Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
13-011
HOME nrt 4. M5 "No Substitute for Quality" WORCESTER SPRINGFIELD HARTFORD 459 M:v\ SI RI I'.O. 110X 51033 SPRINGFIF,I 1). M'\ 01 151 MA. RI-(Ig 151711 C I RI:Gtt 601525 877 -3 1 I \\ 413-i43-3200 \\ \1N 'It RI)llit) \II..(() \I OWNER PERMIT AUTHORIZATION Name: ha,,• 6 Zraci Address: 2)--1 W te Reccdo w 14. City /State /Zip: t tail ) N-11 4 - 0 ( OcQ 0 I HaY- �,v traA ( owner), of the property located at: 2 - , . e �ru r, .uthorize Sturdy Home Improvement, Inc. To act as my agent for the construction project taking place at the above address. I also, authorize Sturdy Home Improvement,lnc to obtain a building permit for this project. I understand and accept responsibility to comply with all regulations and required inspections. tog / Signature o $ ner ate 1 ,� ') /R77 ) Signature of Ow her Date • The (.'onunonweulth of liassac/rusetts ';�� Department of Industrial Accidents G = �i..:.. Office of Investigations 600 Washington Street Boston, MA 02111 �►� www.inass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information 1 Please Print Legibly Name ( Business /Organization/Individual): � r 40int T-1 /2 1— C Address: E- 5, (9�� 1,� ��- S � I UUU . City/State/Zip: 6 -v t? O0&i -2k., )-- Phone #: te(qi 5tt3 Are you employer? Checlthe appropriate box: Type of project (required): 1. am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or pan - time).' have hired the sub-contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t 7 . ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. 0 We are a corporation and its • officers have exercised their 10.0 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 4 - comp. insurance required.] 13.ther Lt,>> Any applicant that checks box ill must also fill out the section below showing their workers' compensation policy inforttwtion t Homeownets who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. L l Insurance Company Name: � f'Ct, t-L t. 2n.s . Policy # or Self -ins. Lic. #: L) C- 0 d'1 t.} 1 Expiration Date: -' 2,112.01,--2 Job Site Address: cs2 y (01. ht.Qft.j.f LIA j2-cL 1 0flr1. City/State/Zip 01010 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. 1 do hereby certify id a sins and penalties of perjury that the information provided above is tr a and correct. Signature: / Date: ? // Phone #: / .f / S'' f9jc 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 6. Other Contact Person: Phone #: MI VO/ VG / CV I I IJ 00 IN IJ J4 J4J I Ununnnu_1NJUnnnut nuCr1I•Y EDI44 r VU I /LI) 1 nL# Jf VM ti I 11-1 ATE OF LIABILITY INSURANCE DATE (MWDOtVYW) — 08/02/2011 PRODUCER (413)543 -3344 FAX (413) 543 -4918 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ORCHARD INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 144 MAIN STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERA AFFORDED BY THE POLICIES BELOW. P.O.BOX 51088 INDIAN ORCHARD, MA 01151 INSURERS AFFORDING COVERAGE NAIC INSURED Sturdy Home Improvement, fnc. iNSUREA Western World Ins. P.O. Box 51033 INSURER B! Granite State Ins. "— Indian Orchard, MA 01151 INSURER C . Safety Insurance INSURER D; INSURER E: COVERAGES 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. 'NSA ADD' TYPE OF INSURANCE P OLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION I TR NSR DATF IMMIOO/YY1 , MITI; IMMIAILYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1, 000, 000 Ti COMMERCIAL GENERAL LIABILITY NPP 1286184 08/07/2011 08/07/2012 ORMA t ES OREN c ED ^ ,� ) $ 100.004 CLAIMS MADE U OCCUR MED EXP (A y w'• panto) S S 000 A ■ PERSONAL $ ADV INJURY 5 1,000,000 X ADDITIONAL INSURED GENERAL AGGREGATE i 2,000,000 GENT AGGREGATE LIMIT APPLIES PER. PRODUCTS • COMP/OP AGG S 2,000,000 © POLICY ■ JEC ■ LOC AUTOMOBILE LIABILITY 6203817 06/24/2011 06/24/2012 COMBINED SINGLE LIMIT S ANY AUTO (Ea ecc■Sent) • ALL OWNED AUTOS BODILY INJURY S X SCHEDULED AUTOS (Per person) 50,000 ■ HIRED AUTOS BODILY INJURY S NON -OWNED AUTOS (Pet occident) 100,000 PROPERTY DAMAGE S (Per ncidsnl) 100, 000 GARAGE LIABILITY AUTO ONLY • EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S _^ AUTO ONLY: AGG $ EXCESS /UMORELLA LIABILITY EACH OCCURRENCE S OCCUR n CLAIMS MADE AGGREGATE $ $ 1 DEDUCTIBLE $ yyyy 11 yy f 5 r XXIYE01041/HMYOMrL/VI6 XIEIX XX: X TQRV T I IVITSI lOFR• EMPLOYERS' LIABILITY WC 007-42-4511 07/21/2011 07/21/2012 E.L. EACH ACCIDENT S 100,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE OffICER/MEMBER EXCLUDED' E L. DISEASE - EA EMPLOYEE S 100,000 I y cs, teTCIIEC unOEr S PECIAL PROVISIONS b& E L DISEASE • POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDEO BY ENDORSEMENT I SPECIAL PROVISIONS dome Improvement Contractor $500 deductible /occurrence applies to General Liability ** * **iri.icir The Workers Compensation policy does not provide coverage for Adam Lucey." r R "* * * ** * * *j:?o °`' '` *" * * ** * * "0* t'e *ieirir,,ir 00,, A:: :c ;;:`:; :: : :: I?ODO ir,Yirici0**iririr * *CL C 0000 0000000*;: ^.o*OD0 *0*0***AA ** *000:::, 0000000000 ic*:::a000R** *000**,`. Ai:* ot':i:ir *I',*!:. : :v Q;ct:C+ Orsini* re***** ic ire **1: . »::Cr t, *WO Gir*dr *** dviv*** it Crir ir ,Y**i.ic:r **tl::RC>0" ie* **it it Ye i—PioY C+0,DVi'r "N*:4 * * **is ir';AA C Cr . Ca0000Vh0r01,000*0* *0*0 **CC CA0 000 i r* 0********* 4* 00""** iricir,; ic* 0, Ylc:: i0aei0a.V Y(V rbirir *** *i.0 *0* CERTIFICATE HOLDER CANcELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES OE CANCELLED BEFORE THE i.;,* *;.,:•r3::* *:c:rQ a0d0,Yir*** *, **4.