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Date: 10/22/2009 Time: 12:57 PM To: @ 19783554582 Page: 2 ACORN CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYYY) 10/22/2009 PRODUCER 978. 355.4536 FAX 978.3 55.6939 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Heal y Brothers Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 10 Common Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 99 Barre, MA 01005 INSURERS AFFORDING COVERAGE NAIC # INSURED Higgins Energy Alternatives, Inc. INSURER A Hermitage Insurance Co. 7 Worcester Road INSURER Fr Commerce Insurance Company 34754 Barre, MA 01005 INSURER National Union Fire Ins Co 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 INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSRC DATE (MMIDDIWW) DATE (MMIDDIYY Y) GENERAL LIABILITY HGL505882 -09 09/13/2009 09/13/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES O (Ea occ $ 50,000 CLAIMS MADE X OCCUR MED EXP Any one person) $ 1,000 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 POLICY PRC JOT LOC AUTOMOBILE LIABILITY 09MMYH6881 02/01/2009 02/01/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 500,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) B X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY 08MMYY2634 11/03/2008 11/03/2009 AUTO ONLY - EA ACCIDENT $ 250/500 B ANY AUTO OTHER THAN EA ACC $ 1,000,000 X Hired Autos AUTO ONLY AGG $ 3,000,000 EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION W0009 -87 -3940 08/06/2009 08/06/2010 TORY LIMITS 0 R AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/E{ECUTIVE YIN E L EACI- ACCIDENT $ 100, 000 C OFFICER /MEMBER EXCLUDEDY (Mandatory in NH) E DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under SPECIAL PROVISIONS below E . DISEASE - POLICY LIMIT $ 500, 000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS 'VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 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 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Tovi of Florence William J. McKenna, CIC/TLC --- - ACORD 25 (2009101) FAX: 978.355.4582 ® 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ur\r\RC, IVI/ - U I UU5 Update Address and return card. Mark reason for change. I Address j =1 Renewal Lj Employment Lost Card DPS -CA1 i) S0M- 04/04- G101216 ✓lie �iomrinanurea/ o� aaaac /uiaCta e Office of Consumer Affairs & Business Regulation License or registration valid for individul use only r =* = t HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 156825 10 Park Plaza - Suite 5170 Expiration: 8/9/2011 Tr# 287523 Boston, MA 02116 Type: DBA HIGGINS ENERGY ALTERNATIVES CHRISTOPHER HIGGINS 7 WORCESTER RD BARRE. MA 01005 Undersecretary Not valid without si a re • � o • AIN J �l a1saa1110IS D clr;u tmcnt it PUNIC •afet■ Board of Builclin2 RC■ulation\ and titanclartl� Construction Supervisor License License: CS 94776 Restricted to. 00 CHRISTOPHER P HIGGINS 7 WORCESTER ROAD BARRE, MA 01005 Expiration 9/28/2011 ( nnni mri Trw. 2884 The Commonwealth of Massachusetts Department of Industrial Accidents °= Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 1 C.1 1Ii5 k U41 041.--- rte-44A" j Address: 7 \LI & + .tt 1Zp • City /State/Zip: F.1444- "1 1 a P . Phone. #: 55 e you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with"' Zo 4. 0 I am a general contractor and I 6. New construction employees (full and/or part- time).* have hired the sub - contractors 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 working_ ..forme in any capacity. employees and have workers' 9. 0-Building-addition- [No workers' comp. insurance CO. mp insurance required.) 5. 0 We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have xercised 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 employees. [No workers' 13.0 Other comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. - I 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-contactors 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. r � N1 © mp y Y\1 MID >) A L_ V . T 1 lit, 1 : . c :o • Insurance Co an Name: p� Policy # or Self -ins. Lic. #: tJ C O C) 1 -€51 p 1 ' 6 1 1 -1 u Expiration Date: - W /D(!3 /10 Job Site Address: 3 2 &-14-e4- P-ct Te-mt - City/ State /Zip: 1Z fe F.NCk 4 A ll � ?Z, Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage. as requited under Section•25A ofMGL 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 Inve,tirations of the DIA for insrrrance'coveraee verification I do hereby ce u the pains and , %;s ofperjury that the information provided ttbo .e ' and correct. Signature: Date: q I Phone ##: l 78 5 (10• 5 I Official use only. Do not write in this area, to be completed by city or town official City or Town: - City 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 r Contact Person: Phone ir: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ '7 j Name of License Holder : p f~ 1 /N 5 CS 9 r ( License Number IO( - c ; F.L . 6 E MA" b loos 9 / Zb / o i 1 A r s Expiration Date 97g -Lss- (.3`13 S lure Telephone : ei7iste[ t klotl lntlintD�reHlinitE`,. ur�tia t° a :; ,s z ». .:.... x.. . >;a:, Not Applicable ❑ N I ail !US Ei CTE. C 0471' 6r �g - ais'il3�'I 4i6 lap E)25 Company Name ( Registration Number I n4 e? GS h is M•i r i t s 8/q/ 2.011 Addr J Expiration Date Telephone ' 7 Q °155 - 6 4 3 SECTION 10- WORKERS' COMPENSA INSURANCE AFFIDAVIT (M AL. 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 ❑ _The cun- ent -exemption.for.`hiozpe.Qwuers" was extended to include Owner - occupied Dwellines 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, von 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 n ._..* .l-N . • as • ■■ .i lY - v:Y - Y "I: :' 6 " w;44:WJ_Arinotated. Homeowner Signature tu. 414 G fir , SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [❑ Siding [DI Other [0) .Brief De§criptiqn of Proposed L Work: /)1 t1 / it/00e1 a CAi Inhey (p pipe) Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 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 ,F.QR, BIALDING PERMIT I, , as Owner of the subject iiimmiiiimmimmi ... property hereby authorize ` to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner . ___ .._ ._ - - -- Date I, I�Aay/at P Psi� (/ , as Owner /Authorized Agent hereby declare that the §tatemen 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. t /140J ?eve Pint e ,d_ 44:14Y5 /> 7 i1 Signature of OwnerrAgent Date Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." ; ✓ Additionally, MGL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall" enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out -the wo : - ' T + m• ! ` e.. -•• • . o pletel3', -by checkiug thehexes thatappi3'_= te�'ou situationand, if necessary, supply sub - contractor(s) name(s), address(es) and pone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' . compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year Where a home owner or citizen is.obtaining_a license or permit not related to any business or- commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.._ The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to us a c.a. The Departinent's address, telephone and fax number. The Commonwealth of Massachusetts - Department of Industrial Accidents Ohre of Investigations 600 Waahington Street Boston, MA 02111 Tel. # 617 -727 -4900 ext 406 or I - 877 - MASSAFE Fax # 617 - 727 -7749 Revised 11 -22 -06 www.mass.gov /dia • The Commonwealth of Massachusetts � t Department of Industrial Accidents Office of Investigations ; 1 = a 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/IndividuaI): Address: City /State /Zip: Phone. #: • Are you an employer? Check the appropriate box: Type of project (required): / 1. ❑ I am a employer with 4. I am a general contractor and I 6 ❑ New construction employees (full and/or part-time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner - listed on the attached sheet. 7. [1 Remodeling ship and have no employees These sub - contractors have g. El Demolition working forme in any _capacity. employees and have workers' 9. - 0 13uilriingaddition [No workers' comp. insurance comp. insurance.: required.] 5. fl We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 3. ❑ I am a homeowner doing all work o 11. ❑ 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 . 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. Iam an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. #: 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 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 fin 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 I do hereby certify under the pains and penalties of perjury that the information provided above is true -and correct. Signature: Date: Phone #: • 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 #: HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he /she resides or intends 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 home owner." The building department for the City.ofNorthampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulation' The inspection process_ equuires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure .these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper ----------- pennit& conjunction to thebuilding permit issued,_and_ they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are l `ade 4 understand the above. (Home owner /reside is signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. e a C � Address of work / // location Ct e4 P/ I-L/1 1Y6% Fl o re,,c 1 a) 0 e The Commonwealth of Massachusetts =.■ Department of Industrial Accidents 0, Office of Investigations • + lil h p ,� 600 Washington Street r =° Boston, M-4 02111 VIII ' www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/IndividuaI): Address: City/State/Zip: Phone. #: Are you an employer? Check the appropriate box: Type of project (required): / 1. ❑ I am a employer with 4.. fl I am a general contractor and I 6. 0 New construction employees (full and/or part- time).* have hired the sub- contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling ship and have. n n loyees These sub - contractors have 8. ❑ Deruo;on employees and have workers' worming for me in any capacity. # . 9. Building addition [No workers' comp insurance comp - - insurance. ed] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions I am a ameowner tieiaa�ll�veric _o c vv xersise_ - eit— - 11-.0-Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12. D Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required .j *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. Cont 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. lain an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. #: . 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. Ile advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. _ I do hereby ce fy under the p • and penalties ofperjury that the information provided above_istrue and_correct Signature: 7 /7 11 Date: A / f o f Phone# y/ — 5 - R =g22 - `-Official use only. Do not write in this area, to be completed by city or town o City or Town: Permit/License #_ Issuing Authority (circle one): f: Board of Health 2. Building Department 3. City/Town CIerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other r Contact Person: Phone #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Registered Home lmprovement:Contractor wz a , a. ,... .. , , >. r Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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 ❑ � 1 entrition ' 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 1083.5.1. 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 Employers 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 responsibility for compliance with the State Building Code, City of �_.. - :. aws- Annotated. 414 n ampton �r�triattc`s,`� y � • • ..- • � ,_. , .. - .� . 4u4 a Homeowner Signature _ 11 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition [] Replacement Windows Alteration(s) ❑ Roofing (l Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [D] reef Descripti of Proposed Work: I Yl'S tt 7i ti/oOti T tie a h z t c i lnhey CMe -ha 4 r ip Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative . Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa if,.Ne iff5ij and or..a`ddifiadialkisfii to lfausiiaq . coiriptefe i t e foliouviriq: 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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN , OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner _- Date _ Agent /4y , o P4 2U e ## , as Owner /Authorized g hereby declare that the tatement 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. Y (it +. P4 - Pap' e P e ir7414-14). Signature of Owner Agent Date q/z_q_thl • 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 DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book ` Page and /or Document # w_ B. Does the site contain a brook, body of water or wetlands? NO 4 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO *14 IF YES, describe size, type and location: - D. °ate thine any proposal changes to or a - ltions o signs intended for property ? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, exc- vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO bi IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ti + � n I City of Northampton Stat Pehnt Building Department 212 Main Street �� Aysrtny a Room 100 15° c ,;JJ Northampton, MA 01060 phone 413 -5 7 -1240 Fax 413- 587 -1272 � 10 • APPLICATION. TO ONSTRUCT, 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 3Z Piacit (�/ / Map Lot Unit r V`j YGh �l�G� � .I /� / �j Zone Overlay District /1 v 1 M P� if l v 6 e Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Nam (Print) Curr V ail . i T in L ` A it ss: 0/1) Telephone y ! -1-Kg ' r b C (!b Signature 3 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - (ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 4 20 60 (a) Building Permit Fee i/ 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) Check Number of-3 ® - _ This Section ForrOfficial Use Only Date Building Permit Number Issued: Signature: Building Commissioner /Inspector of Buildings= Date 32 BLACK BIRCH TRAIL BP- 2010 -0475 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37 - 127 CITY OF NORTHAMPTON I,ot: -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 -0475 Project # JS- 2010 - 000656 Est. Cost: $2000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor l of Size(sq. ft.): 16160.76 Owner: BAKER KARIN L & RAYMOND L PAQUETTE ?or.ir.!o Vin. 100)/ Applicant: BAKER KARIN L & RAYMOND L PAQUETTE AT: 32 BLACK BIRCH TRAIL Applicant Address: Phone: Insurance: 32 BLACK BIRCH TRAIL (413) 588 -8274 0 FLORENCEMA01062 ISSUED ON:10/29/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE & CHIMNEY 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: er , .95- THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION Oe ANY OF ITS RULES AND REGULATIONS. //�9/? l .-° y r / Certificate of Occupanc ' - 1, �, ;# ' " t� FeeType: Date aid: Amount: Building 10/29/2009 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo