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38B-245 ;TEPHEN CAMP <. » -�T -Y s•- •�- 1.6 EAST STREET di Member Companies of ASTHAMPTON, MA 01027 -0000 American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 TEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 .D#' U P- RODUCERS NAME AND ADDRESS FINCK & PERRAS INSURANCE AGENCY INC. WORKERS COMPENSATION AND EMPLOYERS 6 CAMPUS LANE LIABILITY POLICY INFORMATION PAGE EASTHAMPTON, MA 01027 -1430 NSURED IS PREVIOUS POLICY NUMBER NDIVI DUAL RENEWAL 008271078 3THER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 ITEM 2 POLICY PERIOD 12.01 A.M. standard time at the Insureds mailing address FROM 04/04/09 TO 04/04/10 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state fisted in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500.000 policy limit Bodily Injury by Disease $ 100.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, fisted here: SEE ENDORSEMENT - WC200306A D. This policy includes these SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 rrEM 4 The premium for this policy will be determined by our Manuals of Rules. Classifications, Rates and Rating Plans. Ali information required below is subject to verification and change by audit Estimated Total Rate Per Estimated Classifications Code Number Remuneration $100 OF Re- Premium © Annual ❑ 3 Year muneration © Annual 03 Year SEE EXTENSION OF ITEM 4, OF THE INFORMATION PAGE - WC7754 TAXES /ASSESSMENTS /SURCHARGES $142 XPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $ 3 38 MA IINIMUM PREMIUM $ 500 MA TOTAL ESTIMATED PREMIUM $ 2 , 597 indicated below, interim adjustments of premium shall be made: 1 .1 Semi - Annually El Quarterly 0 Monthly DEPOSIT PREMIUM Stephen Camp Construction 46 East St. Easthampton, Ma 01027 (413)527 -7124 Submitted To: Dave Shea Phone- 537 -7292 Address : 12 Park Street Date 7 -20 -2009 Easthampton, Mass 01027 236 South Street Northampton We hereby submit this estimate for- Door Replacement The job is to replace 4 exterior doors. I will install new steel doors. I will insulate and install new trim in the interior . The exterior I will install new storm doors. The doors will swing the same direction as now and the size will be the same. Materials = $ 1800.00 Total = $ 3200.00 Labor = $ 1400.00 Trash removal and building permit is included in my price. Contractor Supervisors License number 082531 Home Improvement contractor Registration number 135204 I propose to supply materials and labor -in accordance with above specifications. This proposal may be withdrawn By us if not accepted within 30 Authorized Signatur .+�►y'1.� _ .� Acceptance of proposal Signature -- - k HOME OWNER EXEMPTION .ACINTOWLEDOEMENT 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 of Northampton 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 regulations. The inspection process requires 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 permits in conjunction to the building permit issued, and that 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 made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts y7 , Department of Industrial Accidents Office bf Investigations G� �n r 600 Washington Street Boston, MA 02111 www.inass. /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly • f Name ( Business /Organization/Individual): '� P� c 4-L-_' Address: e//‘e.S"r 5 *t'es'` City /State /Zip: S 4 11 l i . n /027 Phone #: 5,2 7- 2/2 Are you an employer? Check the appropriate box: Type of project (required): 1. Vam a employer with 4. Ej 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. Remodeling ship and have no employees These sub - contractors have 8. 0 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 3. 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 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. 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 employee`s. 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: 6;44v �-C � f Policy # or Self -ins. Lic. #: 082.- / Expiration Date: lO Job Site Address: 234 > ° t".4-4. 54 City /State /Zip: 0, 4, /14 et, 6(W; (` 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. I do hereby certify unde the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 52 7/2 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 Supervisorr: -- Not Applicable ❑ 511 Name of License Holder : iv eti/ (7 � S 3- 3 ) License Number Address Expiration Date 52-7- ?/2y Signate Telephone S. Registered Tom � Hon ie.Imprd 2 F ,,,_ , . `, �.... 2 ,.�`x; f Not Applicable ❑ kt ( ,24i Co c l f-✓ /3 r20 Company Name Registration Number 4G �:�'t � 4- t6 A J-®13- 10 Address Expiration Date Telephone 5 7/2/ 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 buildin permit. Signed Affidavit Attached Yes No ❑ 11. Home ©caner xe plaa'>i> 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 4 , 4 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) I I Roofing Or Doors NI Accessory Bldg. ❑ Demolition U New Signs [0] Decks [E7 Siding [0] Other [0] Work: Description Proposed � j /� Work: /CL /� e era l ) �/ '• Alteration of existing bedroom Yes a No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes k No Plans Attached Roll - Sheet 6a. If New house and rr piete'the:fallowing: 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 hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date c 7 +4 1 614 C , as Owner /A thori Agent hereby declare that the statements and in ormation on the foregoing application are true and accurate, to the best of my knowledge an elief. Signed under the pains and penalties of perjury. ina ,... Print Name 6-/ 4 '1 Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information Existing Proposed Required by Zonmg This column to be filled in by amminooepumoent Lot Size Frontage — Setbacks Front F r---� �--- Side Rear Building Height r �---] r Bldg. Square Footage F --- F---- �4 F--- r F Open Space Footage (Lot area minus bldg & paved parking) #of Parking Spaces ^---� ' —' ^---- Fill: ---- (volume &Location) A. Has a Spe a(Permit/Variamce/Findingever been issued for/on the site? �� 0 0 NO �� DON7KNOVV �� YES »�� IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? �� NO DON7KNOYV YES �-� IF YES: enter Book Page � and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (3 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained �-1 Obtained ^�� Date Issued: ' '----- �~� �~� , ' L_____-______| [. Do any signs exist on the propert »�� » �� y� YES �_� 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 / '-------------------- r �-------------- / IF YES, describe size, type and location: E. WIU the construction activity disturb (dearing, ring, gradingexcavation, or filling) over 1 acre or is it part of a common ptan that will disturb over 1 acre? YESK } NO � ) �� �� IF YES, then a Northampton Storm Water Management Permit from the DPW is required. i ''` Cry of Northampton s ��� �� i , 1 ding Department E:tt YC6trD F � ?,>ve0 ,. � .; �� �I i 2 Main' Street ,$ S epf[ i ilb -6�: P � �� � �� d Room 100 W c/ ekl,.0 C _ IV � � � , � � Northampton, MA 01060 Twq etsai` r `� i.** = ��� } ' �� gyp .�nnQ �: si � i . tYbri� 413:=587 1 240 Fax 413 -587 -1 272 Lt Site l i wo { „t OttieiSteE .. ,, ,. ( Li4f'I I PATIONt' Q NjSTRUCT 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 is > I' J C'v -rit 51- Map Lot Unit Zone Overlay District tn,/ # '� ° `'� Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: DC,,,>� 441,04. /2 P4, - - 5 =f ti, '' -' Name (Print) Current Mailing A dr ss: 2 212 Telephone Signature 2.2 Authorized Agent: ,51'c v '4, Z.//'. ( 't s f 51 �'�, v Name (Print) Current Mailing Address: 5-27— 7/ 2 y Signature Telephone SECTION 3 - ESTIMATED 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 L 6. Total = (1 + 2 + 3 + 4 + 5) 3 2z 0, c-, Check Number #� S This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date sr BP- 2010 -0178 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 -0178 Project # JS- 2010- 000222 Est. Cost: $3200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN CAMP 082531 Lot Size(sq. ft.): 25090.56 Owner: SHEA BERNARD DAVID & KATHLEEN M Zoning: URB(100)/ Applicant: STEPHEN CAMP AT: 236 SOUTH ST Applicant Address: Phone: Insurance: 46 EAST ST (413) 527 -7124 0 WC EASTHAMPTONMA01027 ISSUED ON:8/17/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL 4 REPLACEMENT DOORS & STORMS 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 8/17/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo