31B-085 (3) onSLMENT DOMINO FLM
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11-114!!
- -- GAR
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ZONE or vA;RR/////, 1?� 1oaPwrr
BASEMENT PROPOSED PLAN
III a 111
11
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iSTORAGE III■ _ EL�/ATION 7._ ELE ELEVATION �� //
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( ERAL NOTES HO / / / //
BOOR � l �/ � � _ i
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hem paleric,a eas ot fere OE.to eo am+ I
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ly Ig. Fle eawr .a / \ 'C'. i v it Iloot p Yom, ,,
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,
fl exiOno su i3e(W SCaedulealt @ •M
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c ibecta sh ll reparIn welch acir Yeel serar s HD
KEYED NOTES ®Existing Storage Floor Plan/Demolition Plan
New Gara 0"Floor Plan
PI; P p t g n r M S. W
seeks w' 1 V 9eek'. a18 Pa yry
mwrce 1 I t Bt . I H M 'w d ME . retr.l a a Newa my 1 late gyp (z N layer'''. ry (0 meclowe. �t9-1��� w
it/
p . el - ry. ra fid (Oct sides) at 1 0 ah. _ See 9 m plata plat nheight ol(AW / �J/q/
9mgn Se. t.' HFLIw a'
floor ex A I It Diva Wrap oenetsN N 9 0, pN deo) .'��/� I 4. iY ,/ r �t/c9 (� OO V
aPPI Bailer61 Provide n tltl a .. 10fare 'ateastevial. / I �/. _
doorwe & See (3 F br framing g Y cadre 5 W
CP Wider existing masonry P 1I t10 P n all nod P.11 11 1 r ]2 ! p allorms
garage h t pl .. 1 G al J N
1 S. tl I18SIll d T N ,feel '1'creed aP Ex I gco cele'boor toremar Z
Henn' .: bolls'r. ^ n Provide w NUM 14-n Iso WPI IL City Of Northampton m
presa atior[or-ryas() ry H (a) New0 widef HO CNN) r Seal go-RD-ate,. G muhw(Barging ,vxe // . Building Department
Z C
n OHO lo, JE e electric car d, Hallow Metal Don &Same i,m 28 xbd' Gem nc B3) fxUxlO or ra0N1snloMS P.pttlity room. `/ Plan Review m mZ
door 20 ailed - _s LEDs . n . Set eve'existing . ) I ' r W212 Main Street Z r
t Hflc Mal Doe xD�am loam x(1- slab dig I apr ro�dp�l;wnoal., Oa1a NOrthan1PtOn, MA 01060 IH a , _Jm
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a m ZONCOFWORK/////. r�t
9ASEM[NT PROPOSED PLAN East Elev: Exsting/Demolition # „, s „ ,.
a m m m Ose�
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STORAGE
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a ZONE OF WORK/////. F O
FISPAMINIIIII Cz
GENERAL NOTES a
Geee al rcrtractr,resDN'ilttere,worn latieo -I 1East Elevation Utlhty Room, ,—'_ 2S .
style. va _,.D
Steel Lintels a_Garage
G„,,, prr,n_ etr
of zone 0 we 1o orevent(-nest.-NI^^rabic.cl d
onreanp area,oaside the erne owa
O le 1b tl etwells
re II _ll etcI 1rr.,,vl t.vw ;.t 15:791111.'1474.1471Essa.4li°1a ..%v.
n.
Nee, aIle l v gyp J metal II 4 �_ a u• •411:04,16 sits ur••...
