25C-001 NOV -21 -2011 16:37 FINCK & PERRAS 1 413 527 5970 P.001/001
ACQRD CERTIFICATE OF LIABILITY INSURANCE iiiiiiioii
F'DDDD ER (413) 527 -5520 FAX (41 527 -5970 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Fi nck & Perms Insurance Agency, ONLY AN THIS CERTIFICATE DOES NOT AMEND. OR
6 ,s Lane RECEIV m $ E COVERAGE AFFORDED BY THE POLICIES BELOW.
EaSthan, ton, MA 01027
Oak L' a mit S AFFORDING COVERAGE NAIC #
i AD Soup to Nuts Construct on, I . Jl General Casualty 24414
10 McKinley Avenue w Granite State Insurance Con>pan
Easthampton, MA 01027 DEPT OF BUILDING INSPEC �Ii •
N ORTHAMPTON, MA 01c. a h1$VFtER ■ : —�
JNSURER E: 1
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE 1NSl R " ABOVE FOR THE POLY PERIOD INDICATED. NOTWITFJSTANDING
ANY REQUIRE1dENT, 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 WREN fa acrwecr Tld ALL THE TERMS, ExevealONS AND r. OF' JJCH
POL AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS.
Par :r. 1L TYPE OF.uRANCE POLICYNuFIBER = P'O YI9W1, .0j UINIYL
:1' - 1 _ 7T1'1 QQ(0394728 01/03/2011 Ol /031 ° N� $
500,111
GEM. AGGREGATE LIMIT APPLIES PER
Q «.
.... 7+ $ 5 0 I I
•_ „
PERSONAL & ATM INJURY $ re+ II I
(Ea acNcient)
■ Au.owNED Amos
11.1 NON-OWNED AUTOS
IIIII
111 .. COMBIMEASINGLE.IJAILT $
BODILY INJuRY
(Per permn)
BODILY INJURY
Tor accidal5
1:111 GAPACE immure' ++ r
. ANY AUTO
EXCESSAJNBABLLA LIABILITY EACH OCCURRENCE $ DEDucTeLE $ it
OCCUR E CLAIMS MADE AGGREGATE $
, , CATE TO BE ISSUED I 01/03/2022 I - !• .
IIMILDYER7 1446111"7161 Alin cuTivE CE T•RY .
I
DIRECTLY EL. EACH ACCIDENT S
OFFICER/MEMBER . . EL. ASE -EA • .- 5
-„ , DISEASE r E - _ DISEASE - POUCY LIMIT $
1 OTHER
DISCRl'iIoN of OPERATIONS 1 LDCAnONS I VEHIGL IS I EXCLONIONS ADDEO RY ENDORSEIIENT I SPECIAL PROVISI0118
•roof of coverage.
CERTIFICATE HOLDER CANCELLATION .
SHOULD ANY OF THE ABOVE OEBCRIEED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING MOW WILL ENDEAVOR TO HAIL
City of Northampton _ ___ DAYS TAUTIEN NOTICE To me CeRnFICATE HOLDER NAMED TO THE LEFT.
Att : Bldg Dept But FAILURE TO MAIL SUCH NONCESHAL LTYPi55E Nt7QOCIGNTRA4'OR taaOIILdT't
212 Main Street ,._. ..
Municipal Building up . • - , .15N : ,SRREo4RSEITX4.teeS
Northampton, NA 01060 - , REPRESIBQATINE .
oft ACORD 25 (2001108) 17- X3?.5*`- ®ACORD CORPORATION 19S
TOTA1. P _ f101
The Commonwealth of Massachusetts
Department of Industrial Accidents
�,• .. , Office of Investigations ,
600 Washin Street
; � a
-w � Boston MA 02111
, ,, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Nance ( Business /Organization/Individual): O - 1, - 7. /\J.. (, 0A S YZ-t> c 7\ (
Address: 1(]I fiIC. l C.y
City /State /Zip. ' , ., V
.� � , r - 7 Phone #: - - -
Are you an employer? Check the ap ! opr ate box: Type of project (required):
1. ❑ I am a employer with i 4. ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part- time).* have hired the sub - contractors
2., 0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
These sub- contractors have
ship and have no employees 8. ❑Demolition
for me in any capacity. employees and have workers'
working y p ty. 9. ❑ Building addition
$
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11.❑ Plumbing repairs or additions
3. ❑ I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
w 13.ErOther I7.S�fA,
employees. [No workers'
comp. insurance required.]
*Any 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.
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:
Policy # or Self -ins. Lic. #: Expiration Date:
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 certi under the pains and pena of perjury that the information provided above is true and correct.
Signature: Date:
" ` � i (- 7. 7, - 1 )
Phone • r �
Of:ial 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 #:
• .
Versionl.7 Commercial Building Permit May 15, 2000
.. _,
SECTION 10 STRUCTURAL_ PEER REVIEW (780 CNIR 110.11)
Independent Structural Engineering Structural Peer Review Required ' Yes 0 No kj
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
H pt-F__.00-tc: C.
._____________ _______________________ _____ __ _ _., as Owner of the subject property
) ( (..,
hereby authorize .. ..,t9k.).Y.Z.IC..),,Jsa.S.C...e..,\IN)...,12.1.2.......!.. . to
act on my behalf, in all matters rela to work authorized by this building permit application.
—LIII I L11— '
Signature of 0 er Date
— 41 ------,
---- I, _3. .eaLas?.1._.A...) .... lot•-->C0ek . — __________ , 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 theyains and penalties ofp,ti,
Print a
<,
.,........,...„„,.....,....._ ______
_,.
..... _............„ —
ig of Oymer/Agen V Date
ECTION 12 - CONSTRUC 4 r ICES
10.1 Li sed Construction Su •ervisor: Not Applicable EI
- .
,ff-r5,
Name of License Holder : g ra m ------------ --
._ ,..,..__
— "b.. .....„... . _
License Number
...._,,.,
_1 1110 _ -:- "- WA i ...,_ iilinksA i • 6 _ a 2 te - )2-- 7 1 ' 1_ ,S 1,8 — i 2_
Ad. es- Expiration Date
D3.1... --5-- _
ature ... -4 Telephone
••
. . .
. , 13 -WORKERS' lg. ■ - o<SATION 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 0 No
- -- - -- - --- -
4.
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL. PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF Egpt:OSED r SPACE)
9.1 Registered Architect:
_ ______.' Not Applicable ❑
Name (Registrant): i - _ .
Registration Number
Address __ . , _ .. _ _..._ _..._...._
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
I
Name • Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address . Ristration Number _
I
Signature Telephone Expiration Date
Name Area of Responsibility
Y
s
Address Registration Number .._... __
;
Signature Telephone Expiration Date
Name Area of Responsibility
Address _ __ -- — �� Registration Number ..____ �.._._. __.
Signature Telephone Expiration Date
9.3 General Contractor
_.._..._.__ _. ._ ._ ____..__..._......_._. . _. ___ Not Applicable ❑
Company Name:
_ �^ / __ _....____._
Responsible In Charge of Construction
Address__
Signature Telephone
4
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON: ZONING
Existing Proposed Required by Zoning .
This column to re filled in by
Building Department
Lot Size L. € _ _ __
Frontage _._.__._ _.._.. , __ _ ._. ._.__.._,
Setbacks Front f `s`
Side 1,:" R ? L: R: a
Rear _—....
Building Height .__—.,
Bldg. Square Footage -..
Open Space Footage % - •-- - ---- --
(Lot area minus bldg & paved J s j
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
t
IF YES, date issued: ';
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Books x Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES (:::) NO (3
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
w
Version1.7 Commercial Building Permit May 15, 2000
J
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other tom'
Brief Description =Enter a brief description here. "Z -�P�- I'''v-`
Of Proposed Work: 4 ,--,,...63‹,,,,c. 0 ,r2S 3 � Y"�
iaf s _To _ 1 ccev'F2c).v t re_r_-t rL Zp, L� f o, L.. _ avioS Imcif.:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A-4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ' r ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ - 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B l ❑
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. r _ OFFICE USE ONLY
Floor Area per Floor (sf)
4
15 1
st ...
2nd _ = 2nd .._ _ __ _� ��i
3rd { _.. ____ .___ 3 t
41" . ___ 4 � .... ________
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 ❑ Zone _______ Outside Flood Zone❑ Municipal ❑ On site disposal system
Versionl.7 Commercial Buildin: Permit May 15, 2000
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060 a I = L
phone 413 - 587 -1240 Fax 413 -587 -1272
I 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
j Map Lot Unit
Zone Overlay District
„-.A. Elm;StDistrict •CB District
SECTION 2 'PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
. (�tJG - I`i - Icy
Name (Print) Current Mailing Address:
- Signature )'/ Telephone mm
2.2 Aut orized q t:
Name (Print) `' Current Mailing Addresses
L -i
Signatur __ _ Telephone
SEC ON 3 - ESTIMAITED CON T" ' N COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ? ( ) O C J (a) Building Perrnit Fee ..
2. Electrical w-- (b) Estimated Total Cost of
t Construction from (6)
3. Plumbing _ Building •Permit Fee
4. Mechanical (HVAC) ---
5. Fire Protection
6. Total = (1 +2+3+4+5) Check;Number LY LIb
This Section: For Official Use Only
Building Permit Number Date
Issued
Signatur-: ,,i
-/
• Commis&onedlnspector of Buildings Date
108 NORTH ST BP- 2012 -0525
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 001 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0525
Project # JS- 2012- 000875
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SOUP TO NUTS CONSTRUCTION CORP 004599
Lot Size(sq. ft.): 33628.32 Owner: BARNETT PAUL C & MARJORIE CHAL BARNETT
Zoning: URC(100)/ Applicant: SOUP TO NUTS CONSTRUCTION CORP
AT: 108 NORTH ST
Applicant Address: Phone: Insurance:
10 MCKINLEY AVE (413) 527 -5359 Workers Compensation
EASTHAM PTON MA01027 ISSUED ON:11/29/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR FRONT & REAR PORCH
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 Signature:
FeeType: Date Paid: Amount:
Building 11/29/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner