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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