32A-193 TRAVELERS J WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (I HUB-6A61748-5-11 )
NEW -1 1
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
1. NCCI CO CODE: 13439
INSURED: PRODUCER:
STRUCTURES BY DESIGN, INC. FINCK & PERRAS INS AGCY
125 STRAW AVE. 6 CAMPUS LANE
FLORENCE MA 01062 EASTHAMPTON MA 01027 -1430
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 10-03-11 to 10 -03 -12 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
._. B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
o — Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
MIMI= Bodily Injury by Disease: $ 100000 Each Employee
m_.. C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
° -- WV
aNIIMMIN
D. This policy includes these endorsements and schedules:
aS SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o=
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY .
•
DATE OF ISSUE: 09 -12 -11 GI
OFFICE: SPRINGFIELD MA 354 DIRECT BILL
PRODUCER: FINCK & PERRAS INS AGCY HF399
000071
The Commonwealth of Massachusetts rintFornn
Department of Industrial Accidents
Office of Investigations
1 I H. ' } 1 Congress Street, Suite 100 „ Boston, MA 02114 -2017
www.ma,ss.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): Structures by Design, Inc.
Address: PO Box 1086
City /State /Zip:Northampton MA 01061 Phone #:413 - 586 -1086
Are you an employer? Check the appropriate box: Type of project (required):
1. CJ I am a employer with 1 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. 0 New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
q �
3. ❑ 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 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*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.
Insurance Company Name; Travelers Indemnity Company of America
Policy # or Self -ins. Lic. #: IHUB - 6A6a748 - - Expiration Date: -03 -12
Job Site Address: Phillips Place City/State /Zip: Northampton MA 01060
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certij ; e (he • ains and • enalties o • er'ur that the in ormation provided above is true and correct.
Signature: .J.�r . .. ... • Date 0 1.'2 G • 12
r
Phone #: 4 l3 •
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : V 411 ltd M- t'H1 ?
f - CSL �+ 1 3433
J License Number
fb0 logA) orLilittopo AAA oloof ikiNE 1- °3
Address 46 Expiration Date
k ivy (At, -10k
Signature tap Telephone
9. Registered Home improvement Contractor: Not Applicable ❑
5ff U(.tvfSS t Ot 6(', (NC, iti
Company Name Registration Number
u Igo• CU tb VO(Liltt ' t i al MA 610( f q • t$ • t2
Address Expiration Date
Telephone 4 5 ° 0 (9 " (l) r �b
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 buildi g permit.
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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ® Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [p] Other [d)
Brief Description of Proposed
Work: MPA.t(L 4T it o(L eO(&c1- CROW MM I )&
Alteration of existing bedroom Yes )0 No Adding new bedroom Yes k No
Attached Narrative Renovating unfinished basement Yes ic 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 x 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
5 t, z..'..x,t.
I, c . \r Vv1 . `: �. t a .r ; s Yv\ • t a ti. , as Owner of the subject
property
hereby authorize". �t c m. ►:\ w.+
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
OV( � 1 j , as Owner /Authorized
Agent hereby declar that the statements and 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.
.r t } M. K NI 0 2
Print Name
Signature of Owner/Agent ' ;� d Date
5
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 5 evw -4/
Bldg. Square Footage % a ,�
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 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ® YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES o NO
IF YES, describe size, type and location:
E. WiII 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.
RECEIVED Department use only
City of Northampton Status of Permit:
JAN Z 7 2012 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
pEPL OF BUILDING INSPE Room 100 Water/Well Availability
NORTHAMPTON, MA 01060 Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 -587 -1272 Plot/Site Plans
Other 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
1)6 ?Ifi,t. f 1 . Map Lot Unit
NLr`t t (013 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
+..., I \ -- c •. • .k...., y i ,". 1 . t1 _J C_. - 4 ,, 1/ ? 1 v t J
Name (Print) ... vv1 � J ;` Current Mailing Address:
Telephone
Signature ` / / ` .S _ C -74 l >c 1 j
2.2 Authorized Agent:
,.D Mk M. kmrs (It 2, ro Box tO pot ( rN N MA 0106k
Name (Print) Current Mailing Address:
' 1l 3- S ?a6 -- le 466
Signature Telephone
SECTION 3 - ESTIM CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (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
6. Total = (1+2 +3 +4 + 5) ., -27400,00 Check Number
This Section For Official Use Only
Permit Number:
Date
Building Issued:
Signature:
��
Building Commissioner /Inspector of Buildings Date
36 PHILLIPS PL BP- 2012 -0680
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 193 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0680
Project # JS- 2012- 001173
Est. Cost: $3500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EDYTHE AMBROZ 053433
Lot Size(sq. ft.): 9452.52 Owner: ST ELIZABETH ANN SETON PARISH
Zoning: URC(100)/ Applicant: EDYTHE AMBROZ
AT: 36 PHILLIPS PL
Applicant Address: Phone: Insurance:
P 0 Box 1086 (413) 585 -8181
NORTHAMPTONMA01061 ISSUED ON:1/27/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR EXT PORCH FLOOR FRAMING
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 1/27/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner