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has fulfilled the requirements of the To ' ubstan o j.ecc-tiaw402,,o an s received certification to conduct lead based paint re tion,re nt R Part 745.89
O11 �a :
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All EPA Administered States Tribes and Territories
This certification is valid from the date of issuance and expires May 18, 2015
NAT-36667-1
Michelle Price, Chief
Certification#
.P ` . Lead, Heavy Metals, and Inorganics Branch
May 4, 2010
Issued On `
®NGM INSURANCE COMPANY POWER OF ATTORNEY
06- 0240877
A member of The Main Street America Group
OW ALL MEN BY THESE PRESENTS: That NGM Insurance Company,a Florida corporation having its principal
ice in the City of Jacksonville, State of Florida, pursuant to Article 1V, Section 2 of the By-Laws of said Company, to wit:
"Article IV, Section 2. The board of directors, the president, any vice president, secretary, or the treasurer
shall have the power and authority to appoint attorneys-in-fact and to authorize them to execute on behalf of
the company and affix the seal of the company thereto, bonds, recognizances: contracts of indemnity or
writings obligatory in the nature of a bond, recognizance or conditional undertaking and to remove any such
attorneys-in-fact at any time and revoke the power and authority given to them.
does hereby make, constitute and appoint Cynthia Henderson,Jenna Rodrigue,Nancy Horan, Richard J Webber,
f
SandiGa(;aniacz, Barbara Grynkiewicz, William D Grinnell -----------------------------------------------------------------------
its true and lawful Attorneys-in-fact, to make, execute, seal and deliver for and on its behalf, and as its act and deed,bonds,
undertakin<us, recognizances, contracts of indemnity; or other whitings obligatory in nature of a bond subject to the following
limitation:
I
1. No one bond to exceed Five Million Dollars ($5,000,000.00)
and to bind NGM Insurance Company thereby as fully and to the same extent as if such instruments were signed by the duly
authorized officers of the NGM Insurance Company-, the acts of said Attorney are hereby ratified and confirmed.
This power of attorney is signed and sealed by facsimile under and by the authority of the following resolution adopted by
the Directors of NGM'Insurance Company at a meeting duly called and held on the 2nd clay of December 1977.
Voted: That the signature of any officer authorized by the By-Laws and the company seal may be affixed by facsimile to
any power of attorney or special power of attorney or certification of either given for the execution of any bond,
- undertaking, recognizance or other written obligation in the nature thereof-: such signature and seal, when so used being
hereby adopted by the company as the original signature of such office and the original seal of the company, to be valid
and binding upon the company with the same force and effect as though manually affixed-
tiV WITNESS WHEREOF, NGM Insurance Company has caused these presents to be signed by its Assistant Vice
President,.General Counsel and Secretary and its corporate seal to be hereto affixed this 3rd day of.ianuary 2012.
NGM INSURANCE COMPANY By:
fr' _.25t/OUNOF�qe
Bruce.R Fox
Assistant Vice President, General ,�."
Counsel and Secretary
State of Florida,
j County of Duval.
On this January 3rd,2012 before the subscriber a Notary Public of State of Florida in and for the County of Duval duly commissioned and
jqualified, came Bruce R Fox of the NGM Insurance Company, to me personally knownT to be the officer described herein, and who
executed the preceding instrument, and lie acknowledged the execution of same, and being by me fully sworn, deposed and said that he is
an officer of said Company, aforesaid: that the seal affixed to the preceding instrument is the corporate seal of said Company, and the said
corporate seal and her signature as officer were duly affixed and subscribed to the said instrument by the authority and direction of the said
Company;that,-article IV Section 2 of the By-Laws of said Company is now in force.'
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal at Jacksonville. Florida this 3rd day of January,
0 1-) SNI ASda Poi POT
U
I t. NO'ARr P��I C
STATOFF OR1DA
Can EEi.St37
Eaoires 1 012015
I. Brian J Beggs, Vice President of the NGM Insurance Company,do hereby certify that the above and foregoing is a true and correct copy
of a Power of Attorney executed by said Company which is still in full force and effect.
f IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal of said Company,t Jacksonville,Florida this
day of
WARNING:Any unauthorized-Production oralteration 0i this docunTent IS prohibited.
TO CONFIRM VALIDITY ortlie attached bond please call I-N00-225-%46.
TO SUBMIT A CLAIM:Send all cun'e>pondence to is West Stem,Kcrne,NI1 U34 i 1 Attn: Bond Claims.
rH- rC
j
� 0 'J�02C
GoGl(,a(0 Foi54b G E
6n!1115 H SCJl7C ,)v...o_,raph,b1LB h2 k_crc- ,O.1?ej sep-'(1 li l.colA-2 t U =4'.a.-� d✓3�0 C�DiBX� �,C ip
Main Street America Group
National Grange Mutual Insurance Company
Old Dominion Insurance Company
Main Street America Assurance Company
Bid Bond
KNOW ALL MEN BY THESE PRESENTS, that we(Here insert full name and address or legal title of Contractor)
Northeast Painting Associates, Inc.
881 No. King Street
Northampton, MA 01060
as Principal, hereinafter called the Principal, and (Here insert full name and address or legal title of Surety)
National Grange Mutual Insurance Company
55 West Street
Keene, NH 03431
a corporation duly organized under the laws of the State of New Hampshire
as Surety, hereinafter called the Surety, are held and firmly bound unto(Here insert full name and address or legal title of Owner)
City of Northampton, Central Services Department, 240 Main Street, Northampton, MA 01060
as Obligee, hereinafter called the Obligee, in the sum of five per cent of accompanying bid
Dollars ($ 5%of bid ),for the payment of which sum well and truly to be made, the said Principal and the
said Surety, bind ourselves, our heirs, executors, administrators, successors and assigns,jointly and severally,firmly by
these presents.
WHEREAS,the Principal has submitted a bid for(Here insert full name,address and description of project)
.ademy of Music Painting Work
NOW, THEREFORE, if the Obligee shall accept the bid of the Principal and the Principal shall enter into a Contract with
the Obligee in accordance with the terms of such bid, and give such bond or bonds as may be specified in the bidding or
Contract Documents with good and sufficient surety for the faithful performance of such Contract and for the prompt
payment of labor and material furnished in the prosecution thereof, or in the event of the failure of the Principal to enter
such Contract and give such bond or bonds, if the Principal shall pay to the Obligee the difference not to exceed the
penalty hereof between the amount specified in said bid and such larger amount for which the Obligee may in good faith
contract with another party to perform the Work covered by said bid, then this obligation shall be null and void, otherwise
to remain in full force and effect.
Signed and sealed this 2nd day of June, 2014
Q—` (Prin I 1) (Seal)
(Witness)
(Title)
National Grange Mutual Insurance Company
(Surety) (Seal)
( tness)
S ndi aganiacz
(Tit e Attorney-in act
inted in cooperation with the American Institute of Architects (AIA) by the National Grange Mutual Insurance Company of
j West Street, Keene, NH 03431 603-352-4000. The language in this document conforms exactly to the language used in AIA
Document A310,February, 1970 edition.
68-5302(11/00)
aw-
The Commonwealth of Massachusetts
Executive Office for Administration and Finance
Y Division of Capital Asset Management and Maintenance
4 g� One Ashburton Place
Boston, Massachusetts 02108 GLEN SHOR
DEVAL L.PATRICK Tel: (617) 727-4050 SECRETARY,ADMINISTRATION&
GOVERNOR FINANCE
Fax: (617) 727-5363
TIMOTHY P.MURRAY CAROLE CORNELISON
LIEUTENANT GOVERNOR COMMISSIONER
Prime/General
Certificate of Contractor Eligibility
CONTRACTOR IDENTIFICATION NUMBER: 1259
This Certificate Shall Be Used for Submitting Prime/General Bids Onlv
1. CERTIFICATION PERIOD: This Certificate is valid from 1/27/2014 to 1/27/2015
2. CONTRACTOR'S NAME: Northeast Painting Associates,Inc.
3. CONTRACTOR'S ADDRESS: 881 North King Street,Northampton,MA 01060
4. WORK CATEGORIES: This Contractor is certified to file bids under Massachusetts General Laws Chapter 149,
Chapter 149A and Chapter 25A in the following checked Categories of Work:
Alarm Systems Elevators F]Historical Masonry L%j Painting
F7,Asbestos Removal L Energy Management Systems Historical Painting LPlumbing
[ 1 Deleading Lj Exterior Siding ❑Historical Roofing ( ]Pumping Stations
❑Demolition "Fire Protection Sprinkler Systems ❑HVAC L Roofing
Doors&Windows L Floor Covering L Masonry LSewage&Water Treatment Plants
Electrical [!General Building Construction []Mechanical Systems []Telecommunication Systems
Electronic Security Systems LJHistorical Building Restoration LModular Construction/Prefab ❑Waterproofing
5. EVALUATIONS: Number of Projects Evaluated: 24
Average Project Evaluation Rating: 94
Number of Projects Below Passing Score: 0
6. PROJECT LIMITS: Single Project Limit(SPL): $1,216,000.00
Aggregate Work Limit(AWL): $3,000,000.00
General Building Construction Limit: N/A
7. SUPPLIE FICE CERTIFICATION: N/A
1 Z 7-vi
Tara Grigsby,General Counsel, Approval Date
�o�r Carole J.C rnelison,Commissioner
NOTE TO CONTRACTORS: Col( lete A ications for Renewal of Contractor Eligibility are due no later than three months
PRIOR to the Expiration Date of the Certification Period shown above. Failure to submit Completed Applications timely may
result in a gap in Certification or a lapse in Certification altogether for your company.
Reviewer's Initials <3
Code Review Thomas Douglas Architects Inc
The Academy of Music 196 Pleasant St.
Northampton,MA Northampton, MA
413-585-0641
3.3.1 b. If the work costs sioo,000 or more, then the work being performed is required
to comply with 521 CMR. In addition, an accessible public entrance and an accessible
toilet room shall be provided.
3.3.2 If the work performed, including the exempted work, amounts to 30%or more
of the full and fair cash value of the building, the entire building is required to comply
with 521 CMR.
3.3.3 Alterations by a tenant do not trigger the requirements of 3.3.1B and 3.3.2 for
other tenants.
This project's construction costs are less than 30% of the assessed value of the
building and more than sloo,000.
This existing space has an accessible toilet room and entry.
The i' floor level of the building is accessible via a ramp.
New seats are being installed to replace existing. The new proposed seating layout
provides new compliant accessible seating positions in the i' floor seating areas.
End of Document
5of5
Code Review Thomas Douglas Architects Inc
The Academy of Music 196 Pleasant St.
Northampton,MA Northampton, MA
413-585-0641
705 Means of Egress
This Project will not affect the existing egress elements.
705.7 Means of Egress lighting
This Project will not affect the existing egress devices.
705.7 Exit Signs
This Project will not affect the existing egress devices.
Iii and 607 Energy Conservation:
Level i and a alterations are permitted without requiring the entire building to
comply with the International Energy Conservation Code.Alterations (new
construction) shall comply with the International Energy Conservation Code.
A building that undergoes Level 2 alterations is required to meet a certain level of
energy compliance.
Where there are reconfigurations of the space or new doors or windows, any such
new element is required to meet the International Energy Conservation Code.
Elements within the building that are not being affected do not heed to be evaluated
and do not nee to comply with the energy provisions. Essentially the entire building
is not required to meet the energy provisions; only a degree ofpossible improvement
in the energy performance of the building is intended to be achieved by making the
new elements meet the IECC. In certain cases where the reconfiguration of the space
might have resulted in the creation of new spaces the newly created space should be
evaluated as a whole for compliance with the energy provisions even though some of
the element within the space might actually not have been altered. Likewise, in a
case where an existing mechanical system is being extended to other areas or new
ductwork is being installed to reconfigure and reroute the ducts to various spaces, it
is only required to have the new elements meet the energy provisions and not the
entire system.
Any new replacement windows will have a maximum U value of 0.4
Any new entrance doors will have a maximum Uvalue of o.8
None of the existing exterior walls or the roof are being altered, so no new
insulation is required.
8o6 Accessibility
CMR 52.1
Valuation of Project:
• This project's construction costs are: $$315333
• The assessed value of the building is: $2,136,18o
• The cost of the project is 15% of the assessed valuation of the building.
4of5
Code Review Thomas Douglas Architects Inc
The Academy of Music 196 Pleasant St.
Northampton,MA Northampton, MA
413-585-0641
Level 1 work requirements:
The removal and replacement or the covering of existing materials,
elements, equipment or fixtures using new materials, elements, equipment
or fixtures that serves the same purpose
This Project will have new interior finishes and lighting.
602.1 Interior finishes:All newly installed wall and ceiling finishes shall comply with
the IBC
603 Fire Protection:
Alterations shall be done in a manner that maintains the level of fire protection
provided. This Project will not affect the level of fire protection that is currently
provided.
604 Means of Egress
Repairs shall be made in a manner that maintains the level of protection provided for
the means of egress. . This Project will not affect the existing egress elements.
6o6 Structural:
Structural changes are included in this project.A small amount of floor is being
strengthened. Jacob Smith is the structural engineer.
607 Energy Conservation:
See 711 below
Level z work requirements:
The reconfiguration of space, the addition or elimination of any door or
window, the reconfiguration or extension of any system, or the installation
of any additional equipment.
This Project will not create any new spaces or reconfigure any existing exterior
walls or ceilings.
701.3 Compliance
There are no proposed doors or windows. Windows may be added without the light
and ventilation requirements of the IBC
New electrical equipment must comply with section 708
Length of dead end corridors, comply with 705.6 There are no proposed dead end
corridors.
Minimum ceiling height of newly created habitable and occupied spaces shall be 7
feet. There are no newly created spaces.
3 of 5
Code Review Thomas Douglas Architects Inc
The Academy of Music 196 Pleasant St.
Northampton,MA Northampton, MA
413-585-0641
Work Area Method Calculations
The existing space is:
Basement: 3,000
First story: io,u9 square feet
2nd fl: 4,794
Total building area: 17,913
The new work area is 162 square feet
The work area is i% of the aggregate area of the building.
704 Fire Protection:
704.2, 912.2.1 Automatic sprinkler systems
Automatic sprinkler systems are NOT required in this project because of the
exceptions in 704.2.2 and MGL 148 26G
The following conditions are present: (IEBC)
The Level 2 work area does not exceed 50% of the building floor area
The alterations are not major alterations and ceilings are not being removed.
MGL 148 26G:
Sprinklers are required if:The overall building area is greater than 7,50o square feet.
• The total building area for this building is less than 7,500 square feet
(5851 square feet).
Major alterations are work which is "major"in scope or expenditure, and which
results in changes affecting a substantial portion of the building"as defined in MGL
148 z6G
• The reconfigurations in the work area do not rise to the level of"major
alterations"
Major alterations or modifications are reasonably considered major in scope when
such work affects 33% or more of the total gross square footage of the building,
calculated in accordance with 26G.
• The work area for this project is less than 33% of the total gross square
footage of the building.
Major alterations or modifications are reasonably considered major in scope or
expenditure when the total cost of the work (excluding costs relating to sprinkler
installation) is equal to or greater than 33% of the assessed value of the subject
building, as of the date of permit application.
• The costs for this project are less than 33% of the assessed value of the
building.
2 of 5
Code Review Thomas Douglas Architects Inc
The Academy of Music 196 Pleasant St.
Northampton,MA Northampton, MA
413-585-0641
CODE REVIEW July 28, 2014
The Academy of Music Interior renovations
274 Main Street
Northampton, MA
Applicable Building Code: MA 78o CMR Eighth Addition
IBC, IEBC International EXISTING Building Code, 2009
ZONING DISTRICT: CB
PROPOSED RENOVATIONS:
PROJECT DESCRIPTION:
• Paint the interior of the auditorium
• Install new light fixtures in existing and new locations
• Install additional floor structure to strengthen balcony box seating areas.
There are 2 areas at 81 square feet each.Jacob Smith is the structural
engineer.
• Remove existing seats and install new seats. (seats are not included in the
estimated construction cost).
Use Groups
• Al
• There is no change of use
• Existing separation of uses within the overall building: none required
• The current level of safety or sanitation will NOT be reduced and the
portions altered shall conform to the requirements of the IBC, including
interior finishes, interior floor finishes, and interior trim.
Construction Type
• 3B
Sprinkler System
• No sprinkler systems exist in the building. No new systems are proposed.
704.4 Fire alarm and detection:
• There is a fire alarm system in the space with pull stations. The system will
not need to be modified.
I of 5
Initial Construction Control Document
Tohc submitted with the building permit application bvo
Registered Design Pr*Kmmwiwmul
for work per the 8 m edition ofthe
Massachusetts State Building Code, 780CMR, Section l07.O.2
j Date:
P� oo1 Tlr\o: �
Property Address:
Project: Check one u«both uoapplicable: Il�cw000annotiouL 7-1-
Project:
Project description:
I M����� MA Registration Number: E�� Expiration date: am a
registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design
plans,computations and specifications concerning:
Entire Project [ ] Arc6ik:xoou) [ ] SUnokou| [ ] Mco6unioul
Fire Protection [ ] £loorriou| [ ] O/kcr
for the above named project and that such plans,computations and specifications meet the applicable provisions of the
Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. l
understand and agree that I(or my designee)shall perform the necessary professional services and be present on the
construction site ouu regular and periodic basis to:
l. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
oocu,uoto/ io accordance with the requirements o[the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. 8e present u1 intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
When required 6y the building official, lskuU (see item 3.)together with pertinent
comments,iuu form acceptable m the building official.
Upon completion uf the work,l shall submit oo the hu uootion Control Documcut'
Enter in the space to the right u^^vmt^or
o}ootux`ic signature and seal:
Phone number: Email:
Building Official Use Only
Building Official Name: Pen-nit No.: Date:
Trial Version 10092012
DATE R (MMIDONYYY I
AC V CERTIFICATE OF LIABILITY INSURANCE 7/16/2014
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 endorsemen s.
PRODUCER A Sandi Zatganatcz
Webber & Grinnell (413)586-0111 FAX (413)58 6-6481
8 North King Street cszagraniaez @webberandgrinnall.com
I
INSURERISI AFFORDING COVERAGE NAIC* -..
Northampton MA 01060 INSURER A,Central Mutual
INSURED INSURERB:Commerce Insurance 34754
Northeast Painting Associates, Inc. INSURER C
Attn: Phil Dowling INSURER D:
881 North King Street INSURER E.
Northam ton MA 01060 INSURER F:
COVERAGES CERTIFICATE NUMBWtXxp. 7/35 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.
INSK _ TYPE OF INSURANCE POUCYNUMBER pOLIC EFF .POLICY pCP' LIMITS
.:.GENERAL LL48tUTY __ .. .. ... EACH OCCURRENCE $ 1,000,000
X COMM GENERAL LIABILITY ' $ 50,000
A CIAIMS-MADE �IACCUR •LP8361417 /10/2014 (10/2015 MED EXP(Any one person). $ 10,000
.PERSONAL B ADV INJURY $ ^1,.000,000
GENERAL AGGREGATE _ $ 2,000,000
GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY X P LOC $
AUTOMOBILE LIABILITY E® L $ 1,0 0 000'
B ANY AUTO 'BODILY INJURY(Per person) $
ALL OWNED X .SCHEDULED RD /10/2014 /10/2015 BODILY INJURY(Per accident) $
AUTOS
NON-OWNED PERTY AMAGE $
X HIRED AUTOS X AUTOS
I P nt
underinsured me rill At§Plfll $ 20,000
X UMBRELLA LJ X..,OCCUR .
EACH OCCURRENCE .. $ 5,000"000
A EXCESS UAe CLAIMS-MADE AGGREGATE $ 5,000,000
OE ET NT) N. XS8361418 /10/2014 /10/2015 $
A WORKERS COMPENSATION -- - - X: WCSTI.T X 0TH-
AND EMPLOYER&LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE Q NIA
RI E.l;EACH ACCIDENT $ l"000,000
OFFICEMEMBER O(CLUDED? 836141918 /10/2014 /10/2015
(Mandatory in NH) - - :.L.DISEASE-EA EMPLOYEE $ _1.000., 00
If yyes,describe under _�..^.
:.. ::.:.OE CRIPTI ,OF.OPERATIONS below E.L.DISEASE-POLICY LIMIT._ $ 1 000..000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks 5dwidule,if more space Is required)
RE: Academy of Music
The City of Northampton is listed as an additional insured with respects General Liability coveage and as
subject to the terms and conditions of the polcy.
GERTIFIGA E 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.
City of Northampton
Attn: .Talon Doyle
AUTHORIZED REPRESENTATIVE
240 Main St. , Suite 3
j Northampton, MA 01060
R Webber, CIC/SANDI
ACORD 25(2010105) (�1868.2010 ACORD CORPORATION. All rights reserved
INS025(201005101 The ACORD name and logo are registered marks of ACORD
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more
of the,foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information (if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 7-2010 Fax# 617-727-7749
www.mass.gov/dia
` The Commonwealth of Massachusetts
Department of Industrial Accidents
' = Office of Investigations
'7 I Congress Street,Suite 100
Boston, MA 02114-2017
- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:_� G�_ �
City/State/Zip: i PPhhon371: �
Are you an employer?Check Ale appropriate box: Type of project(required):
1.❑ 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. ❑ 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.❑Electrical repairs or additions
L..LG. ,�
3.❑ I am a homeowner doing all work officers have exercised their 11.❑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 infonnation.
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 certflA ui#fqr tl a ains a d penalties of erjury that the information provided above is true and correct.
Si nature:
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 S. Plumbing Inspector
6.Other
Contact Person: Phone#:
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 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
f as Ownenf 1he subject property
hereby authorize Thomas Douglas Architects
to
act on my half, in all matters r ative to work authorized by this building permit application.
'07/29/2014
Signature of Owner Date
Thomas Douglas 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.
-1 o N^A s c-y q w
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: .. w.. _
License Number
Address Expiration Date
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 W No 0
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:
Thomas Douglas Not Applicable
8944
Name(Registrant):
Thomas Douglas Registration Number
08/31/2014
Address
5(413)585-0641 Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
.Jacob Smith Engineering and Design Structural
Name Area of Responsibility
Jacob Smith 43 0
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 I Expiration Date
9.3 General Contractor
Nor--�keaS� „ 'A1A/�1Nq.•• /�ySOCIa *CJ IN (, Not Applicable El
Company Name:
Responsible In Charge of Construction
MA
Address
��3 sbG 5a �3
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 NO CHANGES
Frontage
Setbacks Front
Side L:. - R: L: R:_
Rear
Building Height ""
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved _
arkin
#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 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 DON'T KNOW 0 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: EXISTING
D. Are there any proposed changes to or additions of signs intended for the property? YES Q 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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Ente/r�brief description ere. `
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 ❑ 16 ❑
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 ❑✓
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: B 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)
w �..� ���.. .
1g` 10,119', 1s� e - - �'
........ .� __. ., _. nd
2nd 4,800', 2 0
3rd 0 3rd 0
4« 0 4
Total Area(sf) 10,898 Total Proposed New Construction(sf)
�.... _ 0,
Total Height(ft) 73
Total Height ft _ Or
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 ❑i On site disposal system E]
Version 1.7 Commercial Building Permit May 15,2000
- Depanent use my
ity of Northampton � sbfl�errnit�
�-� Building Department Curb, ittoriyewrayft
212 Main Street SgwertSept1 AuaiI blllty ti
it 3 0 2014
Room 100 1ty JiNe�Ayt �l
i �
Northampton, MA 01060 Two'",,
Electric, Piumning&G
N i qs
orthampton. 1,i§� TT- 87-1240 Fax 413-587-1272 P�>t8 F
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
The Academy of Music Map Lot Unit
274 Main St
Zone Overlay District
Northampton,MA
._,. .... Elm St,District :CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
;The City of Northampton 240 Main St,Northampton,MA
Name(Print) Current Mailing Address:
.(413) 587-1011
Signature Telephone
2.2 Authorized Anent:
Thomas Douglas 196 Pleasant t St,Northampton,MA
Name(Print) Current Mailing Address.
(413).5.85-0641
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building $274,000.00, (a)Building Permit Fee
2. Electrical $30,000.00: (b)Estimated Total Cost of
Construction from 6
3. Plumbing $0.00,,, Building Permit Fee
4. Mechanical(HVAC) $0.00
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0130
APPLICANT/CONTACT PERSON NORTHAMPTON CITY OF ACADEMY OF MUSIC PULASKI PARK
ADDRESS/PHONE 274 MAIN ST NORTHAMPTON
PROPERTY LOCATION 274 MAIN ST
MAP 31 D PARCEL 166 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 1 —
Fee Paid
Typeof Construction: INCRIOR RENOVATIONS
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
274 MAIN ST BP-2015-0130
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 D- 166 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-2015-0130
Project# JS-2015-000224
Est.Cost: $304000.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 87120.00 Owner: NORTHAMPTON CITY OF ACADEMY OF MUSIC PULASKI PARK
Zoning: CB(100) Applicant. Thomas Douglas
AT: 274 MAIN ST
Applicant Address: Phone: Insurance:
196 PLEASANT ST (413) 585-0641
NORTHAMPTONMA01060 ISSUED ON:811112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INTERIOR RENOVATIONS
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 8/11/2014 0:00:00 $0.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner