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17C-224 (23) BP-2023-1357 3 NORTH MAIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17C-224-001 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-2023-1357 PERMISSION IS HEREBY GRANTED TO: Project# ROOF VENTS/INSULATION 2023 Contractor: License: Est. Cost: 4300 IMPERIAL WORLDWIDE 077508 Const.Class: Exp.Date: 02/28/2024 Use Group: Owner: LLC VALLEY GO WEST Lot Size (sq.ft.) Zoning: GB Applicant: IMPERIAL WORLDWIDE Applicant Address Phone: Insurance: 708 GRAFTON ST (508)791-2200 CS-WC-007368-02 SHREWSBURY, MA 01545 ISSUED ON: 09/27/2023 TO PERFORM THE FOLLOWING WORK: 2 ROOF VENTS AND INSULATION 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: ( Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner The Commonwealth of Massac bo • is < ,„\� Office of Public Safety and Inspection '*3,0-3. Massachusetts State Building Code(780 CMR) .04A, Building Permit Application for any Building other than a One-pr s,n ily I •elling s • (This Section For Official Use Only) 'o''o Building Permit Number;23- 7 Date Applied: 9,17/)3 Building Official: SECTION 1:LOCATION 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 52' Repair 0 Alteration 0 Addition 0 Demolitionem 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other .L9'Specify: 417/1L ALA.%44 e- isuW'et.• �► ��dic�Y Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No V" ✓C�/ Is an Independent Structural Engineering Peer Review required? Yes 0 No IV Brief Description of Proposed Work: cQ r f t�* &i� � 4i► Z Af tf/Qi , 01 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 ❑ A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business ❑ 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❑ I-2❑ I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4❑ 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 ❑ IIA ❑ IIB 0 IIIA ❑ IIIB ❑ IV 0 VA El VB 0 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 0 Check if outside Flood Zone 0 Indicate municipal❑ A trench will not be Licensed Disposal Site[ 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)c -Type-of Construction:, s. f Does the building;contain an Sprinkler Systein?:`. Special Stipulations; ,, Prft Design Occupant Load per Floor and Assembly space:�_ SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Valk-7 6 t r a ec,344 4- • i Name(Print) No.and Street City/Town Zip Property Owner Contact Information: . -GM- ,t-0 - - . ‘ Title 4Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: (14 1a- /Zjau n: elt3 5>e9 i14/tt r Nato'rt% e.14,11 r vcAco_ditaal 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 construction control forms Lee section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) ufl i lial c k_ ®e -A7 - 7J)o g bciduA- ,e.y,r r__ tt -0,7sob Name(Registr t) elep a No a-marl a dress Re tration Number a�7 is „WO(' Street Address City/Town tate Zip Discipline Expiration Date 10.2 General Contractor Company Name U�Y Name o Person Responsible for Construction License No. and Type if A plicable 70g (v 4t * 51111 S a'cic Street Address City/Town State Zip 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 El SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 11360. OD Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal fpctor)_$ . 3.Plumbing $ M� 4.Mechanical (HVAC). $ Note:Minimum fee=$ 04 (contact municipality) 5.Mechanical (Other) $ / Enclose check payable to 6.� 6.Total Cost $ (1,31)6 L6 (contact municipality)and write check number here \, • r 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 accur e best of my knowledge and understanding. a_Foucii/ .fib 7 9, - Please".76 C ds name S st A.fil 0i r ai.ouTelephone No.'Y�11e 't e Street Address City/Tow State Zip Email Address Municipal inspector to fill out this section upon application approval: Name Date City of Northampton .co P 6 S S Il Massachusetts i� e �(_ * .G } s DEPARTMENT OF BUILDING INSPECTIONS -'" ~ 212 Main Street • Municipal Building a! e Northampton, MA 01060 PsNjy' �1^~C 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 ' i 'of U rUlk-"CI40 LA-)Q- - U Location �, 7n & ✓-4 YS7' 1SkRe_ LJ plckc�c- . th 3Lr cA U _r ' is zn ?lied v: Name of Hauler: Cap(jta_/ t S po Sck._ Signature of Applicant: Date: L'^ '� ' The Commonwealth of Massachusetts I .` . ('6 Department of industrial.l ccidents 1 Congress Street.Suite 100 Boston.MA 02114-2017 Yrz MM..mass.gol/dia 11 takers*Compensation Insurance Affidavit:Buildersi('ontractorsfElectricians!Plumbers. 10 HE FILED f11 f11E PERM11"I l\(::11'11tORI 11. Annlicant Information Please Print Leeihls �_ _ 1,/ /,- Name(liustncs%(Irgatatiauon LtJt s:dual 1: ,��1h�1 f)t�� . �C`�Yid GV l Address: 76 g 0,64{$'t9t„ '1.- City/StateiZip: arl/,t l u r y do e/f YI Phone#: . �P/. 70( AadO O Are dew employer°(hark the appropriate Mn: Type of pnject(required): I. :silt J:utploycf wtih !T cntpl'ytxs bull and to part-acre:).' 7. DNow conslruition _. I.ant a VA:pro'rr:t.v ut puttn`-rship anti base nu cntplu?o.rs working t r n►.to 8. ® Remodeling in tJpacdy.(\o workets'contp.isnurancc reyuusal.l 9. ❑ Demolition ?.D 1 attt J ltttttAVNter doing all work tayiell.Nu noskas'cow.ucsuram:rcyuirsal.l' 100 Building addition •i.Q lint 4 lent am nt f and will it,:hiring eznnirsaurs to comlust all tuck on my prupi.-rty. I w ill eruutc that all cunti.ciur%cooler Itas c works-vs'ctmtpcnsawn truurant.t:or are sack 110 Electrical repairs or additions posprictun with no t`rnpluycc^.. 12.0 Plumbing repairs or additions 5C3 I aln a pererat contractor and I base fined the sub-contractors list.J on the attaclt.J shed. Jhcse Nubctmtracton!rase cittployc.s and base warkcrs':.map.anutarxc. 13.0RWl repairs 14.2 --/- ' 6.0 w,are a oaspualion and rt•of tii4.1%teas c csaKc rscJ then nyhi of rkntptwn p►Y l►1GL c. � .tht:uc W.l ld 11 152..1(4),and we flew no tm Iuyre%.(Non wtake 'Comp.inra sunce rcyui ed ,'I 631C9" *Any appbeartt that chucks NA a I rnnst also till nut Ills soctwn twlow%hawing then is urktr t.comfit:n.at ou policy istlittinatuxi. $Homcvwners who uhiud this at'tidrtit indicating they arc dying all work and then hire txttstde we:tractors mot subnnt a tort alit:LA o indtcairlg such. :Candace tx%that thcwi this hr!t moot atu droll an:additional shoot%bussing the moue oldie wbcxndracturs and state wht:ibcr or nut oliow tltiut:s has. slnpltycer. It t1s sub-:ttt:tracta-.t.kat.cugdutut s.they must ptuttdc their ,tucker.'sump lent:,"ttuartht. I am an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site information. /�,� Insurance Company Name:011ie SDYJY�S /�_ 17 ' a2 &W al/p' co.._ Policy#or Self ins.Lic. : CS-We, — 60?3(1a 0 - Expiration Date: a//5id T__ lob Site Address: S 1Q04Art Aie.titlet CityState?Zip:,WfM Aj_ Attach a copy of the workers'compensation policy declaration page(showing the policy number an expiration date). I-allure to secure coverage as required under 1MGL r. 152.*25A is a criminal violation punishable by a fine up to$1,500.00 and or one-year imprisonment,as is ell as els it penalties in tlx:form of a STOP WORK ORDER and a tine of up to$250.00 a da against the s iulator.A copy of this statement may he forwarded to the Office of Investigations of the I)1A for insurance coseraoc‘,ertiication. I do hereby certi unde pa" s nobles erjury that the information provided above is true and correct. S, nature: Date: 071a.3 Phone:=: )/ -2q( ,:?)-elP, OJTcial use only. Do not write in this urea.to be completed by city or town official ('its or Town: Permit/License# issuing.authority(circle one): I.Board of health 2. Building Department 3.('ity/fossn Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other ('ontact Person: Phone#: Initial Construction Control Document �� To be submitted with the building permit application by a • J. Registered Design Professional i for work per the ninth edition of the )-il,-.ls' Massachusetts State Building Code, DSO CMR, Section 107 Project Title: Date: 670)-1 3 Property Address: ? /Ud r al /kIG►N Si-- foctlpssr 'n1 g a- Project: Check(x) one or both as applicable: New construction V Existing Construction Project description: `�✓44s Li a ✓ 1 vewts avi lavo ,.2A WA_ ,hmura a2-1 I MA Registration Number: Expiration date: ,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning:: Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept. shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports (see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a 'Final Construction Control Document'. Enter in the space to the right a "wet"' or electronic signature and seal: Phone number: Wei 74I .3?00 Email: a6oLkctieyGv e_yal400,cokoo Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an'x'project design plans.computations and specifications that you prepared or directly supervised.If'other'is chosen,provide a description. Version 01 01 201S Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing(include local connections) 9 Gas(Natural,Propane,Medical or other) 10 Surveyed Site Plan(Utilities,Wetland,etc.) 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review(521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number ()q.)- ,11,4/7;d /k//ar,/ '�1{� / C b? e g P€PY Street Address City Town State Zip Discipline piration Date - - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. A�D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 2/15/2023 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 CONTNAME ACT Chris Rose Herlihy Insurance Group PHONE • FAX 51 Pullman Street No.Ext): 508-756-5159 I(NC,No):508-751-5747 Worcester MA 01606 ADDRESS: certificates@herIihygroup.com INSURER(S)AFFORDING COVERAGE NAIC 8 INSURER A:Selective Insurance INSURED IMPEWOR-01 INSURERB:Clear Spring Property and Casualty Company Hill Companies, LLC dba Imperial Worldwide Imperial Worldwide, Inc. INSURERC: 708 Grafton Street INSURERD: _ 1 Shrewsbury MA 01545 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:116770286 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 LIR INSD WVD (MM/DD/YYYY) (MMIDDIYYYY) A X COMMERCIAL GENERAL LIABILITY Y Y S 2512815 2/15/2023 2/15/2024 EACH OCCURRENCE $1,000,000 AMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $500,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JE X LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y A 9109223 2/15/2023 2/15/2024 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS xy HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) - A X UMBRELLA LIAB 1 X OCCUR Y Y S 2512815 2/15/2023 2/15/2024 EACH OCCURRENCE $3,000,000 EXCESS LIAB I CLAIMS-MADE AGGREGATE 8 3,000,000 DED X RETENTION$in nnn $ WORKERS COMPENSATION Y CS-WC-007368-02 2/15/2023 2/15/2024 X AND EMPLOYERS'LIABILITY Y/N STATUTE OTH- ER ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Pollution Liability S 2512815 2/15/2023 2/15/2024 Each Inc$300,000 Agg limit-$300,000 A Equipment Coverage S 2512815 2/15/2023 2/15/2024 $100,000 Limit $1,000 Deductible DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Subject to policy terms,forms and conditions.Certificate holder and any person or organization required in a written contract is included as an Additional Insured with respects to the General Liability policy for ongoing operations per form CG8810-04/13 and for completed operations per form CG8583-04/13 when required by a written contract. Coverage is provided on a Primary and Non-contributory basis and a Waiver of Subrogation is afforded on the General Liability policy where required by written contract per form CG8810-04/13.The Automobile Liability provides Additional Insured status and a waiver of subrogation where required by written contract per form CA8828-10/11.A Waiver of Subrogation applies when required by written contract on the Worker's Compensation policy per form WC 00 0 31 3-4/84. Umbrella policy is follow form. 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. Town of Shrewsbury 100 Maple Ave Shrewsbury MA 01545 AUTHORIZED REPRESENTATIVE )il J. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD