25C-251 (3) 8/17/2011 8:42:00 AM 8740 2 02/02
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD /YYY)
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 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
Chase Clark Stewart & Fontana PHONE NONE FAX
Inc (A/C. No. Ext): (A/C. No) :
E-MAIL
P 0 Box 9031 ADDRESS:
PRODUCER
Springfield, MA 01102 CUSTOMER IDN.
INSURED (S) AFFORDING COVERAGE NAIC N
INSURED INSURER A: Associated Employers Insurance Company
Hamp, Frank & Hamp Ag Soc
INSURER B:
dba Three County Fair INSURER C:
P 0 Box 305 INSURER D:
Northampton, MA 01061 INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS I5 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.
I POLICY NUMBER POLICY EFF POLICY EXP LIMITS
Ltr TYPE OF INSURANCE OIIt/DD/YYrr, <MNnD/rrtY,
GENERAL LIABILITY EACH DCCmANCE 8
❑ COMMERCIAL GENERAL LIABIL DAMAGE TO RENTED $
❑ ❑ OCCUR PREt1I5£S(E a.DCCDYIence)
❑ CLAIMS MADE
MED EXP (Any one person) $
❑
PERSONAL & ADV INJURY $
0 GENERAL AGGREGATE 8
GEN'L AGGREGATE LIMIT APPLIES ER:
DI POLICY ❑ PROJECT DLOC
PRODUCTS - COMP /OP AGO 8
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(ea accident $
❑ ANY AUTO
BODILY IINJURY' (per person) $
❑ALL OWNED AUTOS
BODILY INJURY (per accident) $
SCHEDULED AUTOS
❑ HIRED AUTOS PROPERTY DAMAGE
(per accident) $
❑ 000 - OWNED AUTOS $
❑ 8
❑ UMBRELLA LIAR ❑ OCCUR EACH OCCURRENCE $
❑ EXCESS LIAR ❑ CLAIMS MADE AGGREGATE $
III DEDUCTIBLE $
❑ RETENTION 5 $
WORKERS COMPENSATION ® n .,=, OTH-
AND EMPLOYEES LIABILITY ER
THE PROPRIETOR /PARTNERS/ E.L. EACH ACCIDENT $ 1,000,000
A EXECUTIVE OFFICERS ARE
❑ m ci p exci 5004106012011 02/04/2011 02/04/2012 E.L. DISEASE - POLICY LIMIT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
COMMENTS / DESCRIPTION OF OPERATIONS OR LOCATIONS:
WORKERS' COMPENSATION COVERAGE APPLIES TO MASSACHUSETTS EMPLOYEES ONLY
CERTIFICATE HOLDER CANCELLATION
PROOF OF COVERAGE
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 - "
2327
,
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required • Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize _.. _d_.._
to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, 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 ar_jry
Print Name _______ _
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION. SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
S
Name of License Holder : 1
p..ScA I NS
License Number
Address l Be2� Expiration Date
iu ,R ,(1T4 �.
Signature Telephone V
SECT! 13 =WORK ' COMPENSATION INSURANCE AFFIDAVIT (M G.L. c.152, S 25C(6)) O \
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
•
•
The Commonwealth ofMassachusetts
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
Nanie ( Business /Organization/Individual): 1 (Pt mac)
J
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. Z I am a employer with 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. El Remodeling
ship and have no employees These sub- contractors have g. ❑ Demolition
for me in any capacity. employees and have workers'
working Y P ty. 9. 0 Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
f
oficers have exercised 11.
3. ❑ I am a homeowner doing all work h id their ❑ Plumbing 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
employees. No workers'
13. ❑ Other
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
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 #:
Version1.7 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 EILOSED SPACE)
9.1 Registered Architect:
' Not Applicable ❑
Name (Registrant):
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 i
Signature Telephone Expiration Date
Name Area of Responsibility
t
Address , _„. Registration Number
_ __
Signature Telephone Expiration Date
Name Area of Responsibility
----- _
Registration Number
Address
, F
Signature Telephone Expiration Date
9.3 General Contractor
1 1L� r.R. - Rl 5— �'- . .. - t R. Not Applicable ❑
Company Name: ._.,_ __
Responsible In Charge of Construction
Ad.mss
r / 7
ir s' A,/� :.......f, - ,✓► '__ 1� . . �� `c : )
Si` ature V Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning .
This column to 1 a filled in by
Building Department
Lot Size ,
Frontage
Setbacks Front I I^
Side L — R: = L:: 1 R: 1
i
Rear L--_,;
_._ _ _; I
Building Height i - �'�"'
Bldg. Square Footage % -- 1
. € ___
Open Space Footage , % —
(Lot area minus bldg & paved b s _, _ ,
parking)
r # of Parking Spaces 1
Fill: �__.. i m _ .a . — _ �_.
(volume & Location) -- _ — _..
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
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 Book I 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 Obtained (3 , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES C NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, a cavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
-
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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Version1.7 Commercial Building Permit May 15, 2000 ''tNNN"'N,
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 " -,.
CUBIC FEET OF ENCLOSED SPACE • '�
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ dditions ❑ Accesso Bung ❑ / /
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Ld Change of Use ❑ Other D. - . , '
Brief Description Enter a brief description here.' ¢ (y1;1 i c• J L. p ,5 b---; N& k 4 A-+1- , .,
Of Proposed Work (tat__? Ut! C 0641, ,
SECTION 5 USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A j ❑
A-4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
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 I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify: { . _,
S Special Use ❑ Specify:
I _.
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): m_ w.. _ 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 (sf)
1 st r
1st
2nd -- 2 nd ` i
3
4m ._____._ 4th V....-_._ _ _ _ �_
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft) � — _
_ .I.__.. _ ._ _
_ _ ___
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 !� r � Outside Flood Zone❑ Municipal 0 On site disposal system❑
Alt Versionl.7 Commercial Buildin. Permit Ma 15, 2000
•= - D e us 0 I '"n
4 City of Northampton ` - g
[ / �`) Building Department °g °.e
1 1` 212 Main Street ee = a® _
,,.; ' Room 100 AV ' 1410, ® , 4
,. Northampton, MA 01060
° dt" • one 413- 587 -1240 Fax 413- 587 -1272 it: 1 tt- ,"Q �� ��'
of par
A' P - ' TION 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
h rt .'.. Co u„iu `� C vQ -1`(Z Map Lot Unit
$ p1--1 CZ .5
Zone Overlay District
y - A Qa�?t�r. ;.
Y - Elm St District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: __ _... __
Name (Print) Current Mailing Address:
N, � a I. -A � /') _ Qi I16 _
Signature �`� ��`,,.∎' / / Telephone L L ,•; 5 p `/ -...)...'.. '?
2.2 Authorized Anent:
Name (Print) Current Mailing Addresses _ _r__ ......._ ___ _ ._ _____
Signature Telephone
SECTION 3 - !ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant •
1. Building i p 0 0 1 (a) Building Permit Fee j ;yam i3 C
2. Electrical - (b) Estimated Total Cost of
i Construction from (6) ___ .,______w_..,___ ____
3. Plumbing ___ ______ i Building Permit Fee � Q 0
4. Mechanical (HVAC) ___ ...._ .
5. Fire Protection ._. ...__..._
6. Total = (1 + 2 + 3 + 4 + 5) / 0 0 6, i Check Number
/5
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /lnspector:of Buildings Date
FAIRGROUNDS - FAIR ST BP- 2012 -0176
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 251 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2012 -0176
Project # JS- 2012- 000271
Est. Cost: $1000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH JASINSKI
Lot Size(sq. ft.): Owner: HAMPSHIRE FRANKLIN & HAMPDEN AGRICULTURAL SOCIETY
Zoning: Applicant: JOSEPH JASINSKI
AT: FAIRGROUNDS - FAIR ST
Applicant Address: Phone: Insurance:
(413) 584 -0307
NORTHAMPTONMAO1060 ISSUED ON:8/18/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 4 - H FOOD BOOTH ROOF
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 8/18/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner