17C-197 (5) ��lie �iprrvnao�ruuea��2 o��-G�i.1�ac�r�t�'
BOARD OF BUILDING REGULATIO`='_
License: CONSTRUCTION SUPERVISCF.
z" 055146
Number: CS
Birthdate: 05/20/1949
Expires: 05/20/2008 Tr. no: 24912
Restricted: 00
KEITH R SHUFELT '
384 E FOXBORO ST
SHARON, MA 02067 Commissioner
DATE(MM/DD/YY)
ACORD,. CERTIFICATE OF'LIA.BELITY IN§ti :�CE' 03/26/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A AIA'iTE.R OF INFORMATION 01LY
Aon Risk services, Inc. of Rhode Island
SO Kennedy Plaza ANT)CONFERS NO MITTS UPON THE CERTIFICATE HOLDER.1-111S
10th Floor CERTIFICATE DOES NOT ANIEND.EXTEND OR ALTER THE
Providence RI 02903-2393 USA COVERAGE AFFORDED BY THE POLICIES BELOW.
PuONL (866) 283-7124 IAX-(866) 430-1035 INSURERS AFFORDING COVERAGE
INSURED INSURL-RA. National union Fire Ins Co of Pittsburgh
CUMBERLAND FARMS. INC. INSURERB American Home Assurance Co.
777 DEDHAM ST
CANTON MA 020211484 USA I.NSURERC Illinois National Insurance Co
INSURER D
INSURER E
Co l'F:RA1;E5:This Cerlific��te:is not intended to specify all endorsements.cove>•a m terms'conditions and.exclusions ofthe policies shown. SIR. May App y
THE NA I(.ILS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED LAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITI-IST.ANDINC =
AM REOUIRFMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECI TO WHICH THIS CERTIFICATE MAl BE ISSUED OR MAY
I'F RI-NIN.1 HI--INSUR2,NC1:AFFLIRUFD BY THE POLICIES DESCRIBE`:D HEREIN IS SUBJECT 10 ALL 111L TERMS-EXCLUSIONS AND CONDIIIONS OF SUCH POLICIES
AGGREG,AIT LINIII-S SHOWN MAY HAVE DEEN REDUCED BY PAID CLAIMS,
INSR POLICI EFFECTnT POLICYEXPIRATION
LTR -I I FIE W IN51 RANCL P0LIC1 NI'N78L'R U.A TF.(M1f,Al1UD)1'll UATE(M1IM`.UDI\'\'1 LINII"I'S O
B GLnrRNI-uARIL]I') S836089 04/01/07 04/01/08 EACHOCCLmRENCE 51,500,000
General Liability
X CONIMER0:V.GENERAL LI ABILITY FIRE DAMAGEIAn'one file' 51,500,000 N
('L A I,IS N LA Dlf. OC('IAZ NIED ESP(Arse one Person I �O
r\
PFRSONAI.K:\DA'INJURY S1,500,000
GENERAL AGGREGATE 510,000,000
GEVI AGGKL-GATE IANIIT APPI-1ES PILK
PRODUCTS,CONII'10P:NCB S4,000,000
PRO-
POLIC"1 1LCT Lo(
v
r
A 6072972 04/01/07 04/01/08
:\r 10Nioitmr LLkuu-irY Business Automobile - AOS CONILINED SINGLE 1-11117 t`
(Ea accident) S3,ODD,00D
B X ANYAU10 6072973 04101107 04/01/08 u
NI1 U\\nTCD:A)'I05 Business Automobile - MA BODRYINIURY v
A 6072974 04/01/07 04/01/08 (Pet person)
q(IILOCLED W1 OS Business AUto - NH only
X HIR ED:ICI OS BODILY P'AURY
(Pe accident)
PROPERTY DANI:IGE
(Pei accident)
GVIt:\(;I I.1%WLI1I AI.1100NLY-EAACCID"I '
NNN' \(TO OTI IER 11 1AN LA ACC
AVIOOV'LY
\GG
EN(LtiS LI\BILITY EACHOCCUR1L WF
l)CCCN CLAIMS NLADE AGGREGATE
ULIA CI.HiLF
RE1 EN'TION
B 2921215 04101107 04/01/08 X I+'c oTH-
)VORKI:RSCONIPENSATIONAND Workers Compensation- AOS
LNIi'LOY LRS'IJAB LL
III TOR1'LIN11fS FR
C 2921216 04/01/07 04/01/08 K EACHACODEN7 $2,000,000 _=
workers Compensation-FL only FI-r S1ASFPOIX'VL1NI1T 52,000,000
C 2921217 04101107 04/01/08
workers Compensation - MA, NJ E I.DISEASE-EA EMPLONTE S2,00,000
OTIILR kJ
DLSCRIPTIUN Of OPERATION'S tOC.ATIONSA'El 11C LES'EXCLUSION S.A DDE1)131'ENDORS LNIENT'SPECIAL PROVISIONS —
Evidence of Insurance
CTR'FIFICATE.)iOLDER CANCELLA'T10N` �.
Cumberland Farms SIWILLOANl'OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ENI'IRITION
777 Dedham Street DATE THEREOF.THE ISSUING CONIP.AN\'\IILL ENDLAVORTO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
Canton, MA 02021 USA
BUT F.Af1.URE TO DU 50 SIiALI.IMPOSE NO OBLIGATION OR LLAA1llT1'
OF ANY KIND WON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
:WTHORIZED REPRESI:NTATI\'E
ACORD 25-S(7/97).. ACORll CORPORATION 1988 EN
The Commonwealth of Massachusetts i
Department of Industrial Accidents
Office of Investigations
a 600 Washington Street
Boston, MA 02111
s�•�'w www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): t:'i.L�Ull
Address: 7 7 7 12,� .aill -S T
City/State/Zip: -+, APiW 1, IM4 _ d 310 3/ Phone.#: 9W 3L 170a ,V 333s
Are you an employer?Check the appropriate box: Type of project(required):
4. Q I am a general contractor and I
1. I am a employer with turd tA,e,'D 6. Q New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet 7. 5rRemodeling
2.0 I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. employees and have workers' 9 Q Building addition
comp. #
[No workers' comp.insurance co insurance. 10. Electrical repairs or additions
required.] 5. Q We are a corporation and its ❑ p
3.0 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.Q Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13.Q Other
employees. [No workers'
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_
tContractors 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:_116'Al fZl.SLL S€�2�'tCc 1-lu
Policy#or Se If-ins. Lic. #: 5 .3 fte 0007 Expiration Date:- d
Job Site Address: <3 / ,+,(Al S. r City/State/Zip; F,42g& -/19�
IF
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: �� .- LC % Date• 0���,�
Phone#: 0'1:Z �3 F
Official use only. Do not i rite in this area,to be completed by city or torn officiaL
City or
Town-Permit/License#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Version 1.7 Commercial Building Permit May 15,2000
v.•
SEC-TION 90-.STRFICTURAL-PEERREV.IEW(7$O GMR 11`011
Independent Structural Engineering Structural Peer Review Required Yes No Q
SECTION 14=,OWNERAU;THORIZ.ATION=TO-BE-COMP.LETEQ:Wt.tEN
OWNERS AGENT OR CONTRACTOR A.PLIES4:'OR BUILDING PERMIT
as Owner of the subject property
hereby authorize `to
act on my behalf,in all matters relative to work authorized by this building permit application.
i
Signature of Owner Date
i
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 underthepains and penalties of perjury.
i
Print Name
l
4 i
Signature of Owner/Agent Date "
SECT�N"1`T--CONSTRiJCItON SEfttC10ES
10.1 Licensed Construction Supervisor: Not Applicable (]
Name of License Holder,
License Number
1-2'77- Pewee m+l r, C9 w
Address �J Expiration Date
4J 3
Si7('
Sig tore Telephone
`QAVENtIO 'NS)SECTON 33'-WORK=RSCOMP GL.c.152z§25C(6)1
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
i
Version 1.7 Commercial Building Permit May 15,2000
.SECTION .9-PROFESSIONAL DESIGN ANDONSTRUCTIQN SER\%IGES=FOR Bl11LDING$4 NQS7itUGT1RE5lJB.)EC7.tO
_ .
CONSTRUCTION CONTROL:PURSUANTT0,780=C1VIR 116 CONTAINING MORE THAN.3500 C F.OF ENCLOSED SPACE)
9.1 Registered Architect
Not Applicable 0
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
a
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
1
Address Registration Number
I i
Signature Telephone Expiration Date
r
Name Area of Responsibility
I
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
I � '
a '
Address Registration Number
I
Signature Telephone Expiration Date
9.3 General Contractor
FAW&E ZZIC" i Not Applicable❑
Company Name:
77 7 IJ"I Ao
Ressppo`nsible In Charge of Construction
Address
Jgl;ur�e &
Telephone x
Versionl.7 Commercial Building Permit May 15,2000
r 8 T®R -16 MW
x ..y
Existing Proposed Required by Zoning
This column to be filled in by
,i
Building Department
i ;
Lot Size '
Frontage
Setbacks Front
i € y
Side L:= R:= L= R:=
Rear
BuiTdmg HeigIff 1
Bldg.Square Footage i % tI
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
Fill:
s
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book j Paged and/or Document#I
B. Does the site contain a brook, body of water or wetlands? NO Q— DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , 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 NO
IF YES, describe size, type and location: I
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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Building Permit May 15,2000
SECTION =CONSTRI7CTtQl�SERa/ICES fDRPROJECTS;LES55 tHAN 35 OOb
CUBICEEET+DFI=NCLQSENSPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description 'Enter a brief description here.
Of Proposed Work:{ jl lJpG � T� �/L S T07
i
SECTION'S=USE-GROUP=�TID CDNSTRUC ON,TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A71 ❑ A-2 ❑ A-3 ❑ 1A El
A-4 ❑ A-5 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational ❑ 26 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ I-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:
i
M Mixed Use ❑ Specify:
i
S Special Use Specify:1 j
COMPLETE YEA""OPI TF,EXISTINi BU1LDiNG I DE&�GOII�G F2 T7flVATfONS,:AC3pIflON5 D10Ft�CHANGE N USE
Existing Use Group: Proposed Use Group
Existing Hazard Index 780 CMR 34):! ! Proposed Hazard Index 780 CMR 34): 1
5EC-T:ION'6°BUILDING''HE1Gk1�A1�iD�.�1REA:
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION " ='
Floor Area per Floor(sf)
St sc � .
nd
2nd i 2
3rd ' 3rd t
�,
4m ; i 4 ;
Total Area(so Total Proposed New Construction(sf)�
W '
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 E] Private [3 Zone F i Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
-- City of Northampton
�� -- Building Department
r:r--
U:R 212 Main Street
C" Room 100
Northampton, MA 01060
413-587-1240 Fax 413-587-1272 .
CD
APPUCATK*TO Cpl RUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
4
SE�IION 1- NE �d1TION�
� �' r --!� - -- ` �`'.`�. .��t'r�s�oarEo�ecocn•p`Tete�.IzX-affi"ce_
F O x
/nom 67- atf loft kfrttt
d
SECTION 2 P PIAtITHORIZED AGEf�3
x
2.1 Owner of Record:
! r'v waaie .777
Name(Print) /CE[yr-14 J` hkh&L 7- Current Mailing Address:
ef4l7OAl, 44 0,46a at
Signature Telephone 1—s-66 3
2.2 Authorized Agent:
j
Name(Print) Current Mailing Address:
i
Signature Telephone
SEGTIOhF:3--"ESTIIfAATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official.Use t3r,1y
completed b e rmlfa- !icant
1. Building (a1 Building-P,- erif.Fee'
g '
2. Electrical i (bj Estimated Total Cost"of —
Constri�cf+ori from 6
3. Plumbing ' i ;Burtdmg..PermifFee
i
4. Mechanical(HVAC)
5. Fire Protection L I
6. Total=(1 +2+3+4+5) -Check Nurnber
Seehon"For;.Official"Use Onl
BulldmgzPermlt.Number Rafe
1sued
r
Signature:
Building Commissione llnspecfor of Buildings
Date
File#BP-2008-0327
APPLICANT/CONTACT PERSON CUMBERLAND FARMS INC S
ADDRESS/PHONE 777 DEDHAM ST CANTON (781) 828-4900
PROPERTY LOCATION 53 MAIN ST
MAP 17C PARCEL 197 001 ZONE GB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction:_UPDATE EQUIPMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055146
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOIRMATION 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 Co ion
.f
Signature of Building Officia 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.
1 t
BP-2008-0327
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2008-0327
Project# JS-2008-000467
Est. Cost:
Fee: $135.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CUMBERLAND FARMS INC 055146
Lot Size(sq. ft.): 21387.96 Owner: CUMBERLAND FARM,INC
Zoning: GB Applicant: CUMBERLAND FARMS INC
AT: 53 MAIN ST
Applicant Address: Phone: Insurance:
777 DEDHAM ST (781) 828-4900 WC
CANTONMA02021 ISSUED ON.10/5/2007 0:00:00
TO PERFORM THE FOLLOWING WORK.-UPDATE EQUIPMENT
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 10/5/2007 0:00:00 $135.00115
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo