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10D-046 (14) BP-2022-0209 135 MAIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 10D-046-00I 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-2022-0209 PERMISSIONIS HEREBY GRANTED TO: Project# WATER DAMAGE Contractor: License: Est. Cost: 237500 JAMES TROMPKE 071734 Const.Class: Exp.Date:02/28/2024 Use Group: Owner: NORTHAMPTON GOLF INC Lot Size (sq.ft.) Zoning: URA/WP Applicant: SINGLE SOURCE SERVICES Applicant Address Phone: Insurance: 290TAYLOR ST (413)427-5320 422005263906 GRANBY, MA 01033 ISSUED ON:03/04/2022 TO PERFORM THE FOLLOWING WORK: water damage repairs 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: i f • Ts, . Fees Paid: $1,663.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner fk 1 ikr:444.1.„ 1 . i, kr.\. nr• >;:, da..,fiyr,"(N,,,,'. ,/ . t • • The Commonwealth of MassachusettMAR - 3 2022 Office of Public Safety and Inspections Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two`-A'a 3re e s �Q.. (This Section For Official Use Only) Building Permit Number: c a Date Applied: Building Official: SECTION 1:LOCATION ar Met in S.# Leeds 0/0S"3 77orf-hoonp,Eaa7 Ccu, r-y Chub No.and Street City/Town Zip Code Name of building(if applica le) 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 Repair 51.,t 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 ❑ No ®/ Is an Independent Structural Engineering Pee Review required? Yes 0 No fI7� Brief Description of Proposed Work L.v4,tet [carnal f PG,vt b(L'Le.Yl gPcm 1 (ec- Pi'p e R e,ifloi e4 al/ She-1. art wa//S It'n -P/aors + 4I4-w 7-itlSv41. r/c "VP SNiFi teCk t1/'P# -1 01-Ez7R>(,4L _ A/EkJ j e(AlLre 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): 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 0 A-2❑ 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 lie 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 0 IBD HA IIBO IIIA0 IIIBD IV 0 VA El 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 Le Check if outside Flood Zone 0 Indicate municipal Et' A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: Not Applicable 0 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 Adylress of Property Owner-Lrael&,s-ff ecs545(4,,,L sc m4�� 5/ L,ed/f 0/05-3 Name(Print) / No.and Street City/Town Zip Property Owner Contact Information: `z'/3-5f6 f89f - Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: 5/,t.i&LE Se✓RcE S►=E;,')c 021'0 ///yl7/e 5i 6:4nHBy 41ft c/off 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 (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 tollIL o /ree Se(VtCe Co Jny Name,.T riles 7 lit C'2- 07/7.3V —l�rl re Sr/c�ce{ Name of Person Responsib a for Construction License No. and Type if Applicable oZQO jai/4 ,- S brae • Illq o/03 Street Addr City/ own State Zip 4-1//l a 4/07-7 S3 2 V - - ,J k: nt lff ra gr _5 ti l g it Co vrl Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11: (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 0 No Cl SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor pp and Materials) Total Construction Cost(from Item 6)_$ . -3 J 00 00 "LociP / ► 1.Building $ l71/ `)00. Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ 62 tee `'C' appropriate municipal factor)=$/i b 63.n0 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to ('rrY Ot JJoer ya/),o7 ,j 6.Total Cost $ 02'37 544,, "° (contact municipality)and write chock number here (93 4, _ 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. Jones(rn p1. l iv.94.114 0(0 vi.t<" (413- L(11 6-3 3-0 Please print and sign nai}t title Telephone No. Date "ray/es i 0 r 54— (�r a n `1 _±_14 6 l 033 J v i-co*Tic.. e✓l onct Z l xo nt. Street Address City/Towrf State Zip Email Address t )1 Municipal Inspector to fill out this section upon application approval: 1 u-- ' �� ' 3 Name �I _ ate City of Northampton o,. M S .. s ,.. Massachusetts ��+5` �c'<< w ; , DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street • Municipal Building J� �D .4 Northampton, MA 01060 -SN1y ,.�‘'‘�' 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: �.4-S',., �<< �G � � sf-//c SfrJ'T cfrt The debris will be transported by: Name of Hauler: /i4er ,$'I°c#i-c de4« Signature of Applicant: I, , , 1,t4 Date: a-/7-Z2 = ■■■ • Construction ■■■ ■■■ • Environmental r ' 0)i ww 41‘91 ■■■ S,,,,,,, ::: • Facility �, '' a b r .yr �� • ■ ■ • Technology Northampton Country Club Sub Contractors Expert Drywall , C 98 South Washington Services StreetLL, Belchertown, MA 01007 Mercier Carpet Service, Inct spring 1343 Riverdale Street, Wesfield, MA 01089 Rocky's Acoustics Company, Inc 54 Second Avenue, Chicopee, MA 01020 Urban & Sons Insulation Company, Inc 385 Liberty Street, Springfield, MA 01104 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constr-uct6ri'Supervisor CS-071734 E-tipires: 02/28/202,2` A JAMES W TRQMPKE .r 1 290 TAYLOR STREET GRANBY MA 01033 Commissioner : 0 Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.govldpl /'..4,1 JAMEWTR-01 CKELLY ACC, ` CERTIFICATE OF LIABILITY INSURANCE DAT3/E 2/202 YYY) `--•� 3/2/2022 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: AXiA Insurance Services PHONE FAX 84 Myron Street (NC,No,Ext):(413)788-9000 (NC,No):(413)886-0190 Suite A E-MAILDSS:info@axiagroup.net West Springfield,MA 01089 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Mutual Insurance Company 17000 INSURED INSURER B: Single Source Services LLC James W.Trompke INSURER c 290 Taylor Street INSURER D: _ Granby,MA 01033 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYY1 (MM/DDIYYYYI LIMITS A X 1 COMMERCIAL GENERAL LIABILITY ICI 1 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 18500071811 4/14/2021 4/14/2022 PREMSES(EaAMAGE TOENTED occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[X1 JE& LOC PRODUCTS-COMP/OP AGG _$ Included OTHER: BLANKET Al $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO 1020100486 10/5/2021 10/5/2022 BODILY INJURY(Per person) ,$ OWNED SCHEDULED AUTOSRE ONLY X AUUT�OSS I BODILY INJURY(Per accident),$ X AUTOS ONLY I X AUTOS NED I (Per accident4AMAGE $ $ A X UMBRELLA LIAB X' OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAR CLAIMS-MADE 4620093366 02 4/14/2021 4/14/2022 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 i$ A WORKERS COMPENSATION I RIPER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN ;4220052639 06 4/14/2021 4/14/2022 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A , (Mandatory in NH) , E.L.DISEASE-EA EMPLOYEE,$ 500,000 It yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I 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 Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE -)''', ..?„..:?' ' ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD P The Commonwealth of Massachusetts —"'"� Department of Industrial Accidents Office of Investigations , ,_�f. i Lafayette City Center _ 1: " ¢�v 2 Avenue de Lafayette, Boston,MA 02111-1750 44c www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Single Source SVC, Inc. Address: 290 Taylor Street City/State/Zip: Granby, MA 01033 Phone#: 413-427-5320 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ■❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors f El 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 K. ❑ Demolition workingfor me in anycapacity. employees and have workers' p �' t 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.n Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other 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: Arbella Insurance Group Policy#or Self-ins. Lic. #: 4220052639 06 Expiration Date: 04/14/2022 Job Site Address: 135 Main Street City/State/Zip: Leeds, MA 01053 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: JiG-w. Date: 3/3 Phone#: 41 -427-5320 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5111Plumbing Inspector 6.0Other Contact Person: Phone#: