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31B-235 (2)
:' Board uil i g Regulations and Standards is Construction Sup; • } ♦ i. f 3u Lice 7 `, a { ,,,, 10. Y' k. BRIJ I "7E I LUDLOW MA fiii#700,044000 0.400:"04. n 4". , . --0. ;t f ____--1 JACKG-1 OP ID:CG ACOROm CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �� 06/06/13 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). cori TACT Chrystal Greenleaf PRODUCER 413-594-5984 NAME: ry PHILLIPS INSURANCE AGENCY INC 413-592-8499 PHONE 413-594-5984 FAX No): 413-592-8499 97 CENTER STREET (A/C,No.Ext): i CHICOPEE,MA 01013 E-MAIL ES:chrystal @phillipsinsurance.com Chris Rivers INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Excelsior Insurance Company INSURED Jack Goncalves And Sons, Inc. INSURER B:Peerless Insurance Company 24198 172 Munsing Street INSURER c:Travelers Insurance Company Ludlow, MA 01056 INSURER D: INSURER E: 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 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 ADDL SUER W POLICY EFF POLICY EXP LIMITS 'LT .TYPE OF INSURANCE INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CBP8803149 09/30/12 09/30/13 DAMAGE TO A X COMMERCIAL GENERAL LIABILITY X PREES{Ea RENTED occurrence) $ 600,000 CLAIMS-MADE X OCCUR _MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 X XCU Coverage GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY X jF? LOC E COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY (Ea accident) $ A ANY AUTO BA8802549 09/30/12 09/30/13 BODILY INJURY(Per person) $ 1,000,000 X AUTOS NED X SCHEDULED BODILY INJURY(Per accident) $ 1,000,000 ._!_•__ NON-OWNED PROPERTY DAMAGE $ 500,000 X HIRED AUTOS X AUTOS (Per accident) _ $ . X. UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE CU8803249 09/30/12 09130/13 AGGREGATE $ 5,000,000 DED RETENTION$ WORKERS COMPENSATION X WC STATU- 0TH- TORY LIMITS ER AND EMPLOYERS'LIABILITY Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE WC8802949 09/30/12 09/30/13 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C RR Protective SPS-3C470272-IND 10/15/12 10/15/13 Aggregate 6,000,000 Occurance 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) City of Northampton is listed as Additional Insured on the General Liability as required by written contract for the following: 53 GOTHIC STREET SEWER REPAIR CERTIFICATE HOLDER CANCELLATION CITYOFN • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Northampton 125 Locust Street AUTHORIZED REPRESENTATIVE Northampton, MA 01060 aire4-44A n't PRAA40,6 1 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Aumniar- ' Version1.7 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 Kathleen Burke Foley as Owner of the subject property hereby authorize Susan Coffey to act on my behalf, in all matters relative to work authorized by this building permit application. -- ai. 06/06/2013 Signature of Owner C}� Date fill —6 Susan Coffey , 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. 5 ue. C© Print Na 06/06/2013 1 . ._ • .� J. Sig ature of Owner/Agent % V Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: rU- 0 V ejr a"ry License Number 1 CI O lr__0._keyt e(,J i6tve.. to t,.11 Na, G 5 - a `1 3 -3 7 if Address Expiration Date . 4.4,14,,x,,, 1413 - 7q- yo I/ z 0 2 0 /4 Signature Telephone 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 0 No 0 Version 1.7 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 ❑ 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 Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone 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 parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 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 0 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 C) NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Annomplowar 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 ❑ Existing Wall Signs ❑ Demolition p Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief DescriptioEnter a brief description here. E, �/ ZP" t. L, Of Proposed We k: ° -`e-1'I r 2 y SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) , TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ iA I ❑ A-4 ❑ A-5 ❑ 1 B ❑ B Business F 2A ❑ E Educational ❑ 2B I p F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 R Residential ❑ R-1 ❑ R-2 El R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B 1 p 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(sf) 15` 375 1St 2nd 2nd 3rd 3d ' 4th 4th Total Area (sf) 375 Total Proposed New Construction (sf) Total Height(ft) 14 Total Height ft 7. Water Supply(M.G.L. c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public p Private ❑ Zone Outside Flood Zone p Municipal p On site disposal system El Versionl.7 Commercial Building._Permit May 15,2000 Department use only `��® City of Northampton Status of Permit: � ►Cj :uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability `1- Room 100 WaterlWell Availability tu .cvoN• orL'ampton, MA 01060 Two Sits of Structural Plans EC ,01114 � = -587-1240 Fax 413-587-1272 PO# S%epeRe s APP ION 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 This section to be completed by office 1.1 Property Address: 53 Gothic Street Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Kathleen Burke Foley 65 Blackberry Lane Name(Print) Current Mailing Address: (413) 537-9702 Signature Telephone 2.2 Authorized Agent: Susan Coffey 65 Blackberry Lane Name(Print) Current Mailing Address: (413) 537-9702 Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $4,300.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee a tQ 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signat - Bui �ommissioner/Inspector of Buildings Date 53 GOTHIC ST BP-2013-1171 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:31B-235 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit# BP-2013-1171 Project# JS-2013-001930 Est.Cost: $4300.00 Fee:$0.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BRUNO FERNANDES 093374 Lot Size(sq.ft.): 6141.96 Owner: FOLEY KATHLEEN BURKE TRUSTEE Zoning: CB(100)/ Applicant: BRUNO FERNANDES AT: 53 GOTHIC ST Applicant Address: Phone: Insurance: 190 LAKEVIEW AVE (413) 374-9091 WC LUDLOWMA01056 ISSUED ON:6/7/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:DEMOLISH 2 CAR DET GARAGE 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 6/7/2013 0:00:00 $0.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner