31B-246 (10) 116 ELM ST-PARK ANNEX BP-2019-1428
clsM COMMONWEALTH OF MASSACHUSETTS
MaD:B10Ck:31B-246 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:renovation BUILDING PERMIT
Permit# BP-2019-1428
Project# JS-2019-002311
Est.Cost:$33287.00
Fee: 5232.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
UseGrouD: MELISSA FRYDLO 073437
Lot Sixe(sp. R.): 22084.92 Owner: SMITH COLLEGE OFFICE OF TREASURER
zoning:Eu(100VURC(I00 Applicant.- MELISSA FRYDLO
AT. 116 ELM ST - PARK ANNEX
Applicant Address: Phone: Insurance:
123 SOUTH ST#2 (413) 320-6469 WC
NORTHAMPTONMA01060 ISSUED ON.611912 01 9 0:00.00
TO PERFORM THE FOLLOWING WORK:DEMO NON LOAD BEARING WALL,
RECONSTRUCT WALL AND CEILING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspeclorof 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 6/1920190:00:00 $232,00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
File#BP-2019.1428
APPLICANT/CONTACT PERSON MELISSA FRYDLO
ADDRESS/PHONE 123 SOUTH ST#2 NORTHAMPTON (413)320-6469
PROPERTY LOCATION 116 ELM ST-PARK ANNEX
MAP 3 IB PARCEL 246001 ZONE EU(IOOVURC(IOOV
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION LIST
LIECLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out -115P 41u.
Fee Paid Wdf
Tvceof Construction: DEMO NON LOAD BEARINO4A44rE1, RECONSTRUCT WALL AND CEILING
New Construction
Non Structural interior renovations
Addition to Existing
_ Accessory Structure
Building Plans Included:
Owner/Statement or License 073437
3 sets of Plans/Plot Plan
THE FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF_QRMATION PRESENTED:
L�rApparoved_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 feeds 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 Sturm Water Management
Demolition Delay
1-18-20►q
Sig reof guilding 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.
Vemionl T Comm wl RuilgM Pmod Ma 15.2000
City of Northampton
JUN 1 72019 BUI&my Daparbn t
212 Main Street
Room 100
of T OF ruuDiNr.INSPECTION$ orthampton, MA 01060
21HA"PTON.IAA61 e4 }567.1240 Faz413.587-1272
APPLICATION TO CONSTRUCT,REPAIR RENOVATE,CHANGE THE USE OR OCCUPAO*RH AMY WUMOOTHER THAN A ONE OR TWO FAMILY DWELLIN
SECTOR 7-SITE MPoI6IATION
7.7Adgm T,t"Ydlon b •wnOlaNa by of w
SMITH LLE0£ Ill. �Lt9 ,T=" , M.P Loi .1gCe UTA
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SECTOR 3.PROPERTY ONANIPSHrIAUTHORIM AGENT
WoL1 120 V EST STQ�T
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Rem EIWT&W Coot(COWS)b be om"UM ody
tWrAWW by n
1. BuN6lq /'/�tv• 9v . OJ U)BIN I P.net Fat
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3. RumdnO e1J 00 EaadinN Psemx F.
1. Mwhwicat(HVAC)
5.FV.pmteWon 76 per' -
6. TaW-(1-2.3-4• .� m-a NUMv 10 1
This Good" onkm U"Onk
BWM1 Q Permt Nunb.r t1R.
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V.wl.7 C.min c l Building P.n Msy 15,20W
gcim,ACOISi mumu sormEs FOR PROJECTS LEN THAN 35 ON
a MOF SWAA ®SPACE
WIw AMwoons 0 ESWnwasm rw ❑ Dsmom"M RpNn❑ Additions ❑ ATc22ry SulMq❑
Emww A%wmmn ❑ Uwwm Dr"msgn❑ Nswsgs❑ Roollas❑ Changou2❑ Odwr❑
SA0DMCrIPUn Enter&bricrdescription hercm": IsH 4 ). 06vwp gCA04w, VJAL4.+ PGT,
Offtopossd WWW KcG os!70 x-f wA- - rr'w .INf - F-ELa(.A,Lv (IAOIAr-r rAYsa, /IJG.
SECTION I-USE GROW ARD CONSTRUCTION TYPE w Sr-Lk + ASsar.,
hN
USEDIIOUP 2700'" STYPE
A Assw1�01y ❑ Mt ❑ 42 ❑ A-3 ❑ to 13
M ❑ AS ❑ 18 ❑
s B2Yn2 ❑ 2A ❑
E 28 ❑
F Faclary ❑ F-t ❑ F-2 ❑ 2C
N HIO Hawd ❑ 3A ❑
I ❑ M 0 1-2 ❑ W ❑ 36 Q
Y MwnMls ❑
R R-1 R-2 W R-3 ❑ OA [3S 8780. C3 St ❑ 5-2 ❑ 6B ❑
U U y ❑ speffY
Y WW d U2 ❑ sp-ar.. ---
s Spaonl U2 ❑ BsrAY
COKWUM THIS BECTIM F EXISTING BUIUMG UNDERGOING RBICNANKMA AODDIDIS ANDOR CHANGE M USE
EsWF10 UN Group: =- _. Proposed UN Group: _
Nmrd kids 700 COIR 3N}E�- - -----1 Propu2d Hand Midas 7SO CMR 3s : '�
SECTION OO OWNING NWONT AND MFA
BIRLOWO AREA D08TNG PROPOSED NEW CONSTRUCTION j'" -y.. -,.-
i
Row Ana wFloor log &s
t.s
2y1 11-1-11
241
4. •TyZyan4 _
Tom N7 M L w�" J TOW PnPosd New ,-.•'�-M"T+'' T..I,
17 s
Tad Have IN ® . . . .
7.PAHr SOBOP pI.al4 Os,{5<) 7.1 7J
PH'o Pdsws 2ww OuwNS Flopd On pa4issl yswn .
Vmlonl 'Cnmmcmml Building Pcnmi May 15,2000
A. :NORTHAM"ON ZONING
csisung Pmposed Roximmed by Zoning
Thbaalo e aa rind:y
2 MA W$Dapamaaam
Lot Six
Fm a a ,
Selbacts fMal Q Q
g� MI rFq77 0
Building Height ® 1 Q
Bldg.Square Farago % Q Q
Open Space Foomge ® % ® Q
Itoi.m mumu Nat a pined
nor
a ofParking Spaces O O
FW:
r A t.wooi
A. Has a Special Pennit/Variance/Fird mit ever been Issued fa?on the site?
NO O DONT KNOW 0 YES O
IF YES,dale hsued: L_
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT MW • YES O
IF YES: enter Book Page; ._ __ andlor Document/ _J
B. Does the site contain a brook,body of water or wetlands? NO • DONT KNOW O M O
IF YES,has a Denntt been or need to be obtained from the Conservation Commission?
Needs to be obtalned O Obulned O Data humd: I
C. Do any film exist on the property? YES ` NO O
IF YES,describe six, type and location: A O" w I to a dos "(F PAGW I St FL
0. Are there"proposed changes to or additionsof ssgm Intended for the property? YES O NO •
IF YES,describe size,type and location: i
E. YMl Conaeuroona yd rl,tdewmg.padiq.Wmvsftn,w ilrq?weria wkkpWi Ofaomwlonpllr
diet MI diad mer 1 Keel YES O No •
IF YES,then a Nomhar Sw Wafer Atanegwnart Pan*from nn DPW In MWINd.
Vmlonl 7 C.mm .d 6aldmg Pa t May 11,2DOO
==M *- NALDWGN AND CM/atHwym awwwra-FoR*u DIm AND aTnucTumat161ECT TO
CDg1aTM= Md CDKMM.P18WJWTOTDCYl11a AEM1O YORE THAN 35,M C.F.OFENCl MW
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Wniaml T Cnmmcmul Building Pcmm May 15,2000
SECTION 10.STRUCTURAL PEER REVIEW(190 CMR 110.11)
khdepurem$tntdYr SwSral Peer Reww Repuketl Yea Na
tE II -Cm TION-TO IE
OWNERS ADEM OR COM7UCTOR APPLIES FOR SUIOINO PMWIT
f j {�E-fEK v P(rT�aJ,GA?%�?Rt, corJSiKucTlo� D(0. , asOwner dshe RA odIspway
hereby autmdze MEuSSA FR`rDl-O im
as on MYVAO I rafewe m work autnonsed by the WI&V Fannie app "o" -
.r. C L. G yg
sweisee of Oamw., ors
I. CCTw Qi'yLo PRF.SIc,:'JTT CL n.n /�N(�FL ---- as o».,..Mww,tmd
Agent hereby declare hue the statements and idonnetwn on the foregoing aMAi:atnm aro true and acwmte,m the nest o'my knoWedge
and ballet.
S awn d undo mP mY+s end oenelnes d�ariorv.
al --
PhkaNem. --- --
ey�wtun of Ovmw/Awn, _ 00'a
SECTION 12-CONSTRUCTION SERVICES
14.1 Ucensed ConswrLon SuceMeor. Net Appk@W ❑
E ,a,ayy�.l n� Ips , Fn IvwC- 01 At 9'I
!>•'S S•�TN sT. N. I- eb/-Tubrlp(YJ +y oleeco °I�H•d'o2o j
Al
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SECTION 13-WORI(ERS'COMPENSATION W SURANCE AFFTDAVR(MOl tu ISL S 25C(S))
Violent CGmpensebon Insurance aShdew must ba completed and summded wdh this•pOkusabn.Fallum to pmvMe the aRreys will rm*
in the tenial of the issuance of os bwld. penn2
Spred Mgscit AturJted Yes • No
City of Northampton 212 Main Street,Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, 1 admoWedge 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: I1 i%! ST, Hole cl1GTtt�
The debris will be transported by: Swci;ije-p 6a str.ctt °✓1
The debris will be received by: Va k e., Plc a 4'N 13
Building permit number.
Name of Permit Applicant Mel.sca_ .Lnrllo
Date Signature of Permit Applicant
The Commonweakk of Massachusetts
Department of Industrial Accidents
1 Congress Street.Suite 100
Boston,efA 02III-2017
wwncmass gowdia
Workers'Compensation Insurance Af6davil:General Businesses
TO BE FILED WITH THE PERMITTING AUTHORM.
A�oliesnt information Please Print Lezibly
Business/Organization Name:Collins Electric Company, Inc
Address:53 2nd Avenue
City/State/Zip:Chicopee, MA 01020 Phone#:413-592-9221
Aapu an employer?Cheek the appropriate hon: Business Type(required):
1.]J I am a employer with 90+ employees(full and/ 5. E)Retail
or
part-rime).` 6. ❑Restaurant/Bar/Eating Establishment
2.0 1 am a sole proprietor or parmersbip and have no 7. ❑Office and/or Sales(incl.real estate,auto.etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertaimmem
their right of exemption per c. 152,§1(4),and we have l0.❑Manufacturing
m employees. [No workers'comp.insurance required]-,
equired]` 11.❑Health Care -
4.❑ We are a non-profit organization,staffed by volunteers,
with no employers.[No workers comp. huurerce coq.] 12.❑Other
•A,cs Bean dva cicrle boa NI and sten ea old tic recti.bebw:lrowue dry waYees•mmOn �o wary nJmmrtun.
`•Ifthc emrorea amicm have exempmd tivmelver,but the.reorwwa bon ather.gl%em,a woikeri.aq.rn inion polity u rtquierd aM suN.
orgmvrai.should check box#l.
I am an employer lhof is providing workers'comperuallon inwrance jormy rmptoyes Below is rhe policy information.
InsuranceCompany Name:A M Mutual
Insurer's Address:
City/StutdZip:
Polity#m Self-ms.Lic.#_ ECC-600-4000979-2019A Exprtffiion Date; 1/1/20
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to secare coverage as required under Sectiom 25A of MGL c. 152 can lead to the imposition of criminal penalties of
free 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 free
of up to 5250.00 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.
]do hereby certify, a epaim an naffies ofpc jury thar the information providedabooe is me and correct.
S1 nattug Data, JUN 05 2019
teens r.413-592-9221
Officiu/use only. Donor write in left arcs,to be ca pAned by city or lown offwiaL
(:icy or Town: Permit'Licease#
Issuing Authority(circle one):
1. Board ofHaBh 2.Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
waw.mws.gov�dia
TM(�rM1MPwwf'alfh of 1/YssYchavrty
A"irrmemt of lwdavnal datidentr
a / I".Ar , ANYrr.Serif, /do
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SMexYadrOa'4'..;r.f.:M.}'CY aJ xlnd wYYlfw'sYaf YI.YM:YI RTbNY
n❑ua....,+l.�,lx»,a+W.+YeeaL+nan+rMYw M,JrrrYwxin l�W•t . IV QS16rer _
t t.-IIJt.+.d v Ms m rr1.MJfea{IW'YAar'a�f rYwvaeryx>a
•gym eAh.wY Au.fYJ.M:,.srYe:�.,MSw en'Iw.Ak..wen it:r lG..: . . . i. nb..mMs.N:r
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Utwit a r•%of the aerheff'Compm NW pBry d1(Yr.11xw pop ldumis(the plky a/Mhrr as rx .Yrel.
GAihwe to arrear rovmvs ee telplrtd rMn M[il. Y. 1 S.,t:!A n•mm.ul vroWla pttnhuhk In a f nr YC Ir S I.+m m
M&W MM TW MprIYt.E1waL M Walt AN mil pewxhinx m Iht form of a SIUI•%URA URDkR and a rine of up re 3:V1lul a
any apra.W vndaor.A vvm of lt. oa ml Imx 4 imx rW m th.1 Hflvv ofhmv,,lWo of the DI.--\ for..rn
.wanpe.m •
fJ.hnr'hf .NA"a plwrYN trrwadrler nJtwrinr, MYrtM 4/err.Naa prwWA'I.Mwnnr.aflvmf.
P Y 73
mare udr. Ue.w wmY br Al6 en.,MbrwyfeMlr rae.r ll,w.Y�Ij
City w To.'u: Permit Lk. e
IYa.i" Aalhwlp ldrrk Ywi:
L 11"W of Ndth 2.Baidmg novemma 7. In 10.0[.krt 4, 1J 1n w I*Ipnlw 5,Pbu ebft irwpeaew
k Ulhw
CwMun PYrxw: pbY r
The Commonwealth of Massachusefts
Department oflndusnial Accidents
I Congress Street,Suite 100
r
Boston,MA 02114-1017
Im www.massgov/dia
AA orkers'Compeosation Insurance Affidavit:Builders/Contmdors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (HusinesNOrganivrwMndividad):Saeitzer Construction LLC
Add ress:231 Butler Road
City/State/Zip:Monson,MA 01057 Phone#:4136261498
AmvoaaoemplaW.CTa.4 theappmpdNe box: of project(required);
TYPr' P 1 (req );
10 l amaemploye wiN6 employeen our W.,port-time) 7. []New construction
z❑I en.laic poprieaoroc 1a1fterm and have m emyloyar working for me in S. ❑j Remodeling
any eapauitY.INo xmkea'omP.Nsumae required.]
9. ❑Demolition
3.❑1 am a Mmeovmerdoingdl work vyulf INo warkas'comp.imuren¢requbW.]'
4.❑i amahomivwne mdwili be lonr
in,cmacio to c.d.all conA o my popery. 1 will 10❑Building addition
Ure uatall mnoanea dater buve sek 11.❑Electrical repairs or additions
pro,rou s cola m empl,. 12.QPlumbing repairs or additions
5 Ian a gsw camracmr aM 1 have hired Nesubcunuadws IwWon tle amched sleet
rhme am.mnua wnnuw:evploy«s am lmvewo�kers wmm.o,w .z.t 13.❑Roof repairs
d.❑Weereamgwresian
ars]M.ff.Mve.tr uwir.igbtorcxcmpwn pn MOL c. 14.❑Other
15Z 41(4),aW we hove m e 1ploycea.[No workers'comp.inwnMx lvi b d.l
'Airy alpliram tilt checks box#1 must also fill nut the sectio below stowing pear wokess'rompeovation 11-1 Whmm-
t Homeowner who suburb Nis Widavii inciecine Nq are doing 01 cool and Use hire onide orNaclae mart sutsw a new amdavir indiratingsuch.
:CmraactnM Netchak this box nue reached m sddlni sh.sMvnnB the rune of Ne subonmgars eM sreN w Vsv or oa Nou mtifics bavc
employees. IfNe subonuecwrs ha.e employces,they mustpmnde Neir xv 'comp polignumber.
IamanemployerthWisprovi&ng WFLers'compenrsationinsuranceformyemployeM Belmvisdrepoliryondjobsite
inform mon.
Insurance Company Name:EMC Insurance
Policy#or Self-ins.Lic.#:5X48824 Expiration Dace:OMS/2020
Job Site Address:Smith College Cit,/State/Zip.Nonhmpton,MA 01063
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up m$1,500.00
and/or one-year imprisonment,as well w civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification: �^
Idoherebycerbfyu derth painsandpenahiesofperjurythm Wein formodmprovidedabove' eandcorrect
Siondune, d, new r,
phone#:41362 1498
Offiefal use only. Don ®alis urea,to becompleted by city or town officio[
City or Town: PersetlLicense#
Issuing Authority(circle one):
1.Board of Heath 2.Building Department 3.City?own Clerk C Electrical Inspector 5.Plumbing Impectm
b.Other
Contact Person: Phone#:
ACOR& CERTIFICATE OF LIABILITY INSURANCE `�bIMN9aY t
0512312019
THIS CERTIFICATE IS ISSUED ASA 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 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 have ADDITIONAL INSURED previsions or be endorsed.
R SUBROGATION IS WANED,subject to the farms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certNlute holder in lieu of such andoraement(s).
PROpIGEA NAME Mary OdabYhlan
Webber B Grinnell PKNLE (413)SB09111 MC Ne. N13)SBB8181
0 Norm King Street EAoonl[ps. mlMabaelnunGwabbeMMgnnnell can
Mm MurtNl CasmaIiCam any IMC5
NdmemptOn MA 01060 MCURERa: Emgoyen&Nuel CasuaM Company $1415
lmuR MSU.M..
B Mr Conatmdion LLC MSURER C:
Arm CMI,Sweitser MBURER D:
231 Balker Read INSURER E:
Monson MA 01057 UMURaR F:
COVERAGES CERTIFICATE NUMBER: Master Exp 6-2020 REWSH)N NUMBER:
THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTWNIISTANDING My REQUIREMENT,TERM OR CONDITION OF ANYCONRUCT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICES DESCRIBED HEREIN IS SUBJECTTOALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UNITS SHOWN MAY HAVE BEEN REDUCED BY FIND CUIMS.
LTp TYPE OF INSURIMCE PO1LYMllalgl LMnB
lGNEKWAf l•ODOJODDCWU ®OCCUR, Ps . a
BOOM
LEDOU'WnoaPsvr a IOM
A Y 50188 19 B&VN2019 991052020 PERSONALaADYeMIMY a 1,OW,000
CENLAG DAYBLIMRKRESFER. GEHERNAGGRECv1TE a 2'ODO'ODO
PCIGV ❑JI El L6 PRODUCTS-COMPRMAGG a 2'DOO'ODO
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AUTOMOBILE WMMIY .�EmOSINDELMrt f 1,BDD,000
ANYAUTO BODILY INJURY(Fer pent f
A �OBD6Nd 512BODILY SCHCOULED Y 5Z4882419 06/052019 0&0020 INJURY(%r slam) f
HMD NIXYg . PROPERIYDPMPf# a
AVTCM ONLY AUT.Ii. LY Pwevvtlanl
PIP-Basic a 8.000
IMlalOaIAIYBacCw EACH«COOENCE a 1.000.000
A IXCW MAB Y SJ4882419 06952019 gadfu 0 AGGREOATE a 1,000,000
I. PqRETExItlM f 10,000 a
M9NmbCOIMMMATON
AIO EIMLDYERY MABIRY Y/M SOTIIE ER
A AM
PROP,%U:R, LLEMEacurl ❑Y NIA 5MM419 06952019 OBrON2020 FL Ewcx ACCICENT f 1,000,000
OFFILEWM EMBER ERL WLE% 1 OOO OOD
IWnJ[Iayln MN) EL MSEISE.FAEMPLOYEE f
Y4.[rnauser 1.000.000
OESCFIPTION OF CPEMTIOXSNM E.L.DISFACE-POLpY LIMB f
OESCRIPOON OF OPERAMINS I LOCATNNSIWHI:LEB(ACOR0101,A4EMI[al Rnar48cM4uY,my'Y YY[aE Ilmm apu Y rpuln4)
The Trustees of the Smith College and any present&former trustee,dirxMr,oMCer,atlmknksbator,emplyes,student.volunteer Mocker mAgent.Is added
as an addllional insured IO Ige General Liability,Aub,Employers Liability and Excess Palms.as Mae Interests may appearr this insurance Shat rot
terminale without at least thirty 930)day.prior wdDen not.to Me college.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THEEXMRATION DATE THEREOF,NOTICE WILL BE DELNERED IM
The Trustses Of Smeh College ATTN:Purchasing Office ACCORDANCE WTH THE POLICY PROVISIONS.
10 Elm Street
AUTHORRED REPRESENTATNE
College H0204 /J p
L
Northampton MA 01063 {. - -D r'
101908-2015 ACORD CORPORATON. All righb rewrvstl.
ACORD 25(2010/03) The ACORD name and logo are registered marks of ACORD
Inc a.ummunwcwm uj mwanenus'eus
Department oflndustrialAccidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 0211 4-2 01 7
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Busine: 'Orgmintionnndividuap: T J Conway Company
Address:26 Progress Avenue
City/State/Zip:Springfield, MA 01104 phone#:413-732-5131
Are you an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with 46 4. E] I am a general contractor sad
employees (full and/or part-time).* have hired the sub-contractors 6. E]Now construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P tY 9. Buil addition
[No workers' corny. insurance comp. insurance., ding
regi red] 5. ❑ Weare a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work of ows have exercised theft 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof ars
insurance requited.] t c. 152,§1(4),and we have no ❑
employees. [No workers' 13Other HVAC/Plumbing
comp. insurance,required.]
;Any applicmtthat checks bar#1 must also fin our w
the enov below showing their workers'compenseticapolicy information.
t Homeowners who submit this affidavit indicating they an doing a5 work and than hire outside coninetots most submit a new affidavit indicating such,
lContracto s that check this box must attached an additional sbm showing the name ofthe sub-ooniracmrs and use whether or not Nose entities have
employees. Ifthe subtannxmrs have employees,they[tion provide th it workers'comp.policyaumba.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:Associated Industries of Mass.
Policy#or Self-ins.Lia M WMZ80080067772018A Expiration Date:10/1/2019
Job Site Address: 116 Elm Street City/Stam/Zip:01060
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 fore
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.
Ido hereby ce ' and epafnsf perjury that the information provided above is true and correct
6-4-19
i a[e:
Phone . 413-73 3
Oficial use only. Do not ,e 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(rown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
i
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 a 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 perfomrance 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)comets),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 confirmation 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 permMicense number which will be used as a reference number. In addition,an applicant
that most submit multiple penniVliceme 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 ofthe 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. Anew affidavit most 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 bum 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 in number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 7-2013 vaurav mace unv/Ain
i
A OB CERTIFICATE OF LIABILITY INSURANCE a 10/l/2018
THIS
THIS CERTIFICATE IS ISSUED AS AMATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE"OLDER.THIS
CERTIFICATE DOES NOT AFFIRIMTIVELY OR NEGATIVELYAMEND,EIITEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATRAT OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: Hike certificate holder 4 an ADDITIONAL INSURED,the poNcyiles)must b endorsed If SUBROGATION IS WAIVED,subject to
Ula tarn and conditions of Me policy,certain policies army require an endorsement. A stabmant on MN wnfflc ta time not eoMer rights W Um
la tmcats hold.to IN.of such enaon,men9.).
FRaOucFA xAa Lyrma Nadact, tart. 102
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ruuRa Ix,Imeae:ALTa11a Ivdaml IntuxfOw Co 10017
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BprinOfiald HA 01101-2000
COVERAGES CERTIFICATE NUMSER:CL1810111401 Ren REVISION NUMBER:
THIS IS TO CERTIFYTHATTIE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISM5070 THE INSURED NAMEDABOVE FOR THE POLKY PERIOD
INDICATED. NOTAITHSTAN01NGlWY REQUIREMENT.TERM BR CONDITION OFNIY CdITRACT W OTHER WCUMENT WITH RESPECTTO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDED BYTHE PDUCIES DESCRIBED HEREIN IS SUB CTTOALLTNE TERM$.
EACLUSIONSAND CONOMONS OFSUCH POLICIES,UMITS SNOMN SAY HAVE SEEN REDUCED BY PND CWMS.
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t -=" LEAD L.,, - OCC EpN ipe2lN/611m,Rr l0n/lou 10/lnei, OCCVREeCEA40R0Are $30,000,000
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The cartifilate hoLdar n baler 1e ineludal as an aMIJUU vel insorat for liability 0 Iapa for
Ongpivg operetiens if rsguir by arittes rnetraet, permit, or agraesaet me Prior to a lose.
Blanca, WI of subrogation ® Liability as "Crass Covpu.atron applies I required by arittal
contract, permit, or egraaaest e>meutad prior W a loss.
CERTIFICATE HOLDER CANCEL TION
SHOULDAN/CF THEABOVE DESCRIBED P Hcl,BE CANCELLED BEFORE
City Of Nolthasia n THE ExNAATION OATS TIE ,NOTICE WILL BE DELIVERED IN
212 Na3n Btraat ACCORDANCE WITH THE POUCY PROVISIONS.
Northampton, M 01060
AUTnoxufo Rl!PwaannW
Brian Foley/LYNNE
01MM-2014 ACORD CORPORATION. All rights nearved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025 2C•r
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From. Melissa Frydlo
Context Capital Asset Management, LLC
123 South Street. No 2. Northampton, MA 01060
To:
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for
construction control in certain situations. In accordance with code section 100.10, 1 request that you
grant a modification to waive the requirement for construction control of the project at
Smith College 116 Elm Street, Northampton, MA because
the work is of a minor nature,will not affect structural elements,health,accessibility, life or fire safety,
and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration.
Respectfully,