An le yfe,cal rro raviiy s 1 g
_. :.I n,
r°re ro a.. :ICePI c Ws eav lY abovewl rJ y
See 1 B4 Ie0 • I
r a
At D r r v New Garage: Reflected Ceiling Plan s® t1
�_nrean.r a gee,enniageO by ra DI„am and erne rue,eorettcocr l - sew are.=v.o^
P / Y B Demo T rr r L..s a ea ieceeeie grruje
KEYED NOTES e garage Ill coyly S 11 1 e 9 S clac ne-nareLnsa . ` yl `-
l 1 t est arc steelI^el stall IR a '�
meter
I _ LU
I Instal ed by Q On 0'0100 From-pee lactLer Proves adlace.. ny lv. space,sbovaac g. C r rolery, azbrnryer J 1I. _ tr, Ur
power and moon rc olccerg ;noticed,
R _Iv b cross P .L I Y [ii_. o CC
2 T .aY /TY xqY 9 ateec p-ne t _o'elect-Ica 0 P llo Y ITy 1 1 i)2., 12 I Q
v •sp 1 ) seal al s p 9Gyp 1 I m
en n
PT
ry r glass‘10E" — r o
wree orals: ewees eels See2a3 fi N t ,3T81 ay aocCirve b< oa e., rde Coo.OY°ewe'� _ N Z
.nes)Dem Ileoro(Wee abo-e.see ) 1_. - 1 L W N
dl Sika W priotemeflI oa onareaacpea et..ac #e t wbl ral too par 'bLL'seal to SMe Wap panel cif Pmitle . .o cres2iV lar .0 ::-rose. on' •
W �
s,omn / See oei B3 Y ry ..- m li <O
' ep _ a - r .l l seal Cavity ;'"°e°" , East Elev Workroom: New People Door East Elev Garage. Prep'd for Garage Door Installation Z m F
pp L lamb Ince P 9 P' 9
o
ladle a4 veal
scale: 1/4'=,•.0" scale.-,la"=,-0' Cu ¢ _I WI
P.nen see rare colnq. 1 o o CC I 1cn
BASEMENT LXISTING PLAN -
® m PI D C rgj sue mouet Lg l beye,
fr ,Perry p panels � 4��1 � 41 B
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below car ter
+ry ■/ 1 e� la IPoI Ig lv n 10` \ .111 � � a
1 � . ' . g 1 n apse __ - - - __ - o `n E
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elevOa' E-
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BASEMENT aR_orosro Pun r ..
Oli ��� 1t x Wall ;.Ong north wall Of garage `-- p _. .. .. A
�rew B0lall eVi
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seals: ale 1.v LU
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elev ga
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vi `Jl stele. ore' rw^ n D r . o ... Sy . . r Q }}O--
. / / F/ .i ()veil . elr mon Dy Raynor Door 7j R
/ b •p. 4 // / E mamoton
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4. 20151005 3I
WN By JLS 65 HENSHAVd AVENUE ACQUEUNE SCO AA
NORTHAMPTON, MA Mass n ense: 50045
BASEMENT GARAGE jacouc ine L i_scocottCma�
g !.con'i
ET NO.: 84
65 HENSHAW AVE BP-2017-0466
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B-085 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:GARAGE BUILDING PERMIT
Permit# BP-2017-0466
Project k JS-2017-000775
Est. Cost: $54780.00
Fee: $356.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ALDER CONSTRUCTION INC 071067
Lot Size(so. ft.): 5662.80 Owner: SCOTT JACQUELINE L&RICARDO B METZ
Zoning:URC(I00)/ Applicant: ALDER CONSTRUCTION INC
AT: 65 HENSHAW AVE
Applicant Address: Phone: Insurance:
35 JEFFERY LANE (508)246-4533 WC
AM H ER5TMA01002 ISSUED ON:10/13/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:CONVERT BASEMENT STORAGE INTO FUTURE
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 10/13/2016 0:00:00 $356.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File/i BP-2017-0466
APPLICANT/CONTACT PERSON ALDER CONSTRUCTION INC
ADDRESS/PHONE 35 JEFFERY LANE AMHERST (508)346-4533
PROPERTY LOCATION 65 RENSHAW AVE
MAP 3IB PARCEL 085 001 ZONE URC(IOI�
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ������
Fee Paid fQZ z"`��
BuildingBermit Filled cut
Fee Paid
Tvp of Co t Con: CONVERT BASEMENT STORAGE oro FUTURE GARAGE
New Construction
Non Structural interior renovations
_Addition to Existing
_Accessory Structure
Buildine Plans Included:
Owner/Statement or License 071067
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR ATION PRESENTED:
pproved 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 Registy 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
S roe of':uil s m_Official ate
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 or MGL 40A. Contact Office of
Planning&Development for more information.
,_-. 6epartltasntuseotdyt
I: J City of Northampton Status of Pam*
Building Department Gab Penmt
OCi — 7 212 Main Street SamriSepticAvaBaidlity
{ll Room 100 Iffattdirlfelkirakbaty
Northampton, MA 01060 Tiatr ets a#*4n tragi Pleere
----=—phone 413-587-1240 Fax 413-587-1272 P1e[15iMtr Ptatt�,
Oilier Specify_,,_,__
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
(, 5 Ne-..••g�a , AJ4 . Map Lot Unit
HO. [kLA we%Sikh vs Mk 01 01e0 Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1` l,,,t l 1` 1 t, 1, l
3„{u4��v{ SA ��sCt0 t 4Q ` . (.S^ TtP....S�.l4�W PVC . NA�`wwytvto...
Name(Pint)V Current Mang Address:
Telephone
Sgnature
2.2 Authorized Agent; p !
r,„ , (,c l tt q 3 S S r (+v es) (c e / ten � a7i
Name ant) g Current Mating Address
&posture TNepnoae
SECTION 1-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building L‘41100`!'700 - Do (a)Building Permit Fee
2. Electrical j (b)Estimated Total Cost of
— y,O O . a Q Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) .)/
5.Fire Protection I c�—r�v {� .00 ,.,y� 7,,
6. Total=(1 +2+3+4+5) S4� lt0 .co Check Number /L/7j 3'�9(y
This Section For Official Use Only
Building PermitNumberNumber Date
Signature:
Bulking Commreionedinstedor at Bullrings Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Tbis Required n parto be fiiW ening
cMwnSo by
IlnlNiing Department
Lot Size
Fru° .�e
Setbacks Enna
Side
Rear
Open Space Footage e a
(Lot area minus bldg&.paved
INIME=1
111.1111111.11111.1.1.11111.1.1111.
Fl:
ill:volume er Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES,date issued:
iF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES,describe size, type and location:
E. Wil the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre oris it part of a common plan
that vdll disturb over I acre? YES O NO 0
IF YES,then a Northampton Storm Water Management Permt from the DPW is required
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition 0 Replacement Windows Alteration(s) ® Roofing 0
or Doors O
Accessory Bldg. n Demolition ❑ New Signs [O] Decks [q Siding[CO Other[17]
Brief Description of Proposed
Work: r40 v.,, .\ b..Y-, 't..4 SSha-••/q r .s,n'ltb c..�.✓t y —St
Alteration of existing bedroomYes ?f No Adding new bedroom Yes k No
Attached Narrative Renovating unfinished basement X Yes No
Plans Attached Roll -Sheet
sc.If New house and or addion to existing housing,complete the following:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
1. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 1D0 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer_ Private well, City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT�� OR CONTRACTOR
\`A(Py`Pll-EESS FOR BUILDING PERMIT
I. -itit'�'�)'(V- �' " -"' " ,as Owner of the subject
property v /� ,�
hereby authorize 13(% Cc'aLa / kt C'tiiS Lh �"
to act o/ry'my behalf,,in allgmatters-celati.- work authorized by this building perrn application.
VlM./ Alv\ , 1 ]O J 3-1 Z--O((p
Signature cf Oen Date
I, ,as OvmerrAuthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knoviedge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Constructio(n�Supervisor. (r 1 Not Applicable 0
Name of License Bolder lir 540 t,,„ CAsseNk s. cS — 011061
License Number
3 ]L` "••.J<n Lot 1>c .�na s� t 11 0t007 s/t1. Li
Address I Expiration Date
CAS- - AS-53
Signature Telephone
t Reaiatered Home h rwownwnt Contractor Not Applicable ❑
MA Le' C«..S\Ne t,1:E1,, Tra-r . t% ti 3 0
Company Narne Registration Number
34a-- tf—Cc � L r, 5 f c 1 t-1
Address Expiration D e
IltsrsosciAtfS)' )t-k un Telephone SwbS.As5
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C.152 fe 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 % No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
As sufwrvisor,CMR 780. Sixth Edition Section 108,3.5.1.
Definition of Homeowner;Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures. A person who constructs more than one home in a two-rear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
t-nu.'i.L r : h _yo to. 'din•
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
— Department of Industrial'Accidents
t le5!t Office of Investigations
•
vs-niihr-t- 1 Congress Street, Suite 100
Boston, MA 02114-2017
wwwmuss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information p { / L Please Print Legibly
Name (Business/Organization/Individual): r1 WU,..r tr o.i.S'�r .+ s-v...., tat,,,
T
Address: ?z� St�cGage-1 L ..
City/State/Zip: (>cti,,,kA f, ..\ tIN Q\6O Z Phone#: o$- usdo- AS 3 3
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. Nil am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 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. 0 We are a corporation and its 10.0 Electrical repairs or additions
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. 1.52, §1(4),and we have no
employees. [No workers' 13.❑Other
comp. insurance required.]
*Any applicant that checks box#1 must also fin 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 subcontractors 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 polity and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lie. #: 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#:
i Official use only. Do not write In this area,to be completed by city or town official.
City or Town: Permit/License It
i 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#:
OCT-07-2016 15:32 CONGDON & COLEMAN INS. 5082281054 P.001
44.4C7(:).Ro CERTIFICATE OF LIABILITY INSURANCE °ATE,MWOD T„
10/07/2016
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
NAYR:
Congdon B Coleman insurance j
Agency, Inc. Ce 508228-0544MK NETp IJ
Ne508-228-1064
II
57 Main Street,P.O.Box 1199 EMAIL '—
ADDRESS,
Nantucket,MA 02554
INSURENS)ACFORC4NG COVERAGE I NA/CX
INSURER A:Western World Insurance Co. i
INSURED Alder Construction Inc INSURER B:
35 Jeffrey Lane Ixv,JREA c:
Amherst,MA 01002
INSURER D:
INSURER C:
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.UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS-
LTR TYPE OF INSURANCE INso POUCY NUMBER IMWDDIYYYY) (MWWpph Y) UNITS
A X COMMERCWL GENERAL LIA ILIT' , EACH OCCURRENCE $ 1,BDD,DBD
cIAN6W�nEOCCUR NP%138781 05/21/2016 05121/2017 PREMISES gee uTsrcf) E 50,000
MED EXP WY one Pn.eni 5,000
PERSONAL AVV INJURY $ 1.000.000
GENL AGGREGATE LIMIT APPLIES PER'. GENEPALAGGRFWTE •$ 2,000,000
X POLICY jE<} LOC PRODUCTS-COMP/OP AfiG E 1,000,000
OTRER: u I rE
AUTONO&LE UAe41T' COPONE0 SINGLE LIMIT E a
IEe naen9_.„
"I-in./AUTO BODILY INJURY(APyaw
pn) 3
�ALL ONNED '--- SCHEDULED BODILY IWURY Per ac dent) 5
�'AUTOS _ AUTOS
HIRED AUTOS _
NON.OWNED IpRM6PF 0A%O:GE $
aouPmoS
IUMBRELLAUM 1 OCCuR EACH OCCURRENCE $
' excess LMB CLAIMS-MADE AGGREGATE IE
DED I I RETENTIONS r
WORKERS COMPENSATION PER 1 0TH-
AND EMPLOYERS'LIABA.T YIN STATUTE ER__
ANY PROFRIETMFARTNERAXECU1YL ^�"�I EL EACH ACCIDENT 5
OFFICER/HEWER EXCLUDED, iJ NIA -
(M[MLMP/MNIG EL DISEASE-EA EMPLOYEE S
Nyev R PTI0N OM,
OERCRIPTbN OF OPERATIONS W W EL OISFA4E-POLICY LIMA II$
DESCRIPTION OF OPERATIONS/LOCATONSI VEHICLES ((CORD 101.Addltlmul Renwb Scmoot may Ca MYc'hed II man paw It NCWn0)
Contractor
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Si CANCELLED BEFORE
City Of NOfdlBMptOn THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Building Commissioner's Office
212 Main Street AUTHORQED REPRESENTATIVE
Northampton,MA 01060 cZt` : Q «pN*1.IL52
v --
®1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
OCT-0?-2016 15:32 CONGDON 6 COLEMAN INS. 5082281064 P.002
A GU CERTIFICATE OF LIABILITY INSURANCE J DArem o°M1""
15
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 INSURENS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the Certificate holder Is an AOOIIIONAL INSURED.the polioy(ies)must be endorsed. H SUBROGATION IS WAIVED,subject to
the terms and condttlens of the policy,pilin poilcos may Moire an endorsement. A statement on this cortiicate does not confer Ors to the
certificate holder in lieu of Such cndersamem(s).
'RODUC S4 tGNIA T
NANa Jp Kymer
CONGDON&COLEMAN INSURANCE AGENCY,INC. .tW�g.N`I,N Fos (503)118-0344 w,c.Inr
"Keg jkymergitcandcins.com .
P.O.BOX1199 _ nqugENt5}AFF01104Nr.Ca+ERACR i ARC•.
NANTUCKET MA 025S4 wsuRER A: HARTFORD UNDERWRITERS IN$COr 30104
INSURED INSURERS::
ALDER CONSTRUCTION INC INSmwRC, -_ _„
INSIINER o:
35 JEFFREY LANE elsuRETS E:
AMHERST MA 01Q02 INSIDER F: I
COVERAGES CERTIFICATE NUMBER: 92107 REVISION NUMBER:
TINS I$TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTMTHSTAr4DING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WWITH 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 CONC4TIONS OF SUCH POLPORS.LIMITS SHOWN MAY HAVESEEN REDUCED BYPMDCLAIMS
SM '--_ ADOLISIWR,I --_ PL�ER'SOSIer6Itir .'—. ••"
LTR TYPI Or INSUPANCE INSO`I`I wvo POLICY NUMBER IHM' Oriv,v Mnicone VI OMITS
IcosomeCLAL ageisL psalm( EACHCCCVRRENOE S
CWM$iMUE I ICCCUR FSI ISE ms5selgJ.4-5
L- - MED AAP(Any onervS I f
WA PERSONALS Aov MUMS 'S
GEN%AGGREGATE IIMR APPLIES PRR'. GENE'RALAGGRVGATS S
PoLICY ,Pigg F LOC PRODUCTS-COMPASS AGG I,5 _
1 DINER. 5
AUTeMOeILLLMMUTY _SEA
SINGLE LIMY
-$
AN?Aura ,EDGILY MJUY%>cr) S
ALL OWNED r'SCHEO44E0µ N/A I BODILY IWyRY(PR asrWnV S
AUTOS NON-CM DPROPERTY DAMAGE S
If REDutas Ga + _M4rni
5
UMBRELLA LIAR I_ QCCUR FALAI OCCURRENCE S
I FXCESSLAS 1 CII0AIS.554,5E WA AGGREGATE
I I OED RETENTION$ 5
YORKERS CGYRfNSATO( I X y`YATuTE Kt' i
AND EXMOYEW'LIAIMATY YIN
AN YMMAVETORIPARTNEWEXECUTIVE 'EL.EAGNACCIOENi L 100,000
A DFFIrFRME50EREXCLUDEOS WAi NIA NIA 6S60UB5B40032518 '051232016 05/231201'/'
IMIMNIOK At NPR EL-0.1SAsE-fA EMPLOYER S 100,0p0
C94IrnO '
0.9DN5rr ._... 'EI.DISEA.'rPPOLICY LAMA'13 50,0,.000
—.
: NM
I I
00ONIPRON Of OPERAToO Soots Na IbeNICAea/AGSMs lot.seINsMIRIMrkseo.*. may Madschi Holum
orsemnt S.04%004
to
tte
Persian to
ven
claims for bene its totoB payees vet
1statee paid
oher than Maassachus ttemployees insured hires.or has those employees oatide of authorization
Ise s, o�y
The cenifaate of insurance shows the pocky In forte on the Sala that tis Cedficste wee issued(unieae the expiration dole on the above pokey procadas to
issue dale of this centric*,of insurance). The status of vis coverage can be monitoted dally by accessing the Proof of Coverage-Coverage Venn cation
Search tool at www.masa.gov?.W/workers-tnmpensadonenvestlgatIons/
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRABON PATE THEREOF, NOTICE WILL BE ORLWERED IN
CITY OF NORTHAMPTON-BUILDING DEPT accQRBAHCEWm+THE PQI.teYPRariswns.
212 MAIN STREET AUTHORIZEL REPRESENTATIVE
NORTHAMPTON MA 01860 �'M
Daniel M.Cy.CPCU.VIED President-Residual Merkel-WCRIBMA
M1933-2014 ACORO CORPORATION. AU rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
TOTAL P.002
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: G s v./ .r
The debris will be transported by: ti au,% I/ �,e_ L `
The debris will be received by: llG fiR.r <.�.1 tc,f Gti fol 6 td (1'1
Building permit number
Name of Permit Applicant
(L,74
Date Signature of Permit Applicant