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23A-111 (6)
BP-2021-2309 2 MAIN ST COMMONWEALTH OF MASSACHUSETTS Map:B lock:Lot: 23A-I 1 1-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-2309 PERMISSIONIS HEREBY GRANTED TO: Project# DENTIST OFFICE Contractor: License: Est. Cost: 176500 RIVER SHORE BUILDING SERVICES 114413 Const.Class: Exp.Date:02/01/2023 Use Group: Owner: DESCHENE, NANCY TRUSTEE Lot Size (sq.ft.) Zoning: GB Applicant: RIVER SHORE BUILDING SERVICES Applicant Address Phone: Insurance: 30 COVE WHARF LANE (774)644-3043 6zzub-4n86980a-21 HIGGANUM, CT06441 ISSUED ON:12/17/2021 TO PERFORM THE FOLLOWING WORK: BUILD OUT FOR DENTIST OFFICE 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. Signature: )• - 3-11I 0 Fees Paid: $1,236.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner C ; .E _ ._ Plavis ;,tF sIrs/fir -----o ff ,z * v DEC ' The Commonwealth of Massachusetts 1 c. 5 2021 Office of Public Safety and Inspections ',� ��' I Massachusetts State Building Code(780 CMR) r).F+LI+B.uild1i ng Pe it Application for any Building other than a One-or Two-Family Dwelling T.,_ CTION (This Section For Official Use Only) Building Permit Number: ,l'- Pate Applied: Building Official: SECTION 1:LOCATION Z Ma.tvn 5 t'. F.to rum cc_ O I o fo Z — No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State C de used If New Construction check here CIor check all that apply in the two rows below Existing Building htr Repair❑ Alteration { 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 Vir No VIs an Independent Structural Engineerin '..A eer Re 'ew required? Yes ❑ No Brief Description of Proposed Work u l a Ci V r r Pe vIn0/i- o c c1 Z‹ G VI rrs 1 Floc), c, .en« h 3 &ttG4iv1 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) CI 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) 3 Total Area(sq.ft)and Total Height(ft) SECTION 5:USE GROUP(Check as applicable)` / A: Assembly A-1 ElA-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business g E: Educational ❑ F: Factory F-1❑ F2❑ H: High Hazard H-1 0 H-2 0 H-3 0 H-4❑ 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❑ U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ill IIAD IIB ❑ ILIA ILIB ❑ IV VA VBref7.-- SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supp Flood Zone Information: Sewage Disposal: Trench P• 't: Debris Removal: Public Check if outside Flood Zone s l Indicate municipal'1 A trench w'. not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system 0 required a or trench or specify: permit is enclosed 0 Railroad right-of-wa . Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable Is Structure within airport roach area? Is their review completed? or Consent to Build enclosed❑ Yes 0 or No Yes 0 No ❑ 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 lclief ' Degc.ele ie Z. Aka, -S4- rtor‘tnc_c_ . 610 C&- Name(Prmt) No.and Street City/Town Zip Property Owner Contact Information I Pr. - - 774 b14= -vl )101Q 5 icvt� odd,(ow\ Title Telephone No.(business) Telephone No No. ( e-mail address V If a licable,the property owner hereby authorizes: far'c.k AAe1&vt-T 30 Co tic r,J P L«.r,( 1 ,N-wo w, c f 06 4.1( 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 ki(- Otherwise provide construction control Corms(see section 107 in the code)as required. 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 II Rig v1 � 1,N0rC 34.411cl.t` Sfeli L_CS Company Name R4r LlC Alkt kevt.r. C5 t14kt3 Name of Person Responsible for Construction License No. and Type if Applicable Cdire W koLr i-o-vte_ n aA,,,., 0f O �E4 ( Street Address Yy/Town State Zip E0-971 5154k patievxe_kruC? C Mgt. •1e/- 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 Acciden must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the' suance of the building permit. Is a signed Affidavit submitted with this application? Yes No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 14 i i 6 06 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ /ZI 000 appropriate municipal factor)=$ . 3.Plumbing $ ( c+ DUD 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ -- Enclose check payable to 6.Total Cost $ l 'l tl ,j 60 (contact municipality)and write check number here SECTION • IGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby a st er the pains and penalties of perjury that all of the information contained in this application is true and accurate in the t o y knowledge d understanding. W'riCkMtkrJ Ank,a,. .,! $�-519 -5 5 /2-/ It Please print and s�' nname Title Telephone N . Date 30 covt. L,Jttst. Law-t N K,N....�... 2 4k I p4\t-me ki'�4-g6h,,,,,, t". Street Address Cr Town State Zip Email Address nrt- -' Municipal Inspector to fill out this section upon application approval: 1 • 3)Y 'r, a 7 Name re Da City of Northampton �oa< Mp 0' ` i '"rr G, Massachusetts �?7 1 A. N DEPARTMENT OF BUILDING INSPECTIONS t '* 212 Main Street • Municipal Building -� ', Northampton, MA 01060 • h _�\ 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: wc�l-i -. Po c cry\ 1 ZO 6 v f3,,d-o iW I AI A The debris will be transported by: Name of Hauler: ( 5 A ‘&I VA-i 1. c,1` / Signature of Applicant: Date: f2'I4'Ll The Commonwealth of Massachusetts it,.,, '.-','_ Department of Industrial Accidents = i 1 C(ingress Street,Suite 100 '� : cmt: a::filw r Boston,MA 02114-2017 }.:,.. - wow mesas gate/die - 11 pikers'Compensation Insurance Af iday it:Builders ifontractorsiElectrician.±Plumbers. t(l BE FILED N fill"IDE PIERMITIING AI"171(/ltlfl. Applicant Information ) / Please Print Legibly Name(Husinessickganitatton Innis tdu.s6 M: (Z\J G 1._...5 nS "�_13`�-t i l(.1,`{. �j Cuv t, ,'S .._ -, Address: (i0 Ct; arc W L c !"__._G`c`.wt V City/State/Zip: _C 44.(. Phone#: 34 14 - S 1 S1 .____ Are yew an rntphw er?('heck the a ..a d.Ie lr s: Type of project(required): 11.0 I am a employer with _ _alriluyce. Ilult ausd urpart-iime)• 7. D N` construction 20 1 am a sole proprietor or puttnerxhip and base Illy employ crs working liar me in g_ ; modeling any capacity.No workers'comp.usuranee eyun:d.J 9. ❑Demolition 1.Lj 1 am a homeowner doing all work myself:.(:No wisdom,'comp_ine unirier required" IUD Building addition .II.El I ant a twumctn lei and will be hiring contractors to conduct all Avg'.on any paatwrts. I wail noun:that ad contractors either have workers'compensation insurance or an:sole i 1a Electrical repairs or additions put ton wsth no o nplart;ce.. 12.0 Plumbing repairs or additions S an a general contractor and I fuse hued the sashs,contracton ha`tcd am the attached street. these sub contracture fuse engsloyees and ha.e workers'core.insurance..; 13.171Roofrepairs Id. 6.0 We a a carrpuratum and its officers Isaac exa:wed then nglit of exemption par Wit_c. Othei rc 152.§I(i).and we liaise eau employees.(?Now takers'cutup.insurance ft:win i J *Any applicant that checks box al mast also fill out the section below%hosting their wavier,:comps lrlallOtt policy iafan alias. 'li nncsn n e s who sit snit dos afftahns at indicating they are doing all work and then hue outside itemitrateors rams submit a new at-Wand endi atlnir such :Contractors that check this box must attached an additional slicer showing the pain of the stalsetvitrathers and state whether or nut those entities lease employees.. if the sub-contractors base allphnoes,dal;mug prusidetheir worker;clop..twslic number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. lttsttt.uit:c t'ontratt) Manx: _ Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City State!_ip: Attach a copy of the workers'compensation policy dedaradoa page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,1125A is a criminal violation punishable by a tine 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$2.50110 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifiea I do hereby c fy u dry the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /2 --/4—Z.,-1 Phone#: %a- gj/4--S15A Official use only. Do not write in this area,to be completed by city or town official City or Town: Pernnitll.icense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City lossii('lerl. 4.Electrical Inspector 5. Plumbing,Inspector 6.Other ('outset Person: Phone#: RIVESHO-01 CHRISTINE ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/VYYY) �--�� 12/14/2021 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 CONTACT Christine Sullivan NAME: Phillips Insurance Agency,Inc. PHONE(A/c,No,EXt): (413)594-5984 FAX (NC,No):(413)592-8499 97 Center Street Chicopee,MA 01013 ADDRIEss:christine@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:American Zurich Insurance Co 40142 INSURED INSURER B: River Shore Building Services,LLC INSURER C: 15 Oak Hill Terrace INSURER D: Haddam,CT 06438 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 INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ . MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AfRE PROPERTY DAMAGE UTOS ONLY _ AUUTOOS ONLYY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N 6ZZUB-4N86980A-21 3/24/2021 3/24/2022 500,000 ANY EXCLUDED?ECUTIVE N N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 600,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Doctor Joseph Deschene THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 2 Main St Florence,MA 01062 AUTHORIZED REPRESENTATIVE ACORD 26(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YVYY) `•� 12/14/2021 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 CONTACT NAME: Linda R.Daniels Connecticut Insurance Exchange, Ltd. (A,c N EXt): (860)666-6443 FAX No). (860)666-2131 112 Market Square E-MAIL ADDRESS: lindaBcieltd.us Newington, CT 06111 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Main Street America Insurance 29939 INSURED INSURER B: River Shore Building Services LLC INSURERC: 30 Cove Wharf Ln INSURER D: Higganum, CT 06441-4144 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00003670-286841 REVISION NUMBER: 2 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 EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY MPT9782S 08/09/2021 08/09/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 600,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _, AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB I CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Dr.Joseph Deschene THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. 2 Main St. Hartford, CT 06102 AUTHORIZED REPRESENTATIVE (LRD) ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD Printed by LRD on 12/14/2021 at 03:14PM