*iri:- c;th::00**** *ir EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ]X1 MAIL TO WHOM IT MAY CONCERN ""* * * *''" * **** 00000 .ra,ri:"iri; it iri *ir,•a*ir *ir irfc 4,Y is :: ^.::: ::auuuor(,Y *�YVir *ir **A' 000 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, .,.',* 1:;:::::::::, G,:�,pa ?,'“*.*O",''**Ve**irir* y ,r Ir ,� ^ y�y,y L ry� LVININf/Y I A � V XXXXX V XX X I � 000 ** **A*4ti:* *0*IY*,1 ^� �f l X9OMIC {IM.OMXI I<7{� R �XXAA .. , MA 01151 AUTHORIZED MAMMY* Yt / I _ Jennifer Lawto iv _ - , ACORD 25 (2001108) ACORD CORPORATION 1988 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �, �) ^� Not Applicable p„,..------- Name of License Holder : �, -(� kLL* `I i /�vL L 3' to Q3 License Number Address Expiration D %1-1(2,3 to Scrt . cS (4 i(r- d t I oq . Signat(' 'y Telephone 1/ 1:-...i Q_ gl.' 15 . 9. Restistered Home Impro nt Contractor: Not Applicable L9' S v klAr c% - 0 .1- at.E+0„uA.1 - TILL. . 1 51 - 1 Company Name Registration Number ►kt.,N I A s I a . r t 3 . 474(261 -dm Address Expiration Da X ; (A/vs- CD.(t"iL {d, / 1N ik Telephone(1 f) 3 S9()( SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit m t be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin ermit. Signed Affidavit Attached Yes No ❑ 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 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 buildine 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [0] A Brief Description of Proposed �` J Work: "DU t e „di— t - ,,,s ku.Qs U -u g-e c_` r - 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 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? 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 I, L k . Ma, f I e'►x. t. Zii- i , as Owner of the subject property A hereby authorize C -41 - 47 – � V I (_��-�" .4_ to act on my behalf, in all matters rdiekive to work authorized by this building permit application. Signature of Owner Date I, v t � y Fes--. , as Owner /Authorized Agent hereby declar hat the statements and in information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. '— c-rr c Print Name CO �'1 ` may 7/ / Signatur of Owner /Agent 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 parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , 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 0 NO 0 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. - 1 "Fh S SOO 4 Department use only RECEIVED of Northampton Status of Permit: B ilding Department Curb Cut/Driveway Permit S EP 2 72011 212 Main Street Sewer /Septic Availability Room 100 Uitater/Well Availability y N. hampton, MA 01060 Two Sets of Structural Plans NoRrNAmintoi ;� _ 41 F ax 413 587 - 1272 P lot/Site Plans p87-1240 ther 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 ay COt s fV-. ° tA) c cct Map Lot Unix {5UT`�'LCi m , ft A Zone Overlay District Elm St. District CB Di SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: MAY t. 1 a 2Lt. Cc H Name (Print) v Current Mailing Address: Telephone Signature v 9 Z6 2.2 Authorized Agent: �rl,� 1—F e 1�Mprr ` tS�t 1' 1k . �� e ►3 Name (Print) Current Mailing Address: �( I ')J 5L-( Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building jol (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection /C 6. Total = (1 + 2 + 3 + 4 + 5) � 1 1 J "= Check Number 70? il — This Section For Official Use Only Building Permit Number: I sssuu ed: Signature: Building Commissioner /Inspector of Buildings Date 24 COLES MEADOW RD • - BP- 2012 -0303 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 13 - 011 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2012 -0303 Project # JS- 2012- 000492 Est. Cost: Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STURDY HOME IMPROVEMENT 093603 Lot Size(sq. ft.): 29620.80 Owner: BRADLEY MARILYN J & RHONDA MARIANI Zoning: SR(100) //RI /WP Applicant: STURDY HOME IMPROVEMENT AT: 24 COLES MEADOW RD Applicant Address: Phone: Insurance: P O BOX 51033 (413) 543 -5906 WC INDIAN ORCHARDMA01151 ISSUED ON:9/27/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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 9/27/2011 0:00:00 $70.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner