5A.‘34 q(1_3c1- - 3y�ta totigo Name(Registrant)n Telephone No, n e-mail address Registration Numbe C oer1-21 fkvt .\� Ole erg el 0( Discipline Ex �/�� Street Address City/Town State Zip p p Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date - - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. 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. ,g Address of the work: /00 - ,) Flo/QIc- /V1 1 The debris will be transported by: LOA Pi ( I1.--LC-L - q f 3 2 Gy The debris will be received by: 10U v"e d„if ge-c 7-- Building permit number: I V : fA Nam of PermitApplicant , AkArt&Mft Date Signature of Permit Applicant The Commonwealth of Massachusetts w,Mi Department of Industrial Accidents _ I`E=— 1 Congress Street,Suite 100 1`—0'1E_ Boston,MA 02114-2017 www.mass.gov/dia V ye Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Rebuildex Of Plymouth County LLC Address:6 Commerce Way City/State/Zip:Carver MA 02330 Phone#:888-732-8453 Are you an employer?Check the appropriate box: Type of project(required): 1.19 I am a employer with 24 employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'camp.insurance required.] 9. 0 Demolition 3.1=II am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑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 11.0 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�r Other Loading Dock replace 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. t 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:StarStone National Insurance Company Policy#or Self-ins.Lic.#:WC-0002313 Expiration Date:12/31/2021 Job Site Address:100 Bridge Road City/State/Zip:Florence MA 01062 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 certi der a pai s and penalties of perjuty that the information provided above is true and correct Signature: Date: 7 I 2-N4A 1.o 2-I Phone#:781-9 - 2 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#: w • _____,........40 REBULLC-01 AWILFONG ACORO° I DATE(MM/DD/YYYY) k...------ CERTIFICATE OF LIABILITY INSURANCE 1/12/2021 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 NAM-ACT Gwen Vosburgh Armfield,Harrison&Thomas,LLC PHONE FAX 458 South Ave. ran.Ext):(603)356-3392 (Arc,No):(603)356-9290 E-MAIL Whitman,MA 02382 ADDRESS:gwen@mmins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Evanston Insurance Co. 35378 INSURED INSURER B:Star Insurance Company -_ _ 18023 Rebuildex LLC INSURER C:StarStone National,Insurance Company 25496 6 Commerce Way INSURERD:Lloyd's of London, - A1122J Carver,MA 02330 INSURER E: , INSURER F: 1 , 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 OTHERIDOCUMENT 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 !NM WVD IMM/DD/YYYY) IMM/DDIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR MKLVIPBC001315 11/1/2020 11/1/2021 DMMGEESTOEEoNcTDe ncel $ 100,000 -- MED EXP(Any one person) $ • _ PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PPei 2,000,000 POLICY LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _AUTOSN BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS ONLYY (Per acEcidentDAMAGE $ . $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE MKLVIEUL102593 11/1/2020 11/1/2021 (AGGREGATE $ 5,000,000 DED X RETENTION$ 0 $ B WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY WC0002313 12/31/2020 12/31/2021 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N N/A - - - (Mandatory in NH) IE.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below IE.L.DISEASE-POLICY LIMIT $ C Commercial Umbrella S89888201ALI 11/1/2020 11/1/2021 Per Occurrence 5,000,000 D Pollution Liability ENP000381902 11/1/2020 11/1/2021 Each pollution claim 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES JACORD 101,Additional Remarks Schedule,may be attached if more space Is re uired Additional Insured status is granted for Brook House Condominium with respect to Commercial General Liability ONLY if such status is required in written contract or agreement per the terms and conditions of forms CG2010 04/13&CG2037 04/13. Blanket Primary&Non-Contributory Status Is granted to Additional Insureds with respect to Commercial General Liability ONLY if such status is required in written contract or agreement per the terms and conditions of form CG 20 01 04/13. Blanket Waiver of Subrogation Is granted with respect to Commercial General Liability ONLY if such status is required in written contract or agreement per the SFF ATTACHFD ACOR❑7n1 CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Brook House Condominium THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 55 Pond Avenue#103 Brookline,MA 02445 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD *‘* ;,,•"1,41.4,44. . !;! , 3 1, • .' . A tv a 1 „.: . Cell, ir "h, 0 91 's WZ.....';''.7'.!".',•-•,--',.”0-,-,-.v eIN '..... 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