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43-024 SINCE 1940 MILES BUILDING MATERIALS SUPPLIER Installed Project: 6 t ;/e Z/A-0 LO A)a bA Oi l Subcontractors: If you have employees you must provide your Workers' Compensation Insurance Policy Number Subcontractor /4AIDI)./ Name : /Q� 9 � Sl�/}✓ /3X110 7-/A) c Address; I( � N E • / living-rim/IV-Toro 1 t 9 NicY • Phone. 4/ /L 9 Fi7 ..... Policy # 01 /2,..3k. Insurance Company: r 6 P Y� (This form must be attached to Project Workers' Comp. Affidavit) Installed Project Subcontractors 2/12/2010 .. , It ACORD DATE (MMIDDlYVYV) TM CERTIFICATE OF LIABILITY INSURANCE 01/05/2011 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 Miles, Inc. INSURER A: Firemen's Ins Co of Washington PO Box 1125 INSURER B: Manchester Center, VT 05255 -1125 INSURER C: INSURER 0: 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. INSR ADD'L TYPE OF INSURANCE POUCY NUMBER POLICY EFFECTIVE POLICY EXPIRATION UMITS I TR NSRC, HATE IMM/DD/YYI HATE IMM/nnrrn GENERAL LIABILITY CPP 0012473 26 01/01/2011 01/01/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY - P MI RE NT �I a 250,000 CLAIMS MADE r i g OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 T1 POLICY n jECT n LOC AUTOMOBILE UABIUTY 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 LIABIUTY AUTO ONLY - EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG S r EXCESS/UMBRELLA UABIUTY EACH OCCURRENCE S D OCCUR I I CLAIMS MADE AGGREGATE - $ $ DEDUCTIBLE S _ RETENTION $ $ WORKERS COMPENSATION AND WCA0240314 -13 01/01/2011 01/01/2012 1 TDRV I M Td I OFR EMPLOYERS' LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT a 500,000 OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 500,000 tt es, desuiba under SPyECIAL PROVISIONS below E L DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LQCATIONS I VEHICLES I EXCLU IONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Installation of Windows, Doors etc. in Massachusetts. CERTIFICATE HOLDER _ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 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 J Marianne Connor/MCONNO ACORD 25 (2001108) © ACORD CORPORATION 1988 .� r • The Commonwealth of Massachusetts Department of Industrial Accidents "1"'" Office of Investigations M� =I y� 47 600 Washington Street ,, ........m.1.4 - 7- = 1 �r Boston, MA 02 111 `; _ www.mass.gov /dia , Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organization /Individual): �9llSr_, J` Address: 1, - r-/ City /State /Zip: 14 / FI Ci, �h v , [ `b Phone 4: _.,/ l - f 0 i v- Are you an employer? Check the appropriate b x: Type of project (required): 1.0 I am a employer with 4. _I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction listed on the attached sheet. 7. 0 Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have g, 0 Demolition workin for me in an ca aci employees and have workers' g Y P tY 9. 0 Building addition • [No workers' comp. insurance comp. insurance.. required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 / Roof repairs insurance required.] t c. 152, §1(4), and we have no m employees. [No workers' 13. , they /,U//1/01 M ,�ac comp. insurance required.] / R0 G6/t AT , *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 subm?.t 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. _ -- Insurance Company Name: /(AL) /A t NV LR,4 /o C.F. • ,, Policy # or Self -ins. Lic. #: 1,vrA �, 02403/4-- `3 Expiration Date: � / .0 � 1 - h Ar Job Site Address: CS %7!V( � /biz, i City/State /Zip: 7 D- N l l i` 010 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 t y under epai, s and penalties ofperju that the info/lotion provided above is true and correct. _- Signature A t` / t / �1/1 , /lrrfk Date: Phone #: 4/3 -4'7 iS M Jt 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): ' L Board of Health 2.- Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - — ConfacfTerson: --------------- - - - - -- - - - - - - - -- _ - Phone # 11111111111111 11/27/2@11 18:07 4135870%6 PARADISE - CITY,INC PAGE 05/05 SECTION 8 • CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: )'` /� `•? Not Applicable � ❑ Name of License Holder : .DA v! LJ Na J ✓ 0 1i d jQQ��/ (� [[ ^ �� /�- } �G�- j yj� ,8 license Number /9 7J F �JVL/�! ,J!. r1/ /L13P • ' // /� / �� Address / /� /- Expiration D to /� 3j/ �f + l. V( J / f Signature Telephone • 9. Registered Home lrtprovemerit Coiitractoi- Not Applicable ❑ 1 L S . �� , Registration 66 43J'" • Company Name Address Expiration A ate G^� i NnrF'a P4 Telephone *l °47 0 JV SECTION 10- WORKERS'' COMI ENSA?iT1ON INSURANCE AFFIDAVIT`(M'G:L. 152,: §:26C(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:' 0.1fne> Q f E r nrrtl b 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 10833.1. Definition of Homeowner: Person (s) who own a parcel o f 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 r e s p o n s i b l e � .— _ . . 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. Homeowncr.Sigtiat re .... • • 11/27/2011 18:07 4135870966 PARADISE- CITY,INC PAGE 04/05 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [] Addition ❑ Replacemen doves Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [Cl] Decks [j= Siding [D] Other [I:1] Brief Description of Proposed a ptiAcjE / /Ao 'S (J/ 15i ,JO & o r) )0G �` Work: 6 d/ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet se:, if New. house: and: Ar• .a'ddition: :to:eidstingtaiielni ::comnpletethe.followincf: 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 , 1. 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 . � 6t7) if.e9 /13s , as Owner of the subject • property a1,2E / .. hereby auth. -2e 1 � " r 0245 o F , . / /� 11 l 6 J,, 2c - to act on • -half, ' all matt rel five to work authorized by this building permit application. Sig . , re o • ne-,i 42-6/ e / i, 'M 3 /4 Gtr: / t/ / L�' i o ...art t uthorized • gen %ereby dp I- - t <t t e state - nts and information on the foregoing application are true and accurate, to the • - o • - ow edge dr • •elief. Signed under the p s and penalties of perju7. (_ orif . Pas i J9 W. /\}5 4., Prin , N ,� - /6- ill?Z )9' ; / 7 /— A = c o ;rr - • ent Date 11/27/2011 18:07 4135870966 PARADISE-CITY, INC PAGE 03/05 Section 4. ZONING AU 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:. Lr . . 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 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES 0 IF YES: enter Book Page: and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained - - •- Obtained- • Q - - ;-Date Issued:: - ... - .. - C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO 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. • j � 9 y 11/28/2011 17:27 4135870966 PARADISE-CITY, INC PAGE 01/01 RECEIVED , Olepatmi,,tlse �►� n 'ty of Northampto B ildi g Department r ��ir�rOa{/17i'lv�,�� WE tr�it � • � � � �� � . NOV 30 2011 21 Main Street I`e ' yalFatulrt �� oom 100 GQs`teiliUetl�i3ilttjr i • i ha pton, MA 01060 DEPT.OFRULDIN i — 87 240 Fax 413 -587- 1272IrsttSite Clttter Sp't:Tci y , ., , 'r APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: �1 � • S / 4"7 /Q. i/' L - L ...- Map Lot • Unit F L REsl.5CE fl Di+oe '2 Zone Overlay. District Elm 3t. District CE District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: t A )61) (7C1 . < ' )0 FOMV Name (P „'r etf Current Maiing Address: ,/$ � — 96 Telephone Signature / r 2.2 Au orl ed Men • • I ) /4v/ O. zRti Vic? f t1/71 ..5 i C 2 AtST Vii f�/ J & ) PIA A Name (Print) Current Mailing Address: Signature Telephone • SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1 Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 3 S7P {a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 3. Plumbing Ruiiding Permit Fee 4. Mechanical (HVAC) 5. Fire Protection . 6. Total = {1 + 2 +3+4+5) }' j,, � / 2 Check - Number , - 7/7 3 tj , This Section' For' Official Use Only. Building Permit Number: _ . Issued: • Signature: Building Commissioner /inspector Of Buildings ' . Date 525 PARK HILL RD BP- 2012 -0533 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 43 - 024 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit # BP- 2012 -0533 Project # JS- 2012- 000888 Est. Cost: $6322.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R K MILES INC 10388 Lot Size(sq. ft.): 29272.32 Owner: POST GEOFFREY B & LINDA H Zoning: SR(100) //WSP II Applicant: R K MILES INC AT: 525 PARK HILL RD Applicant Address: Phone: Insurance: 24 WEST ST (413) 247 -8300 (455) WC WEST HATFI ELDMA01088 ISSUED ON:11/30/2011 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 11/30/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner