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24D-070 Tandem Bagel BP-2022-1623 238 KING ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24D-070-001 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-2022-1623 PERMISSION IS HEREBY GRANTED TO: Project# INT DEMO 2022 Contractor: License: Est. Cost: 8500 THOMAS BACIS 070061 Const.Class: Exp.Date: 03/06/2023 TARLIN LLOYD D& JACOB RABINOV ARTHUR L Use Group: Owner: SHERIN&SIDNEY R RAB Lot Size (sq.ft.) NEW ENGLAND REMODELING GENERAL Zoning: HB Applicant: CONTRACTORS INC Applicant Address Phone: Insurance: 75 VALLEY RD (413)478-5272 WCC500601501 SOUTHAMPTON, MA 01073 ISSUED ON: 12/16/2022 TO PERFORM THE FOLLOWING WORK: DEMO INTERIOR TO PREP FOR TANDEM BAGEL FIT OUT 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 VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: II,,nn NN 1\_, ,cpoirty Fees Paid: $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner E DEC 14 2022 1 I >: T 0.r no The Commonwealth of Massachusetts ,E ';F M^rpH i�a o ,ONS Office of Public Safety and Inspections �`I 7 Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number:A a. I(/A3 Date Applied: Building Official: SECTION 1:LOCATION 2,11 K4i J $ 7. up Ti- Alee 7/i t*p ron Ns a',Go 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 Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building Repair 0 Alteration 0 Addition 0 Demolition yil (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 0 No 0 Is an Independent Structural Engineerin Peer Review required? . 1 Yes 0 No 0 Brief Desch tion pf Proposed Work: t)(Y'D 'Z'n 7G✓1 G c S d FF- 7 -T C ovkrer. f`Pe 1 h pit?4r41/Ir. Fo,- 4/Ls- Tandems. (� cSe ( Co. qc,, d ol,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): 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❑ A-5 0 B: Business ill E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 Hal 0 ` H-5 0 I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-ID R-2 0 R-3❑ 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 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV El VA El VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Dis sal Site Public al Check if outside Flood Zone Ip Indicate municipal�j7 A trench will not be Po la, Private 0 or indentify Zone: or on site system 0 requirecrVA or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Reyiew Process: Not Applicable q 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 ciao .-f ShoP 13 $S Lrcock 5 Z Q01 cy, Ow, • 1(; Name(Print) No.and Street City/Town Zip Property Owner Contact Information 6 r i'4'1 Da ley Te,t6 366 3366 - - e baler ae74,1 al'Sni.S-v,,ces' Title Telephone No.(business) Telephone No. (cell) e-mail address • Cpt/V1 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 ap•lication. 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❑. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin document submittals) �, Ic �r6w G-rS �o r�,. '"lvNn ►0ovy/af 't03 _SSA 064i doc/ylus.Q 7 y s �d `1 `1 fi( Name(Re.gis trant) Telephone No. e-mail address Registration Number q 6 wapiti/ S7. �or1lt i p7,vr /ka. o(ibi Arcs;>1c7w 4 -1 r 3 Street Address City/Town State Zip Discipline Expir tion Date 10.2 General Contractor /Vey £et 3 lard (Zemolt'fM1 aen c>al c-an 7/a c7a✓c Lit c: Company Name �hA_ S (G s 07 one, , U Name of Person Responsible for Construction License No. and Type if 2plicable 7 ,S" VG /ley (Ld So•"717a l� m �i,.t 707 4 die 77 Street Address City/Town State Zip tl!37T S.7-7)L 4/ -tag- Sal. T aces 71 d2 64,4t /e 66444 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 El No Cl SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building • $ Building Permit Fee=Total Construction Cost x (I -rt here 2.Electrical $ appropriate municipal factor)=$ . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ I (contact municipa ity) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ e i S 0 D (contact municipality)and write check number here .00 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 best of my knowledge and understanding. lvw. &"c,s- &L...— efe j,'d sr 7 to i 7? 1Z 1?J-1 Z—,0202� lease tint and sign name Title Telephone No. Date .S� Vti i IPt IR-/ 54✓TAemP7i4^ i.t^ a 1123 T c • 7 ram11 , Con Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: _4(.._ ___•,�� ! �� Name Date City of Northampton sI a Massachusetts #.x._ 'r DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building vb e _¢ Northampton, MA 01060 fsNjY ~, 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: V6r /lt'Y 1` �G c, 106 The debris will be transported by: Name of Hauler: A-4(On S Q ' i( (0 Cr' S lSignature of Applicant: Date: 2' ZsoZ A ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMID022YY) 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 Scott King,CIC NAME: King&Cushman Inc. AHICOHNo,EM). (413)584-5610 FAX No): (413)584-9322 P.O.Box 447 E-MAIL sking@kingcushman.com ADDRESS: 176 King Street INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURER A: Northfield Insurance Co INSURED INSURER B: Safety Indemnity Insurance Company 33618 New England Remodeling INSURER C: Scottsdale Ins Co General Contractors,Inc. INSURER D. AIM Mutual Ins Co 75 Valley Road INSURER E: Southampton MA 01073 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2212905072 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 ADDLSUBR 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 DAMATO RENTtl.) CLAIMS-MADE X OCCUR PREMISE S(Ea occurrence) $ 100,000 - _ MED EXP(Any one person) $ 10,000 A WS514639 10/23/2022 10/23/2023 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 —1 POLICY PRO $ 2,000,000 JECT LOC PRODUCTS-COMP/OPAGG OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED �/ SCHEDULED 2395873 03/09/2022 03/09/2023 BODILY INJURY(Per accident) $ _ AUTOS ONLY /� AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) PIP-Basic $ 8,000 X UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS-MADE TBD 12/06/2022 12/06/2023 AGGREGATE $ DED RETENTION$ _ '$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITYri STATUTE ER Y/N 1,000,000 D ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WCC5006015012022A 09/04/2022 '09/04/2023 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 10 ,00000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The Stop&Shop Supermarket Company,LLC is included as an Additional Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD . ,, The Commonwealth of Massachusetts -- litsmil lema,, rows Qt Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.govidia Si inkers'Compensation Insurance Affidavit:Buiklers/ContractorsJEkctriciansiPlunibers. 11)RE FILED V.'rill"r HE PERMITTING Al rTHICHUTE„ Applicant Information Please Print Legibls Name illusincss;Orgaimatiort'Indrviduall: Neu, Cill /art, item odet,hy G e,e, Prot/ k_el 7?4,‘ Address: 7 s- 1/a IJ e y t2d , 1 city/state/zip:Sip/Am/hp 14" ni a 01673 Phone#: "/43 —4f 28 -5?-7'— Are yea in enipioyer?Check the appropriate box: Type of project(required): IJ lam a employer with_ 1: — ertiployees Unit and srt part-timei..• 7. 0 New construction 20 I am a sok proprietor or pienterthip aid have no employee*working iota,e in S. Cl Remodeling any,..-apainay.[No worers'comp.iniairanix nxpriattlj .. ia30 lain Li homeowner doing all wink myself[No woricrsa'comp..inionince riquiresL]* 9 r Demolition i 0 0 Building addition 4.0 lam a homeowner and will be hiring oartracturs to ouoliscr all work on my property. I will emote that all cureviciun either have swelters'compensation insuramt or are mole 110 Electrical repairs or additions propmetor4 with no einployem I 2.[J Plumbing repairs oil additions .50 I am a tritest contractor aril I hs.,c hired the stib-contrectors listed on the attached thee. I 3.:11Rooftt-paits The..sub-cuninttors FrAve onpluverN.and tsn 4.:woriers comp.anNuntrice° 141:10ther. 6.0 We.at ocorpocabon and its officers have exervised their nglel of exemption per Mut.c. 152,'I/10i,and we Moe no employees.[Na,workers'comp.insurance required.] 'Any applicant that cheeks boa#1 nuns also fill out the section below showing their workers'compensation policy inform:shoo_ /Hoineowners who submit this afilfavit indicating they are doling all work and then hire outside contractors trust submit a new affidav it indicakeig such, teontracksrs that check this but most attached an additional sheet showing the name of the sult-c-oritructoe$.antl Aare whether or not those mime,hate employees It the sob-contractors.haw employees,they mum provide their workers-..., ,ir 1 am an employer that is providing worAers'compensation insurance tor my emplovees. Below is the policy and fah site inprination. Insurance Company Name: A 5 Sac i C;(i i'd cirri p/1,,Geo-.1.-- ,1.. pi j' Ca e Policy#or Self-ins.Lie.4: 64/ C C.- _rod ( „-Sal .2cizz.4 Expiration Date: Ci-(i - e 7 Job Site Address: .2 2--1 V:eij 5-r. un; 7 ..1-- CityiStateiZip:4/0/711 of agArz, Attach,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 S1,500.00 aisiior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under r pains and penalties of perjury that the information provided above Is true and correct. Signature: ------ ---- 12', ' 4 ' Date: I 2_— I Z_--2 Phone r-', LI 1 3— ct 7 g S.2- 72 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): .. I, Board of Health 2.Building Department 3.Clty/Town Clerk 4.Metrical'inspector S.Plumbing Inspector 6.Other I , Contact Person: Phone#: 0 SHE cOMMO _ _.. - • �. IMPROVE $@�siRess HUSE17'S NE Resist* �_���oNT12gCTpeR 1at;on • r IA/Cw Eli.1-4,.. MDf ?� 8 ' 3;rtion�va�d#or�use only before the 1 1 R a f C GF R41-Cpexpiratin date. iffvend return to 1 i 75 OMgS NFRAC7- 1 1 Office of Caper Ads-and dtiwa # vACLEYAGS y \ \} 1 on meet -Sege 7!0,MA G2118 1 1 . SOUTNAMP ON MA 1 �� ��y s''• I yam' „v� ! ersecret ,--'. :1-t/< ,d- 1 ,...------.., : ,•.... 1 : ' Not wed signature ! —_-______ .___________________,, , ri. ; • ,.„... .1 .....,„4„,..„..... -- - Commonwealth of Massachusetts Construction Supervisor 1 pjvjsion of Professional Licensure Unrestricted -Buildings of any use group which contain Board of Building Reyulatios and Standards less than 35,000 cubic feet 991 cubic meters of enclosed Isor space. Consr �' • 1 Ires:031061202" i1. ' • j CS-070061 1HOMAS M CISin, c 1 75 VALLEY A `1 S OUT H AMP TOSd MM 1 Failure to possess a current edition of the Massachusetts X &I LIIJP— State Building Code is cause for revocation of this license. ICommissioner For information about this license Call(617)7273200 or visit wwwmass.govidpl I i i