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32C-137 (22)
BP-' 022-1356 395 PLEASANT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32C-137-001 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-2022-1356 PERMISSION IS HEREBY GRANT; D TO: Project# ADD WALLS Contractor: License: Est. Cost: 12000 REVAMPIT LLC 053791 Const.Class: Exp.Date: 05/26/2023 Use Group: Owner: DIMENSION REALTY LLC Lot Size (sq.ft.) Zoning: GB Applicant: REVAMPIT LLC. Applicant Address Phone: Insurance: 251 RIVERSIDE ST (413)244-4805 WCC-500-5024478 WEST SPRINGFIELD, MA 01089 ISSUED ON: 10/19/2022 TO PERFORM THE FOLLOWING WORK: INTERIOR OFFICE ALTERATIONS 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fees Paid: $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner RECEIVED The Commonwealth of Massachusetts ' +7' OCT 19 2022 Office of Public Safety and Inspections ,. Massachusetts State Building Code(780 CMR) Ruilding Permit Application for any Building other than a One-or Two-Family Dwelling DEPT.or DUILDIPIC IPNSPE 'ONS NORTHAMPTON.MA 01060 (This Section For Official Use Only) Building Permit Number: •7.A• /36-(i Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) 3aC— 137 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 0 Alteration Er 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 I;VNo 0 Is an Independent Structural Engipnring Peer Review required? 441 Yes ❑ NoBrief Description of Proposed Wo Fr4►M e- "N o7 W4/5 W) !K tr S Bt e 4rel* ?Kct� A rec�jWv� O�Q, .i 1I Me1?I .�'1cs 'A" 4# aM-e0 OHS eL.*y IAO✓ An Ofigke QQ . 1 ¢'VAVnt, tr o�nt watt )� f $+i O(CG w‘ .Qoo✓ 4 ' 51 iVtl .e66,444 rl S1IwCINr/umjis SECTION 3:COMPLETE THIS SECTION'IF EXISTING BUILDING UNDERGOING RENOVION,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) 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 le E: Eaucational ❑ F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 E 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 0 HA IIBD MA IIIB ❑ IV 0 VA El VBD 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 Check if outside Flood Zone 0 Indicate municipal 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 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 Address of Property Owner c l tL- �c� - el/ Name(Print) No.and Street City/Town Zip Property Owner Contact Information: cO -c✓ y/3 _.7,a- 65-73 - - Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: 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 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 Company Name /� JSSA Ft� (.,i4re 0531 I (41r-fAvir-�.0 Name o Person Responsible for Construction License No. and Type if Applicable ?S-I A'Cv 5 W- Sp(-itO ► — oioS `1 Street Address City/Town State Zip - - y13 -6)(14- 4l8 os )0e (eVumlpi+pJ'o5, CO v' 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 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ //i 000 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ / el)0 appropriate municipal factor)=$ 3.Plumbing $ ( (t 4.Mechanical (HVAC) $ Note:Minimum fee=$ \" (contact municipality) 5.Mechanical (Other) $ Enclose check payable toti g�f� 6.Total Cost $ ia,t90() (contact municipality)and write check number here _ o 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. / /44A- P ase prinit and sign name Title Tel phone No. Date X( K il�t.r,,� Si' (A)- 5(GQ Mk 0 108 acD re✓qr► ►rp%ro5, carp Street Address City/Town State Zip Email Address L%___ Municipal Inspector to fill out this section upon application approval: :IP w i 1 ID 1ct a, Name Da e City of Northampton Oa(HAMpTO M•, 5„,s ..:•.sic Massachusetts Iti 1 4 � .' DEPARTMENT OF BUILDING INSPECTIONS �? 212 Main Street • Municipal Building \ �" Northampton, MA 01060 S' 1QC 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: III N d( o The debris will be transported by: Name of Hauler: VVil J— (LC Signature of Applicant: Date: 7/ /( - The Commonwealth of Massachusetts =v 1 i tt Department of Industrial Accidents • =lit_ I Congress Street,Suite 100 _'v-= Boston,MA 02114-2017 46" wwwmass.gov/dia Workers'Compensation Insurance Affidavit:Bullders/Contrsctors/Electricians/Piumbers. TO RE FILED WITH THE PERMITTING AUTHORITY. Aotsllcant Information Y Please Print Le�[ibiv Name(ausinesst[k�amatiaollndividual): VC11y�1I / • Address: 02 1\M,✓ 5'1" City/State/Zip: (Al— 5-‘7 "' MA- c9 l 0?.9 Phone#: (4( 3 d-Y V V O__c— Art yeyse employer?Cheek the appropriate box: Type of project(required): i.gei am a employe'with / employees(full aodror part-time).* 7. o New construction 2171 I am a sole proprietor or prtnmlip and haw no employees working for ow in 8. ialemodeling any capacity.[No workers' co . mP ioeuse°e required] 30 lam a homeowner doiq workers' emn all week myself.[No wke s'coup.in .ee required"' 9. ❑Demolition 10 0 Building addition 4.0 I am a homeowner and will he he contractors to conduct all work on my property. 1 will mew that all contra:ton either hew wnrkm'oomperwocm ieauance or are sole 11.Q Electrical repairs or additions proprietors with no employees_ 12.0 Plumbing repairs or additions 50 I am a general contractor and I have hived the tatb.cowrt ctors bard on the attached sheet l 3. Roof airs Them The etbraatraclon have employees and home workers'comp.ieeraoce.; ❑ ' 6.0 We are a corporation and its officers have exercised their right of exemption perMGI c. 14.D Other 152,i 1(4),and we have.o employees.[No waters'comp.insurance required.] 'Any applicant that docks boa II mutt also fill out the section below showing their workers'compensation policy iofarmtiost i Homeowners who submit this atfMwit inc icaties they an doing all work and then hire outside°retractors mud submit a new affidavit indicates such :Comment diet check this box mien attached an additional sheet showing the name of the subcontractors sod state whether or not those nsoiola haw employees If the sub.caatract°rs have enrploym&they mud provide their workers'comp.policy number. I am an employer that Is providbra workers'compensation insurance for my employees. Below is the policy sad job slut information. Insurance Company Name:AI n1 M VTU Ot L /I Policy#or Self-ins.Lic.#: [,U C(—C0O — 5002 '-1 y7 s'- a.0�?A" Expiration Due: 3/1 113 Job Site Address: D'{ti Su S AA94vl , /V City/State/Zip: MAnA d /Yb4 Attack a copy of the workers'compemadan policy declaration page(thawing the policy number and expiration date). Failure to secure coverage as required under MUL c. 152,¢25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for . • coverage verification. r I do hereby c under the pains 9d penalties of perjury that the information provided ove is true and correct. Signature: t'(fmk Date: Phone#: 1(3 c?(/y"l/$Os Official use only. Do not write in this arra,to be completed by city or town of ii clan City or Town: Permit/License N Issuing Authority(circle one): 1.Board of Health 2.Baildieg Department 3.City/Tows Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone N: Call the plumber ; Ziflow i— Renovation Cal ' 0Hampden-Deeds Hampshire-Deeds v. GIS-LINKS 4 Maps 5 more Flotificatv The OfficsaH Website of the Executive Office of EOHED,the Divsion of Professional Licensure,and the Division of Standards.1111P 4,Public Safety ..,„.. . - . - , , Agencies . itt Mass. Mass.Gov Home State ,. / Licensee Details Demographic Information 1 • uIt Name: JOSEPH G LAFRENIERE iOwnererlsdeNasryatmaLteuic:se. _,.... ,i_ ........_ Address Information License Southampton iCitY: ,io.n'i MA State: 01073 , ZiPcode: United States country: .4, im'irtn-'-illel n7-111tS:71111:11------::::-::— License Information S On:3791n C - Renewal: 5/26/2023 liCense No.: Building Licenses *ration D Expl . ate: 10/18/2022 Profession. 5/26/2011 , License Type: Date. Construct—ion Supervi' sor ssue Date: . Active TDoadt ea yosf L a st 5/4/2021 econ sni :. Type: 1 Lice — - oing Busines tatus Chan e Reason: _ tion„iisite inf(4)-1-71-1!!. ----- NNo Fo'clAroesvre:wiu'nb.doleilwtlielD1101firifc'uo , ,_ ,..... A urn DATE(MM/DDIYYYY)CERTIFICATE OF LIABILITY INSURANCE 10/19/22 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: Jenny Murdza Metras Insurance Agency PHONE No,Ext): 413-536-1491 FAX No): 413-532-8522 2030 Memorial Drive E-MADDRESS: jmurdza@metrasinsurance.com Chicopee, MA 01020 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM Insurance INSURED INSURER B: Revampit, LLC INSURER C: 251 River St West Springfield, MA 01089 INSURER D 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 (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPP7384L 02/12/22 02/12/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP ACdG $ 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 CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Northampton Intergrated Medicine ACCORDANCE WITH THE POLICY PROVISIONS. 395 Pleasant Street Northampton, MA 01060 AUTHORIZED REPRESENTATIVE Jenny Murdza ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD la----- I 1 ---1 'Vliv)4 915 (i-i 5 \ „ _ 0m _,U _ rorn oil eau I )j ' A ''` o . I Q� "1 I IN f . \ 1 1 0 ig _i id C-' 2 C) \ -v;1-‘)