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10D-046 (17)
BP-2023-1449 135 MAIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 10D-046-001 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-2023-1449 PERMISSION IS HEREBY GRANTED TO: Project# REPLACING GLASS 2023 Contractor: License: Est.Cost: 30000 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 LLC Applicant Address hone: Insurance: 290 TAYLOR ST (413)427-5320 4220052639 07 GRANBY, MA 01033 ISSUED ON: 10/18/2023 TO PERFORM THE FOLLOWING WORK: REPLACING PLATE GLASS WITH FRAME CONSTRUCTION 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: lI ,2 . Fees Paid: $210.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner Erna (i aUOaC ' l ' G oc� The Commonwealth of ass husetts 20a3 w _' Office of Public Safety and Massachusetts State Building Code gU 7.MG ,P� Building Permit Application for any Building other than a One-o �`""romp elli g 0 l (This Section For Official Use Only) Building Permit Number.2 3'j/' Date Applied: Building Official: SECTION 1:LOCATION /3.5" /21Ri L-eeD.r /119- O/05.3 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❑or check all that apply in the two rows below Existing Building 0 Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy ❑ Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No Is an Independent Structural Engineering Peer eview required? Yes 0 No ISl- Brief Description off Proposed Work p sale_ 3/a a 55 1tl�A me Con ucD'an 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): is Ke 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 l9 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 0 R: Residential R-1❑ R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA CI IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA 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 0 requir Private 0 or indentify Zone: or on site system 0 ti 0 or trench or specify: 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 ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): a Type of Construction:4/1211d_r-v-4 ewe-- Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Acldress of Property Owner n��j NO 4 C• /3.c /17R)n s/, Dr OJ Name(Print) No.and Street City/Town) Zip Property Own C"ontacst�Inform 'a on JI9mES c.�SAC 7f0/✓ VT.: _536 7q'72_ Ws_S36_ 74/72- 11Ap 6a//?(r.e 9.:74 aef Title Pe•ctr" Telephone No.(business) Telephone No. (cell) 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 0. 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 Sin e .Sc) cc c SerVie$ Com y Name �larN.es lI'oeri p4 CS - 07/ 73? Name of Person Responsible for nstruction Ls No. and Type if Applicable a 9'p -a71/ r S4 Cc avdir N o i 6 37 Street Address City/Town State Zip '/!3 - Y21 5320 - - -'Jw fro npke6)5',4 fe5av bete S✓c.. Cc.;-‘ 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(hunt Item 6)=$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ . 3.Plumbing $ I]m 4.Mechanical (HVAC) $ Note:Minimum fee=t DAD (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 3 dtob o ,- (contact municipality)and write check number here 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 accurate to the best of my knowledge and understanding. 1 ,Ja Iv'on'rk,� Ceti. Y,21 53 C ase print and sr name Title Telephone No. Date 290 l / /6r S�' r'a / W14 U l O?.3 P Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: /67 ID`"18.201.3 Name Date City of Northampton e`rir•'- Sys.."'" sip r' ••" Massachusetts I r s A f DEPARTMENT OF BUILDING INSPECTIONS ti D. 212 Main Street 40 Municipal Building f � Northampton, MA 01060 NA, .;,�%�� 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: C04 The debris will be transported by: Name of Hauler: U5l,.d (-1 Signature of Applicant: I Date:/0--6)--2,7 The Commonwealth of Massachusetts _meDepartment of Industrial Accidents (, 1 Congress Street.Suite 100 ' Boston. MA02114-201 4- ` >'� wwwmass.gov/din 11 uskers'Compensation insurance.%ffida'it: Builder%Contractors/Electricians Plumbers. FOUL 111_t:11%1 I I II I III- PERM!I I IN(:At'` l101tlf1. Applicant Information Please Print I.roibly Name(Business Organization!akin iduail �QI ( 5 1/roWa-n ,SUv/C.G S7Cet/� Cc,T es', Address:%IVV l /- 5/— 1 City/State/Zip: (ratLi/ !Pk O167.1 Phone =- y/3 -41‘27—S 32G. Are yes re employer?Cheek the appropriate hex: Type of project(required): ID ism a ci ,kn cr with tmaplo'ecs(full and or part-tank)• 7. CI New construction 20 l am a sole proprietor or ptutncrship and have no etrtploycxa noticing forme in 8. CI Remodeling any alpaca).[No nutters'comp.iataorat►ae reguitul-J 301 am a homeowner an work9- ❑Detrwlittm doing myself.[No workers'camp.insurance mowed.] 4.Q I ant a lxms.'owner and will 1w hams onrttractors to coodw t all work on my property. I wilt 1(1 CI Building addition ensure that all contractors etcher have norke s"cumprraautn insurance or sae auk 11.0 Elec-trical repairs or additions proprietors with no omit,'ctis. 12.0 Plumbing repairs or additions v m a iron ral contractor and I have hied the wb-contractors listed on the attached sheet_ I3.a Roof repairs These sub-contractors have:employees and have*others comp.wuraoe:e. In Other 6.0 We are a c'orptearsan and tt officers have exrn.acd they right of exetrgitnat per Wit.c. It 152.§1(i),and we have no cngflo}m.[No workers'coups insurance required.) 'Any applicant that chcx'ks box a 1 must also fit out the section below showing their*utters'compensation polity otfarmat,un •Homeowners who submit this affidavit indicating they are dung all wink and dam hire outside contractors must submit a new atfidas it nahttalug such. :Contractors that check this box must attached an additional sheet show ing the name ante sub-contractors and state whether or not those entrtic.ha,. empioyees.. if the sub-contractors have tmg+lo,:c,.they mina provide then workers'camp pubes manlier I am an employer that is providing waders'compensation insurance for my employees. Below is the polity and job site information_ insurance Company Name: 4t6 Q//4 u 'o. r ;pt.S Policy#or Self-ins.Lie. =: 4/2-.2,40 57?,.-6 3c(-01 A,, Expiration Date.4'1 T2-Y Job Site Address: l3 S" c-i tt 5-1-5-1— J"t/drene� Met City State Zip. p/e 7 5'3 Attach a 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 and,or 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 be for .trued to the Office of Investigations of the DIA for insurance coverage v erification. I do hereb ij'under the pain,at penaltie. of perjury that the information provided above is true and correct. (iiii sty aunt: 1),i 10— [Z—Z 7 Phone x: / V/2 - 4/27 -5'32 a Official use only. Do not write in this area.to be completed by city or town official ( its or Town: Permit/license>s Issuing Authority (circle one): I. Board of Health 2. Building Department 3.('its Town(jerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone 4: From: •• )4Me5 ro •sin / SUcrrcc Sc,ro,ccs (77 ra Illy `if5S 0/033 To: Jonathan Flagg Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, I request that you grant a modification to waive the requirement for construction control of the project at /3 54— Ro(r 4, ewe s3 because the work is of a minor nature, will not affect structural elements, health, accessibility, life or fire safety, and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. • Respectfully, /44174 JAMEWTR-01 CDANDY ,4coR0 CERTIFICATE OF LIABILITY INSURANCE DATE7/ Y 10/17/2023 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 CONTACT NAME: AXiA Insurance Services PHONE FAX 84 Myron Street (Alc,No,Ext):(413)788-9000 (A/c,No):(413)886-0190 Suite ASS;info@axiagroup.net West Springfield, MA 01089 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Mutual Insurance Company 17000 INSURED Single Source Services LLC wsuRERB: Single Source SVC, Inc. INSURERC: James W.Trompke INSURERD: 290 Taylor Street -- Granby,MA 01033 INSURERE: 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 CONTRACTOR 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 LTR INSD WVD (MWDD/YYYYI (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500071811 4/14/2023 4/14/2024 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ 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 ' 9j LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: BLANKET Al A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ _ ANY AUTO 1020128181 4/14/2023 4/14/2024 BODILY INJURY(Per person) $ AURRTEOS ONLY X SCHEDULED BODILY INJURY(Per accident) $ PX HI)TOS ONLY X AUOTO ON Y (Per ardent)DAMAGE A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 3 5,000,000 EXCESS LIAR CLAIMS-MADE 4620093366 4/14/2023 4/14/2024 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ A WORKERS COMPENSATION XOTH- AND EMPLOYERS'LIABILITY • STATUTE ER 4220052639 08 4/14/2023 4/14/2024 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 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 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