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43-084 .; BP- 2010 -1029 GIs #: COMMONWEALTH OF MASSACHUSETTS { CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -1029 Protect # JS- 2010- 001520 Est. Cost: $13950.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R K MILES INC 10388 Lot Size(sq. 1): 59677.20 Owner: TOBIN JAMES M & MARYJANE MIZE Zoning: SR(100)//WSP II Applicant: R K MILES INC AT. 27 DUNPHY DR Applicant Address: Phone: Insurance: 24 WEST ST (41 3) 447 -8300 WC WEST HATFIELDMA01088 ISSUED ON :511912010 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS 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 5/19/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo gepartment use only City of Northampton StatuSof Permit Building Department Curb Cut/Drive Permit ° F 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability �pAne 41 587 -12 Fax 413 -587 -1272 Pot/S tesPlans uctural Plans Other !Specify APPLICATION TO CONST- Rt10T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 PropertyAddre 1 /� /� This section to be completed by office � l/ 7 aA)F� /y /04 1 Map l Lot Unit o/n / Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Ow er of Record: N e (Pri t) ,�� Current M li ddress Telephone Signature 2.2 Authorized A ent: A '4f A� ME S r Name (Print) Current Mailing Address: 413 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building �d (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of " Construction from 6 3. Plumbing Building, Permit F=ee_ 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2+3+4+5) Check Number This Section For Official Use Only. Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: _ R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved p arking) # of Parking Spaces Fill: (volume & Location)- A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DONT KNOW Q YES Q IF YES, date issued:''. IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW Q YES U IF YES: enter Book Page', and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained O , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacemedows Alteratlon(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [00 Decks [C] Siding [p] Other [p] Brief Description of Proposed A:�A CE- �"t z/Z tozN l��s rxrEP � n � Work: l,� �/� /v Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _No Plans Attached Roll - Sheet 6a, If New house and or addition to existin'a housing, complete thelollowing: 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? f. 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 100 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 APPLIES FOR BUILDING PERMIT as Owner of the subject property fi ) hereby au orize f- /L� 1/ c C LJ �� to act on / y behalf, in all afters relative to work authorized by this building permit applicatio . Signature of Owner Date I, � /�A���I A/m tea/ s as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed underVe pains and penalties of perjury. Print Name Signature of Owner /Agent Date SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder D 9ZJ JA 10 ✓ z License Number ' G,4)�s T 14 13 Address Expiration D to Signature ' Telephone 9. Registered I H me Improvement Contractor: Not Applicable ❑ —, e k // s�C / //9�1)/p o ) s /6/,� Company Name �— Registration Number Address / J /, ,(� /� Expiration at o Date lly I jA7Fi � 'C/, ,/ %� t�'�( O Telephone ��? - ,2 SECTION '10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 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...... ❑ 11. - Home Owner Exemution 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 supervisor. 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 -year 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 responsible for all such work performed under the building permit. 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 Office of In vestigations I � 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit; Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /Individual): K / �' C�� c' Address: e City/State /Zip: , A % ,F1 C4D 20 Z � / Phone #: ` 1 4 Are you an employer? Check the appropriaV X: Type of project (required): 1. El 1 am a employer with 4. am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors b• [] New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E] 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. E] We are a corporation and its 10.❑ Electrical repairs or additions 3. E3 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 c. oof repairs insurance required.] r c. 152, §1(4), and or have no 13. ther employees. [No workers' comp. insurance required.] / t- 1 - - 79G *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / —A ) Insurance Company Name: nn INA v� c r Policy # or Self-ins. Lie. #: 007 j` 4 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 o the DIA for insurance coverage verification. I do hereby ce ti um a der pal s and penalties of perju that the info tion provided above is true and correct ' � LL Si nature: '' p r Date Phone # 4 �3 A ' ` _ ���� Official use only. Do not write 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/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector b. Other _ Coritacf Person: ACORR CERTIFICATE OF LIABILITY INSURANCE 02/10 /20 o' PRODUCER (802)362 -1311 FAX (802)362 -3316 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION W. H. Shaw Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 135 Bonnet Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 1067 Manchester Center, VT 05255 -1067 INSURERS AFFORDING COVERAGE NAIC # INSURED rk Mi es, Inc. INSURERA: Firemen's Ins Co of Washington PO Box 1125 INSURER H: Manchester Center, VT 05255 -1125 INSURER C: INSURER D: INSURER E: COVERA 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION - LIMITS DA GENERAL LIABILITY CAP 1800036 -26 01/01/2010 01/01/2011 EACHOCCURRENCE - $ . 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 250,00 CLAIMS MADE I OCCUR MED EXP (Any one person) $ S A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000, GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2, 000 , 00 0 POLICY X PRO- JECT X LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY ALIT D OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F-1 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WCA0240314 7— WC S 12 01/01/2010 01/01 2011 ATu 0TH- S FIR EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 500, A ANY PROPRI R/PARXECUTNE OFFICER/MEMB ER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ 500, MH It yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,00 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Installation of Windows, Doors etc. in Massachusetts. ERT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. To whom it may concern AUTHORIZED REPRESENTATIVE � e Michael Powers MIKE Y � ACORD 26 (2001/08) © ACORD CORPORATION 1988 SINCE 1940 rkMIL E S BUILDING MATERIALS SUPPLIER Installed Project Subcontractors Project: �����5 �7J3 /A) Subcontractors: If you have employees you must provide your Workers' Compensation Insurance Policy Number Subcontractor f " Name: Address: /O4 ,AJ. N K741AnP7 Phone: 41 .3 - J 7�7 Policy #: C 13P gam y 9S / Insurance Company: Fy (F= l j/ ae? (This form must be attached to Project Workers' Comp. Affidavit) Installed Project Subcontractors 2/12/2010