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24D-070
BP-2023-1325 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-2023-1325 PERMISSION IS HEREBY GRANTED TO: Project# CAR CHARGERS 2023 Contractor: License: CENTERLINE COMMUNICATIONS Est.Cost: 110000 LLC 106586 Const.Class: Exp.Date:09/14/2024 Use Group: Owner: CHRIS ZAWACKI Lot Size (sq.ft.) Zoning: HB Applicant: CENTERLINE COMMUNICATIONS LLC Applicant Address Phone: Insurance: 750 WEST CENTER ST SUITE 301 (844)748-8878 7018111207 WEST BRIDGEWATER, MA ISSUED ON: 09/27/2023 TO PERFORM THE FOLLOWING WORK: ADD 2 EV CHARGING STATIONS 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: i i 3Iho- Ai: Fees Paid: $770.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner chi of Mas- •c etts Fp �� The CommonwealthA ��, j Office of Public Safety and Inspects. . - o q, �0 r Massachusetts State Building Code(780 CM' '9Tyq�i4o Building Permit Application for any Building other than a One-or B". ' Dwell. g (This Section For Official Use Only) �'SoFC`T, Building Permit Number: a a - / ^Date Applied: Building Official: b�O�s SECTION 1:LOCATION 228 King Street Northampton,MA 01904 Stop&Shoo(Parking Lot-existing parking) No.and Street City/Town Zip Code Name of Building(if applicable) 24D-070 001 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 I Alteration 6d I Addition 0 I Demolition 0 (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy 0 I Other 0 Specify: Convert existing parking to two(2)EV Charging Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No CH Brief Description of Proposed Work SIGNED AND STAMPED PLANS ARE ATTACHED. (2)STANDARD PARKING SPACE(S)IS/ARE TO BE CONVERTED INTO(2)STANDARD ELECTRIC VEHICLE(EV)PARKING SPACE(S). (2)ELECTRIC VEHICLE CHARGING STATION(S)IS/ARE TO BE INSTALLED IN A(STRIPED/LANDSCAPE ISLAND(S))ADJACENT TO THE EV PARKING STALL(S). ELECTRICAL CONDUITS WILL BE EXTENDED FROM THE EXISTING BUILDING TO THE ELECTRIC VEHICLE CHARGING STATION. VOLTA WILL ALSO PAINT AND MARK ALL EV CHARGING SPACES 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): N/A Proposed Use Group(s): N/A SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) N/A Total Area(sq.ft.)and Total Height(ft.) N/A 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 0 E: Educational ❑ F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 ❑ H-4 0 H-5 0 I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2❑ R-3 0 R-4❑ S: Storage S-1❑ S-2 0 U: Utility® Special Use 0 and please describe below: Special Use Description: Electrical Vehicle Charging Stations SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB 0 IIA ❑ IIB 0 ILIA IIIB 0 IV 0 VA 0 VB D 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 0 Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Po required❑or trench or specify: PrivateEl or indentify Zone: N/A or on site system❑N permit is enclosed 0 N/A Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable$1 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No El Yes❑ No El 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 Stnp R.Shnp 228 King Street Northamoton MA Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Project Manager 508 -844 -9813 mgentile(iclinellc.com Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: LOA to be provided,if required. 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) Derek Creaser 508_844 _9813 rngentile@clinellc.com 49195 Name(Registrant) Telephone No. e-mail address Registration Number 750 West Center Street West Bridgewater MA 02379 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Centerline Communications,LLC Company Name Jeffrey Sykier CS-106586 Name of Person Responsible for Construction License No. and Type if Applicable 220 Country Hill Drive North Dighton,MA 02764 Street Address City/Town State Zip 508-844 -9813 - _ mgentile@clinellc.com 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 CI No CI SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 110,000.00 1.Building $ 50,000.00 Building Permit Fee=Total Construction 'ost x Insert here 2.Electrical $ 60,000.00 appropriate municipal factor =$ --7 7 O. 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (con r • r pality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 110,000.00 (contact municipality)and write check number here 't 3 3v `I' 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. Michael Gentile Project Manager _508-Rdd -QR14 09/19/2023 Please print and sign name Title Telephone No. Date 750 West Center Street West Bridgewater MA 02379 mgentileaclinellc.com Street Address City/Town State Zip Email Address a Municipal Inspector to fill out this section upon application approval: 11 ! 1'1 .5, ��) 9 a �3 i • Name Dat 1 Page 1 of 2 DATE(MM/DD/YYYY) ACORE) CERTIFICATE OF LIABILITY INSURANCE " 06/26/2023 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 Willis Towers Watson Certificate Center NAME: Willis Towers Watson Northeast, Inc. r c/o 26 Century Blvd (A/C,No,Ext): 1-877-945-7378 (A/C,No): 1-888-467-2378 P.O. Box 305191 ADDRESS: certificates@willis.com Nashville, TN 372305191 USA INSURER(S)AFFORDINGCOVERAGE NAIC# _ INSURER A: Valley Forge Insurance Company 20508 INSURED INSURER 8: American Casualty Company of Reading Penns', 20427 Centerline Communications, LLC 750 West Center Street INSURER C: Continental Insurance Company 35289 West Bridgewater, MA 02379 INSURER D: National Fire Insurance Company of Hartfor 20478 INSURER E: Berkley Assurance Company 39462 INSURERF: AIG Specialty insurance Company 26883 COVERAGES CERTIFICATE NUMBER:W29401169 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 1 TYPE OF INSURANCE ADDLISUBR POLICY EFF :. POLICY EXP LIMITS LTR INSD 4WD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYrn X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) 1$ A X XCU !, MED EXP(Any one person) $ 15,000 Y Y 7018111207 112/23/2022',11/08/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT PRO LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) I X ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED Y Y 7018111191 ,12/23/2022'.11/08/2023 BODILY INJURY(Per accident) $ X AUTOS ONLY I i AUTOS X HIRED I NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY I I AUTOS ONLY (Per accident) 1 $ i X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 C r. EXCESS LIAB CLAIMS-MADE Y Y 7018111238 .2/23/2022',11/08/2023 AGGREGATE $ 10,000,000 DED X RETENTION$ 10,000 '� $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE I ER H X D ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N EL.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? No N/A Y 7018111224 12/23/2022 11/08/2023 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ _ •If yes,describe under I 1,000,000 DESCRIPTION OF OPERATIONS below I E.L,DISEASE-POLICY LIMIT 1$ E Professional/Pollution Y PCAB-5020958-1222 12/23/2022.11/08/2023 Each Claim $5,000,000 Policy Aggregate $5,000,000 Retention $50,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate Holder is included as an Additional Insured as respects to General Liability, Auto Liability and Umbrella/Excess Liability. General Liability, Auto Liability and Umbrella/Excess Liability policies shall be Primary and Non-contributory with any other insurance in force for or which may be purchased by Additional Insured. Waiver of Subrogation applies in favor of Additional Insured with respects to General Liability, Auto Liability, Umbrella/Excess Liability and Workers SEE ATTACHED 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 Proof of coverage /7 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 24324899 BATCH: 3027614 AGENCY CUSTOMER ID: LOC#: ACORD ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Centerline Communications, LLC Willis Towers Watson Northeast, Inc. 750 West Center Street POLICY NUMBER West Bridgewater, MA 02379 See Page 1 CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Compensation policy as permitted by law. Waiver of Subrogation applies to Professional/Pollution Liability. XCU is included under General Liability INSURER AFFORDING COVERAGE: AIG Specialty Insurance Company NAIC#: 26883 POLICY NUMBER: 02-113-10-37 EFF DATE: 12/23/2022 EXP DATE: 11/08/2023 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Cyber Liability Limit $5,000,000 Aggregate $5,000,000 Retention $350,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 24324899 BATCH: 3027614 CERT: W29401169 ne commonweairn of ivlussucnuserrs Department of Industrial Accidents (-19, Office of Investigations Lafayette City Center • Y " _/ 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Centerline Communications, LLC Address:750 West Center Street, Suite 301 City/State/Zip: West Bridgewater, MA Phone #: (844) 748-8878 Are you an employer? Check the appropriate box: Type of project(required): 1. ■❑ I am a employer with '500 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11.0 Plumbing❑ I am a homeowner doing all work repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Willis Towers Watson Northeast, Inc. Policy#or Self-ins. Lic. #: 7018111207 Expiration Date: 1 1/08/2023 Job Site Address: `City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above.is true and correct Signature: •_� • Date: 9/5123 Phone#: 08-505-5839 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.❑Other Contact Person: Phone#: ;d ..._o. .x,7 C S, 1 . I .a,:r JEFF11EY SYto1.1E14 '..:- 220 COLJNT1tt*it" H y,., NORTH 016t ' - � L , ......,., , ....„ , „, ,,..,,,:‘,. ,. c I urtrttlittIcitt„,c, ., ,,., , ,%.,_. , s of „Only ti,se gr.,941r, vit,h,ictt ccw4a4n ,..,,,,',-..,,- its than o+ c£ , n I t ittfict044,04 � i33