17C-223 UNIT 5 BP-2024-0725
76 MAPLE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-223-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2024-0725 PERMISSION IS HEREBY GRANTED TO:
Project# 2023 92.5 MAPLE ST RENO Contractor: License:
PATRIOT PROPERTY
Est.Cost: 6000 MANAGEMENT GROUP CSL1 1 1802
Const.Class: Exp.Date:06/12/2025
Use Group: Owner: LLC BLUE MOUNTAIN PROPERTIES,
Lot Size (sq.ft.)
Zoning: GB Applicant:
Applicant Address Phone: Insurance:
ISSUED ON: 06/12/2024
TO PERFORM THE FOLLOWING WORK:
BATHROOM RENO TO UNIT 5
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: 1/Z_
Fees Paid: $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massach/ fr )
e � 202Q
40
Massachusetts State Bu lding Code(780hCMR) l Office of Public Safety and Inspeconsy� N•
�'�NSp
Building Permit Application for any Building other than a One-or Two-Fame A' g
n
l (This Section For Official Use Only)
Building Permit Number. o)y•7� Date Applied: Building Official:
SECTION 1:LOCATION
76-96 Maple Street, Florence MA Parsons Block
No.and Street City/Town Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building IX Repair IX Alteration 0 Addition 0 Demolition ❑ (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes l No 0
Is an Independent Structural Engineerin¢Peer Review required? Yes 0 No le
Brief Description of Proposed work_Bathroom remodel work in units 92.5 Maple St Unit 5
Work includes replacing vanity, toilet, demo walls and install new tub/
showers and corresponding drywall.
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5❑ B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile❑ I R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB 0 IIA ❑ IIB 0 IIIA 0 IIIB ❑ IV 0 VA 0 VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit:
Debris Removal:
A trench will not be Licensed Disposal Site 0
Public 0 Check if outside Flood Zone 0 Indicate municipal❑ required❑or trench or specify:
Private 0 or indentify Zone: or on site system 0 permit is enclosed❑
Railroad right-of-war Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
\\-` SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Blue Mountain Properties, 268 Cold Spring Ave Ste B West Springfield MA 01089
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Jordan Healy 4137170635 Jordan@patriotpmg.com
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
Patriot Property Management Group,268 Cold Spring Ave Ste B West Springfield MA A 01089
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Steve Drakulich and Associates
Name(Registrant) Telephone No. e-mail address Registration Number
27 James St Greenfield MA 01301
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Patriot Property Management Group _
Company Name
Jordan Healy CS-111802, Unrestricted CSL
Name of Person Responsible for Construction License No. and Type if Applicable
268 Cold Spring Ave Suite B West Springfield MA 01089 •
Street Address City/Town State Zip
413.717.9635 Jordan(patriotpmg.conl
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 2,000.00 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ 2,000.00 appropriate municipal factor)=$
3.Plumbing $ 2,000.00
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 6,000.00 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
plyntesu.s. 444Manager
Please print and sign name Title Telephone No. Date
268 Cold Spring Ave Suite B West Springfield MA 01089 jordan@patriotpmg.com
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: � fi',Z.Zd V
Name Date
/._
City of Northampton
Massachusetts
*
1 lk DEPARTMENT OF BUILDING INSPECTIONS • ,=
212 Main Street • Municipal Building yJti cam
Northampton, MA 01060 SYW„ ;10
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility:K&W Materials and Recycling, 138 Palmer Ave West Springfield MA 01089
The debris will be transported by:
Name of Hauler: Joe Bruno,All State Disposal
6/6/2024
Signature of Applicant: /o.rI..k. .ke4 Date:
The Commonwealth of:tilas_sachusetts
of Department De artIndustrial.Accidents
n
,� Congress Street.Suite 100
- Boston,MA 02114-2017
wow ntass.go►/dia
Workers'Compensation Insurance Aflidasit: Builders;('untractors/Ekctricians/Plumbers.
In BE:FILED W'1111'TNE I'l.R'111-1 ING At THORI f1'.
.Spnlicant Information Please Print Legibly
MUM,f Business Urgsrntzznon hndrstdtr:ti}: Patriot Property Management Group
Address: 268 Cold Spring Ave Suite B West Springfield MA 01089
City/State/Zip: Phone#: 413-707-4434
Air an en eti»planer?Check the appropriate fox:
Type of project(required):
1.gil 1 aka a eniplayis with 9- employees(full and'ur part-time 7. New construction
2.a 1 am a sole txupnetor or p ertner,hlp and have n r employees working Of nx in 8. IA Remodeling
any cpacity.[No winters'comp.insurance resluircol.]
i 9. ❑Demolition
❑1 am a homeowner doing all wort myself.INu wvr5er comp.anuratxe regional)"
♦.a t am a huua l ncr and will be biting contractors to conduct all Murk on my property. 1 N i
I0 a Building addition
etrelrn:that all contractors either line wsnkcrs'coarl+ensateon uburunes or arc sole 11.a Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
3C1 I am a general contractor mid I have hired the solo-cuntracwra listed on the attached sheet
These sub-contractors have cmpluyec',and have workers'comp.insurance.: 13.oROOT repairs
6.0 Vie are a corporation and its officers have excrciacd their nght of exemption per MU.c. 14.❑Other
1'52,,I141.and we has,:no employees.[Na workers'comp.insurance required.]
'My applicant that checks box#1 must also till out the section below showing their waiters'compensation policy mturrnat►on-
r H n icuwuerx who submit this affidavit indicating they arc doing till work and then hue cxltaide contractors muse submit a new allidar it indicates such.
:Contractors that check this box must attached an additional sheet showing the name of the subcontractors and gale whether or not those entities have
,-npluyecs_ tf the suh-c.ntracturs have employees.they must paw ide their workers'tennis pokey number.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ACE AMERICAN INSURANCE COMPANY
Policy#or Self-ins.Lie.#: 841886672 Expiration Date: 07-01-2024
Job Site Address: 76- 96 Maple St Florence MA ciryrswte z;p:
Attach a copy of the workers'compensation police 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 tine up to SI,500.00
and'or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 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.
I do hereby certify under they/'pains and penalties of perjury that the information provided chore is true'and correct.
Signature_ vierweasa, 4t Darr: 10/25/2023
Phone 413-717-0635
Official use only. Do not write in this area.to be completed by cii)'or town official.
(ity or Town: PermiUhicense#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. I'luntbine Inspector
G.Other
Contact Person: Phone#:
Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required. The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing(include local connections)
9 Gas(Natural,Propane,Medical or other)
10 Surveyed Site Plan(Utilities,Wetland,etc.)
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
"Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Please follow this link for construction control forms to be used by Registered Design Professionals.
-1 imonwealth of Mas iusetts
r C pion of Occupations.. censure
Board of Building Re ulations and Standards
- , . I rif Cons ion rvisor
CS- 111802 S" E ires : 06/ 1212025
JORDAN PA1RICK HEALY ;'
268 COLD SPRING AVE '`''
SUITE B r ;,;
WEST SPRINGFIELD MA 01089 w g
M - 4
iv,.., d
Commissioner 21A1:49,11441 ,,
AC n DATE(MM/DO/YYYY)
cc CERTIFICATE OF PROPERTY INSURANCE 07/26/2023
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.
PRODUCER CONTACT Cyndie Henderson CISR,CPIA
NAME:
Alera Group,Inc. ((AHHO No,Exit: (413)586-0111 FA No): (413)586-6481
Webber&Grinnell Division E-MAIL chenderson@webberandgrinnell.com
ADDRESS:
8 North King Street PRODUCER 00025071
CUSTOMER ID:
Northampton MA 01060 INSURER(S)AFFORDING COVERAGE NAIC
INSURED INSURER A: Union Mutual Fire Insurance Company 25860
Blue Mountain Properties,LLC INSURER B:
Attn: Marc Murphy INSURER C:
268 Cold Spring Ave Ste B INSURER D:
West Springfield MA 01089 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: Blue Mountain Exp 2024 REVISION NUMBER:
LOCATION OF PREMISES I DESCRIPTION OF PROPERTY (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Loc#00001 Bldg#00001:76-96 Maple Street Blue Mountain Properties Florence MA 01062
See Attached Overflow Pages
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION COVERED PROPERTY LIMITS
LTR DATE(MM/DDIYYYY) DATE(MM/DD/YYYY)
XI PROPERTY X BUILDING $ 4.297,000
CAUSES OF LOSS DEDUCTIBLES PERSONAL PROPERTY $
BASIC BUILDING BUSINESS INCOME $
10,000 —
BROAD CONTENTS — EXTRA EXPENSE $
X SPECIAL RENTAL VALUE $
EARTHQUAKE BLANKET BUILDING
— B0P020612102 06/22/2023 06/22/2024
A $
WIND BLANKET PERS PROP $
FLOOD ^— BLANKET BLDG&PP $
$
$
IINLAND MARINE TYPE OF POLICY $
CAUSES OF LOSS $
NAMED PERILS POLICY NUMBER — $
CRIME
E
TYPE OF POLICY $
I BOILER&MACHINERY/ $
—
EQUIPMENT BREAKDOWN
$
General Liability X Per Occurrence $ 2.000.000
A B0P020612102 06/22,2023 06/22/2024
X General Aggregate $ 4,000,000
SPECIAL CONDITIONS I OTHER COVERAGES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS.
210 Main Street
AUTHORIZED REPRESENTATIVE IJ
Northampton MA 01060 '/11/ ,_
1995-2015 ACORD CORPORATION. All rights reserved.
ACORD 24(2016/03) The ACORD name and logo are registered marks of ACORD
r- 1 U C$ Cc
ISSUING COMPANY Workers' Compensation
ACE AMERICAN INSURANCE COMPANY
NCCI CARRIER CODE and Employers Liability
12165 Insurance Policy
Information Page
POLICY NUMBER I I New n Renewal I I Rewrite
Symbol: WLR Number: C5 27 95 29 1
PREVIOUS POLICY NO. Individual I1 Partnership Association
Symbd: WLR Number: C71459779 I XI Corporation ❑ Joint Venture I I Other Legal Entity
Item 1. FFRINET GROUP, INC. Inter/Intrastate ID No.:
Named 1 PARK PLACE, SUITE 600
Insured DUBLIN CA 94568 Federal Employer ID No.: 953359658
Mailing
Address
Employer's ID No.:
PIIC CODE: 6531
For other named insured see Extension of Information Page—Schedule of Named Insured,WC 99 99 99 A
For other workplaces see Extension of Information Page—Schedule of Other Workplaces,WC 99 99 99 B
Item 2. Policy period: From 07-01-2023 To 07-01-2024 12:01 A.M., standard time at the named insured's mailing address.
Item 3A. Workers'Compensation Insurance: Part One of the policy applies to the Workers'Compensation Law of the states listed here:
MA
Item 3B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 2,000,000 _ each accident
Bodily Injury by Disease $ 2,000.000 policy limit
Bodily Injury by Disease $ 2,000,000 each employee
Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT
ND,OH,WA,WY,
AND STATES DESIGNATED IN ITEM 3.A
Item 3D. This Policy includes these endorsements and schedules:
See schedule of Forms and Endorsements WC999999D
Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information
required below is subject to verification and change by audit.
SEE EXTENSION OF INFORMATION PAGE—CLASSIFICATIONS
If indicated here, interim adjustments of premium will be made: Minimum Premium collected in MA $
U Semi-Annually adjustments
Quarterly U Monthly Total Estimated Premium $
Deposit Premium $
PRODUCER NAME AND MAILING ADDRESS
AON RISK SERVICES SOUTH INC
3550 LENOX ROAD NE SUITE 1700
ATLANTA GA 30326
PRODUCER CODE: Z12362 56-0927967 DAU
MARKETING OFFICE: DALLAS BRANCH
ISSUE DATE: 06/26/2023
Authorized Representative
WC 00 00 01A(05/88) Copyright 1987 National Council on Compensation Insurance
INSURED COPY
EXTENSION OF INFORMATION PAGE
Named Insured Endorsement Number
TRINET GROUP, INC.
1 PARK PLACE, SUITE 600 Policy Number
DUBLIN CA 94568 Symbol: WLRNumber: C52795291
Policy Period Effective Date of Endorsement
07-01-2023 TO 07-01-2024 07-01-2023
Issued By(Name of Insurance Company)
ACE AMERICAN INSURANCE COMPANY
Insert the policy number.The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.
SCHEDULE OF NAMED INSURED
ITEM 1., NAMED INSURED, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS:
NAMED INSURED FEIN
PATRIOT PROPERTY MANAGEMENT GROUP, INC. 841886672
For the state of CA refer to state specific endorsement.
Authorized Representative
WC 99 99 99 A(10/06) Page 1 of 1
EXTENSION OF INFORMATION PAGE
Named Insured Endorsement Number
TRINET GROUP, INC.
1 PARK PLACE, SUITE 600 Policy Number
DUBLIN CA 94568 Symbol: WLR Number: C52795291
Policy Period Effective Date of Endorsement
07-01-2023 TO 07-01-2024 _ 07-01-2023
Issued By(Name of Insurance Company)
ACE AMERICAN INSURANCE COMPANY
Insert the policy number.The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.
SCHEDULE OF OTHER WORKPLACES
ITEM 1., OTHER WORKPLACES, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS:
OTHER WORKPLACES FEIN
PATRIOT PROPERTY MANAGEMENT GROUP, INC. 841886672
268 COLD SPRING AVE
STE B
WEST SPRINGFIELD, MA 01089
For the state of CA refer to state specific endorsement.
This endorsement is not applicable in NJ.
Authorized Representative
WC 99 99 99 B (10/06) Page 1 of 1