31D-148 20 CENTER ST BP- 2012 -0057
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 31D - 148 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP- 2012 -0057
Project # JS- 2012- 000086
Est. Cost: $10000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ORCHARD GLASS AND MIRROR INC 073684
Lot Size(sq. ft.): 9278.28 Owner: FOWLE EVERT N & TRUSTEE OF CENTRAL CHAMBERS REALTY TRUST
Zoning: CB(100) Applicant: ORCHARD GLASS AND MIRROR INC
AT. 20 CENTER ST
Applicant Address: Phone: Insurance:
32 OAK ST (413) 543 -5979 Workers Compensation
INDIAN ORCHARDMA01151 ISSUED ON :711812011 0:00:00
TO PERFORM THE FOLLOWING WORK.- Install Replacement Windows
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature:
FeeType: Date Paid: Amount:
Building 7/18/20110:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
Versionl.7 Commercial Building Permit May 15, 2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address This section to be completed by office
Map Lot Unit
16 Center St.
Northampton, MA 01060 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Heon Realty 16 Center St. Northampton, MA
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 +2+3+4+5) Check Number
This Section For Official Use Onl
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
Jul 13 11 09.22a Carol Heon Real Estate 413- 586 -9076 p.1
CENTRAL CHAMBERS REALTY TRUST
Evert N. Fawic Trustee
16 Center Street
Northampton, Mass. 41060
(413) 58B 46
July 13, 2011
City of Northampton
Building Department
212 Main St.
Northampton, MA 01060
Regarding 16 Center St_, Northampton
We respectively request you to grant a modification to waive the requirement for
controlled construction in the project we have to replace windows in the building
above. We are not changing anything other than the windows. Everything is the
same, same color and look as the current windows that are in place. It would be a
real problem for us to have the cost of control construction for something that is
just going to make the building more energy efficient and comfortable for the
tenants.
we are only going to do 12 windows at this time in order to cut down current
costs and be able to spread the financial burden over time. Within the next few
years we hope to replace all of the windows, but again, it will be the same look.
Thank you for your consideration.
Sincerely,
Carol A. Heon, manager of Central Chambers Realty Trust
16 Center St., Northampton, MA
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations El Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑� Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description The installation of vinyl replacement windows.
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A ❑
A -4 ❑ A -5 ❑ 113 ❑
B Business ❑� 2A ❑
E Educational ❑ 213 I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑✓
Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 36 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 513 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (so
1 St 1 St
2nd 2nd
3rd 3rd
4th 4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ I Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO () DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T KNOW ® YES
IF YES: enter Book Page and /or Document#
B. Does the site contain a brook, body of water or wetlands? NO e DON'T KNOW ® YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Versionl .7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable El
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Orchard Glass & Mirror Inc. Not Applicable ❑
Company Name:
Acacio ( Casey ) M a r ia
Responsible In Charge of Construction
32 Oak St. Indian Orchard, MA 01151
Address
(413) 543 -5979
Sign re Telephone
Version] .7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes ® No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property
hereby authorize ��-C_- [--s to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder Acacio S. Mar CS 73684
License Number
10 A St. Ludlow, MA 01056 16 — 3 _ dol d
Address Expiration Date
(413) 221 -0774
Signature < Telephone
L
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached Yes e No 0
05/17/2011 23:26 4134390148 PAGE 02/02
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Construction Supervisor License
license: CS 73584
ACACIO S MARIA
109 ALFRED ST
LUDLOW MA 010
Expirat+on'. 10/3/2012
Tt'2•. 4565
Office of Consumer Affairs & Business Regulaiion
{�• HOME IMPROVEMENTCONTRAC'iOR
Registration:...... 449324
Expiratfvn;...,12I91011 TO 291849
Type' Pri4ate:GBrporation
ORCHARD GL,ASS'$101RROR INC
ACACIO MARIA
32 OAK ST'
INDIAN ORCHARD, MA 01 51 Undersecretary
has eucceestu�hy oo (tea a SO�our c uprvo-vo safety amo He'Vh
7raRuoB Canse+r
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): '� ��+� � ����j ti (b C .
Address:
City /State /Zip i f M 14 Phone #:
Are you an employer? Check the appropriate box: 0 d$0 Type of project (required):
1. I am a employer with 4. ❑ I am a general contractor and 1
employees (full and /or part- time).
* have hired the sub - contractors 6. El 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 g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10. F1 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #I 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.
Contractors 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 >L°(��d [A
Policy # or Self -ins. Lic. #: (�� �C �r3 �� O� Expiration Date:
Job Site Address CPnl -e c S�. City /State /Zip: g policy = ) Attach a copy of the workers' compensation policy declaration page ( showin the olic number and ee .
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 certi under the pains and penalties of perjury that the information provided above is true and correct.
I � �
Si nature: Date:
Phone #: ' I� 7 `J
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
(Policy Provisions AC A
INFORMATION PAGE
WORKERS COMPENSA TION AND EMPLOYERS LIABILITY POLICY
INSURER: r!ARTFORD FIRE ' : N S - T
-RANCTE 0,MP ANA
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n 'A D
_F?,T ��'A"A, `AR - R",
NCCI Company Number:
Company Code: THE
HARTFORD
suffix
LARS RENEWAL
POLICY NUMBER: W 11:1',' N J. 1 92 , 36
Previous Policy Number:
I I 'v S I N U CODE:
1. Named Insured and Mailing Address: ORCIHAI`'�_: A,%-: M.RR� R,
No Street, Town, State. Zip Code)
R L
1,N'-' A 1% h AR '�!A
FEIN Number: 04 %4 1
State Identification Number(s):
77-7 The N a m e d I nsure d i S: C',) R P',_') FCA I "'IN
Business of Named Insured: 3-ass Stor L r is V;, a
Other workplaces not shown above: 3 2 OAK L RAF''
NC I 'RCHARi
Policy Period: From : 0,, 1 " 3/ _ 11, To
":01 P.m.. Standard flare at Me insured's mailing address. IDPA 1NSURANCE AC3ENC' 1.NT
Producer's Name:
EAS'_ STREET
Producer's Code:
Issuing Office:
DR F
N TON
'600 96�-61
Total Estimated Annual Premium:
Deposit Premium:
Policy Minimum Premium: ".A DES 1 %T ED I, I MI MiN -REM.
Audit Period: A-N INUAL Installment Term:
to policy is not binding unless countersigned by our authorized representative
Countersigned by
Authorized Representative
Form WC 00 00 01 A (1) Printed in U S A Page i ' Continuea on next page)
Process Date: 0, �,; 21 1 �' Policy Expiration Date: 10 1 0 311 -1
)RI�"-_NAL
05/18/2011 00:06 4134390148 PAGE 01/01
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OP ID: TS
CERTI OF LIABILITY INSURANCE
05!18!11
THIS CERTIFICATE t$ ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERIIACATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE P
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 185UNG INBUREN% AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED the policy(ies) must be endorsed. H SUBROGATION 18 WAIVED, subject to
the terms and conditions of the policy, Cortain policies may require an endorsemeoL A statement on INS eorlificete does not confer rights to the
certiftcale holder in lieu of such sndorasm s
PRODUCE R 413- WS-09DI rNMe cr
Ideal Insurance Agency, Inc 4113- M3451111 AA Ne
1 s7 East St.
rwr
LudIQw MA 01086 App Ess
House -- T - —
as ORCHA -1
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Protsctlon ins Co 1260
32 Oak Street vwjRERThe Hartford 00914
Indian Orchard, MA 01151 M>
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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.
TYPS OF 1144 11NCE POLICY NUMffiR A)LYYYYY Llltrl'0
GENERALLIABMJTY EACY.00CURRENCE E 1,000,0
A X COnr F-nr IAL CENER�p--1� - 00030344 03101/11 03101112 pRE►It m t 100.
CLAfMS-MADE L•, ' OCCUR MED E)w (" one person) t 6,
PERSONA- & AOV NJJRY t 1,000,
GENERAL AGGREGATE If 2,000,
GEN'L AGGREGATE LIMIT APPLIES PM I PRODVCY$• COMP/OP AGG 1 2,00
POLICY PR F71 LOC 1
AUTOMOeLLE UAeOJrY COMBINED SINGLE l MIT £
IES ecd0elll)
A ANYAUTO 7086400001 03!25!11 03/25/12 6pPtt Y rd AIRY (POrPwc n) I t 260,
ALL OWNED AUTO& BODILY INJURY (Per ecdoeM) t 600,
X SCHEOULECAUTOS PROPERYYDBMAGE
H IR EC Aur05
(Per secloort) t 100,
NON -OWN£p AUTOS S
t
X waRr LALIAB X OCCUR EACH OCCURRENCE : 1,000.
ExcEOBLMB CLAIMS -MADE AGGREGATE t 1,000.
A 3913 03/01111 0011/12
DEDUCTIBLE t
X RETENTION / 10000 t
VIOWEReCOMPINIATION 7 C 5TATU• X Op
AND EeePL0YFA8' UlAa1l..ITY
B ANY PROPRIETORIPARTNER/E)C-CUTIVE Ya NIA 09WEGNa 10103/10 10103!11 E.L. EACH ACCIOSq t �,
OFFICER&SYSER MLUDE07
(Mlentw4ryInNH) E.L ING&M. EA EMPLOYEE 3 600,00
It yys, oe9anbe under E.L. DISEASE - POLICY LIMIT I t 500,00
QLSQRPTQ OPERATIONS below
DESCRIPTION OF OPERATIONS ( LOCA71W4I (Attith ACORD 101, Addlleft Famfm "odL4 N moo @OWS Iero Wnu)
!ASS DEALERJREPLACEMENT
Glas
CER TIFICATE HOLDER CA
SHOLLO ANY OF THE ABOVE OESCItM® POLICIES BE CANCELLED BEFORE
THE EXPIRAUON DATE THEREOF, NOTICE WILL BE DLUVERED IN
Noo Realty ACCOROANCE VI1TH T044 POLICY PROM IONS.
16 Canter Street
Northampton, MA 01060 ALJT� REPREBEWATive
a 1988.2009 ACORD CORPORATION. AB rights reserved.
ACORD 25 (2008108) The ACORD name and logo are registered marks of ACORD
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