18D-053 (25) •
aragritLi 1 t-i)( rs(c. y+c BP-2007-0389
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0389
Project# JS-2007-000576
Est. Cost: $44000.00
Fee: $220.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CLARK L DORE CONTRACTING_
Lot Size(sq. ft.): Owner: HAMPSHIRE COMM PROPERTIES
Zoning: GI/WP Applicant: CLARK L DORE CONTRACTING
AT: 80 DAMON RD
Applicant Address: Phone: Insurance:
442 SILVER STREET (413) 733-4080 O WC
AGAWAMMA01001 ISSUED ON:10/6/2006 0:00:00
TO PERFORM THE FOLLOWING WORK:BLDGS 4 & 5 - 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 Signature:
FeeType: Date Paid: Amount:
Building 10/6/2006 0:00:00 $220.002516
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Versionl.7 Commercial Building Permit May 15. 2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify s
APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
�TION 1 -SITE INFORMATION
1.1 Property Address: N� This section to be completed by office
76 j2a- ,-, �� _ - Map Lot Unit
i 4 -
� Zone Overlay District
Elm St.District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
I
Name(Print) Current Mailing Address:
Signat re I,7 .,G . Telephone
SECTION 3-ESTIMATED-CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
. Building ! a
i L i/e U a a ci O Building Permit.Fee
2. Electrical ! (b)Estimated Total Cost of j
Construction from(6)
3. Plumbing -Building Permit Fee
4. Mechanical(HVAC) I
5. Fire Protection ---
6. Total=(1 +2+3 +4+5) Check Number V.5 1 0-ado--
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
r , ^
Versionl.7 Commercial Building Permit May 15,2000
8:'NORTHAM'PTON ZONING"
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size : .
Frontage ii
Setbacks Front 7-1 r—�
Side L:' ' R:: L:' R:'
Rear
Building Height
Bldg.Square Footage F— % ---
I j
Open Space Footage %
1
(Lot area minus bldg&paved i i i i
parking)
#of Parking Spaces
Fill: 1 i i
(volume&Location) 1' I i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES Q
IF YES, date issued:
1F YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book Page: and/or Document#;
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
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 O NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000 -
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Exi ting Wall Signs ❑ Demolition❑ Repairs 0 Additions 0 Accessory Building❑
Exterior Alteration 0 isting Ground Sign 0 New Signs❑ Roofing 0 Change of Use 0 Other❑
Brief Descriptio ter a brief description here. S {� /9 �,..A
Of Proposed W k: �j',P�� ��-trBl. 1- y9'-
1
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ElA-1 0 A-2 0 A-3 El1A I 0
A-4 ❑ A-5 0 1 B 0
B Business 0 2A ❑
E Educational 0 2B I 0
F Factory 0 F-1 0 F-2 0 2C 0
H High Hazard 0 3A 0
I Institutional 0 I-1 0 1-2 ❑ 1-3 0 3B ❑
M Mercantile 0 4 ❑
R Residential 0 R-1 ❑ R-2 0 R-3 ❑ 5A 0
S Storage 0 S-1 0 S-2 0 5B I 0
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
1
Existing Use Group: 1 I Proposed Use Group: i
Existing Hazard Index 780 CMR 34):^ Proposed Hazard Index 780 CMR 34): i i
- SECTION-6 BUILDING-HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION ", OFFIGE.USEONLY
Floor Area per Floor(sf)
I 1st '
1st
�' 2ntl
2 7
3rd i 3`d ! J d.. 17: — ——
i 4th Ii
I -4th
Total Area(sf) Total Proposed New Construction(sf) n
i
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
.
Versionl.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 0
Name(Registrant): _
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
I
Signature Telephone Expiration Date`
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
l
Name Area of Responsibility
Address Registration Number
i j
Signature Telephone Expiration Date
I I
Name Area of Responsibility
Address Registration Number
, ! i
ignature Telephone Expiration Date
.3 General Contractor
Not Applicable Cl
Company Name:-
A DoTh.A__, c mitt/dye/iv/ ;
Responsible In Charge of Constructi
iz $_sue
Address G/!E ` „"7 S ' . 1 Sr- (yYl GI
( `r J 237--yar0
Signature eettA.A n Telephone
Versionl.7 Commercial Building Permit May 15,2000 -
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize •to
act on my behalf,in all matters relative to work authorized by this building permit application.
•
Signature of Owner Date
• ,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 penury.
y- t4i ameU r)U )2 .
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: — •
I -
License Number
i
Address Expiration Date
Signature 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 0 No 0
4 •
O��Kl.l-f pTO -
{I;4 �' Cyif l�f Northam t�)It foil 1 l. MI
4
�,Ilb DEPARTMENT OP ➢U1LDrNc INSPECTIONS 4 -7-4--L-.--'
212 Main Street ' Municipal Building
Northampton, Mass. 01060 NO'
WW'GRKILIZ'S C0MTENSATTON INSURANCE A FED A\f1T
It -- — - - — — - . ._... _ .... -- ---
(li cry sodpermi ttcc)
with a principal place of business/residence at:
(phone')
(sa-rt/city/stairlap)
do hereby certify, under the pains and penalties of perjury, dial
/I an an employer providing the iollowinz worker's compensanon coverage For my •
employees worming on'this job.
rsc_ ... _
„: ,,
-
(ianlranc Comc nv) (Policy Nu. cr) (r=:-pinion Du,^-)
•
( ) I.am a sole proprietor, general contractor or homeowner(cce one) and have hired
the contractors Listed below who have the following worker's compensadon policies:
(Name of Contractor) (Insurancc Coinoanyi?oUci Numb: ) (Cxpiralnon Di1c)
•
•
(I`Iame of Contrmor) (Lnsura.n= ComDaavPoLic-v Nlzincr) (E pir.:tion Dale) .
(Name of Conn-acior) (Insu anc Compan).fPoLicy Nambc-r) (Expiration Date)
•
(Name of Contractor) (Ituuranc ComoanyfPolicy Number) (Expirtion Date) .
(aaaeh.ci.±itiocSJ s±,eG ifnocculy to oc'v.ec inforc»oc pert.' to.11 cocc-o. ) ,
( ) I am a sole proprietor and have no one woridng for me.
( ) I am.a borne owner performing all the work myself.
NOTE:plesc be on-arc th.0,...b:Je bomcowxn wbo employ pezotn w do e•;•-,c",,••= C "--.r,.1o0 a foul Work ov.d..ell_a of
not more then tSoe tmks in which the bocc000 oe racida or co the Qarn6 zpputtca:.a tbe-ao e-c oot t..._„-.ay a.,rici=cd to be
ciiployc:uoG-the wcrtor`i c e u,ca Act(GL152ss 1(5)),applia000 by a hocctoou-oa far c iic- .or porran cozy n-irk-rcc the
Irgal r,_=of ao maloy.r under dso Worlrelt Coc oao.tioa Aea.
I uo4c-sod tta a copy of Ibi.aai.®entt zruny be forwvrd..d to tb•peq.arcm.coa of 1^•^••rric!AzatkaLY Offre.of Saaur.00a for th.
oovcrtge vtciGctioo and the fe.1tze to saaarc :o -vrz>be trodcs soetion 25A of MOL 132 eta Icy to the isprsaioo of cimieal pcniltia
coatiLstg of a floc of up to Si So0.00 anchor is prtsoarDC01 of up to ooc y r cod d vi7 pcoal io io be form or.Slop Wort Onicr aad.
fin=of S100.o0 a day aptiast me ( .
aze.4../fA h..._.. ...._._..,
For dcp.na+=sl ux only —._.---�
Pcrmtt Numb.=
Map: Lot k
Signature of Lim s Pce-miucc L?3ce 1 .,,
From: 10/ /2006 11:55 #093 P.001/002
ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY)
10/5/2006
PRODUCER (413)569-2928 FAx (413)569-2949 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
FSC Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
617-F College Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
P. O. Box 259
Southwick MA 01077 , INSURERS AFFORDING COVERAGE _NAIC#
INSURED INSURER A:Nautilus Insurance Co
Clark Dore Contracting INSURER B:Arbella I surance Group 14168
442 Silver Street INSURERc:American ome Insurance
INSURER 0:
Agawam MA 01001 INSURER E:
COVERAGES
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.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION
_TR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YY) DATE(RRYDDlW, UMITS
GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000,
RENTED
X COMMERCIAL GENERAL LIABILITY PRE'MIS S(Ea oavn-ence) $ 50,000
A 1CLAIMSMADE X OCCUR NC541790 08/09/2006 08/09/2007 MEDEXP(Any one person) $ 5,000
_ PERSONALS ADV INJURY $ 1,000,000
GENERAL AGGREGAT"E $ 3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OP AGG $ 1,000,000
I POLICY 17 JECT LOC ,
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $ 1,000,000
B ALL OWNED AUTOS 02551400003 6/12/2006 6/12/2007 BODILY INJURY
(Per won) $
X SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Pa ate)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGG S
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE S
$
-1 DEDUCTIBLE yyyyRETENTION S �1-s H S
C WORKERS COMPENSATION AND TORY UpM IOER 5
EMPLOYERS'LIABILITY
ANY PROPRILTOR/PARINEWEXECUTIVE EL EACH ACCIDENT $ 1,000,000
OFFICERIMEMBEREXCLUDED? WC00894587000 6/10/2006 6/10/2007 El.DISEASE-FA EMPLOYEE 1,000,000
If yes,describe under
SPECIAL PROVISIONS below El_DISEASE-POLICY LIMIT,S 1,000,000
OTHER
IESCRIPTION OF OPERATIONSILOCATIONSNEIIICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
]on tractor
:ERTIFICATE HOLDER CANCELLATION
4 1 3) 5 B'/-1 272 SHOULD ANY OF THE ABQVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of Northampton EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Linda Lapointe 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
Northampton, MA 01060
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER,ITS AGENTS 0'It:IL•RESENTATIVES.
AUTHORIZED REPRES' ' , I..
'•
CORD 25(2001108) illiF0 ORD CORPORATION 1988
i INS025(0108).05 ELECTRONIC LASER FORMS,INC.-(800)327-0545 . Page 1 of 2