38B-288 SINCE 2940
r k MILES
• BUILDING MATBRIALS SUPPLIER
Installed
Project: gAO,PDgR)W
14?to APE;
j
A), )1(-)-i) rc/J AA
Subcontractors: If you have employees you must provide your
Workers' Compensation Insurance Policy Number
Subcontractor • f
Name: � % 9 ,D51(A)
Address: /0 ALE kA--) 5
N,. IA 6N Miy
4) 9g7P
•
Policy #.
Insurance Company: i a)4
P Y�
(This form must be attached to Project Workers' Comp. Affidavit)
Installed ?rotect Subcontractors 2/12/2010
. r
Acadia Insurance
WORKERS COMPENSATION AND EMPLOYERS
LIABILITY INSURANCE POLICY
ADDITIONAL LOCATIONS
.icy No. WCA 0240314 -12 Issued By Firemen's Ins. Co. of Washington D.C.
Policy Period 01/01/2010 to 01/01/2011
NAMED INSURED AND ADDRESS AGENCY NAME AND ADDRESS 05111
(802) 362 -1311
R. K. Miles, Inc.
618 Depot Street W.H. Shaw Insurance Agency, Inc.
P.O. Box 1125 135 Bonnet Street
Manchester Center, VT 05255 -1125 PO Box 1067
Manchester Center, VT 05255
Location U.I.A.N. Name and Address
Loc 1.
618 Depot Street
Manchester Center, VT 05255
Loc 2.
691A Depot Street
Manchester Center, VT 05255
Loc 3.
88 Exchange Street
Middlebury, VT 05753
Loc 4.
385 Cole Avenue
Williamstown, MA 01267
Loc 5.
24 West Street
Hatfield, MA 01038
Loc 6.
No Specified Location, NH
Loc 7.
No Specified Location, NY
... _..._......
WC 00 00 01A 01/01/10 DAL 12/29/09 Original
Acadia Insurance
PREMIUM l
4. fhe premium for this policy will be determined by our Manuals of Rules, Classifications,
Rates and Rating Plans. All information required below is subject to verification and
change by audit.
SEE SCHEDULE OF OPERATIONS
EST ANNUAL
Minimum Premium $ 1,000 Subject Premium $ 129,790
Premium Discount $ 13,098 -
Expense Constant $ 338
Estimated Annual Premium $ 117,030
Terrorism Risk Insurance Act of 2002 (Code 9740) $ 515
Terrorism (9740) $ 552
Catastrophe $ 552
(other than Certified Acts of Terrorism) (9741)
Vermont Assessment Fee $ 764
MA D.I.A. Assessment $ 2,908
Total Estimated Annual Premium $ 122,321
r I Authorized Signature
WC 00 00 01A Page 2 Original
Acadia Insurance
WORKERS COMPENSATION AND EMPLOYERS
LIABILITY INSURANCE POLICY
INFORMATION PAGE NCCI Carrier Code #27723
P�_tcy No. WCA 0240314 -12 Issued By Firemen's Ins. Co. of Washington D.C.
Previous Policy WRA 0240314 - 11
One Acadia Commons
Westbrook, Maine 04098
1. NAMED INSURED AND ADDRESS AGENCY NAME AND ADDRESS 05111
(802)362 -1311
R. K. Miles, Inc.
618 Depot Street W.H. Shaw Insurance Agency, Inc.
P.O. Box 1125 135 Bonnet Street
Manchester Center, VT 05255 -1125 PO Box 1067
Manchester Center, VT 05255
F.E./.N. 030141661 U.I.A.N. Bureau File No. 911735261
State: VT Entity of Insured: Corporation
I Ilm u vr n ) See Attached Schedule of Locations
2. The Policy Period is from 01/01/2010 to 01/01/2011 12:01 AM Standard Time at the insured's
mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers
Compensation Law of the states listed here: MA, NH, NY, VT
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:
Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed
here: ALL STATES EXCEPT ND, OH, WA, WY AND STATES
DESIGNATED IN ITEM 3A OF THE INFORMATION PAGE.
D. This policy includes these endorsements and schedules: SEE SCHEDULE OF ENDORSEMENTS
This policy is: X Direct Bill 12 Pay Plan
Agent Billed
WC 00 00 O1A Page 1 Original
A Acadia Insurance
WORKERS COMPENSATION AND EMPLOYERS
LIABILITY INSURANCE POLICY
SCHEDULE OF OPERATIONS
MASSACHUSETTS
Policy No. WCA 0240314 -12 Issued By Firemen's Ins. Co. of Washington D.C.
Policy Period 01/01/2010 to 01/01/2011
NAMED INSURED AND ADDRESS AGENCY NAME AND ADDRESS 05111
(802)362 -1311
R. K. Miles, Inc.
618 Depot Street W.H. Shaw Insurance Agency, Inc.
P.O. Box 1125 135 Bonnet Street
Manchester Center, VT 05255 -1125 PO Box 1067
Manchester Center, VT 05255
Premium Basis
Total Estimated Rate Per Estimated
Code Annual $100 of Annual
Loc No. Classification Remuneration Remuneration Premium
4 8058 Building Material Dealer - new 169,000 3.45 5,831
materials only: Store Employees
4 8232c Lumber Yard - new materials only: 188,000 4.87 9,156
All Other Employees & yard,
warehouse, Drivers
4 8742 Salespersons, Collectors or 44,000 .20 88
Messengers - Outside
4 8810 Clerical Office Employees NOC 71,000 .12 85
5 8058 Building Material Dealer - new 200,000 3.45 6,900
materials only: Store Employees
. 5 8232 Building Material Dealer - new 408,000 4.87 19,870
materials only: All Other Employees
& yard, warehouse, Drivers
5 8742 Salespersons, Collectors or 309,000 .20 618
Messengers - Outside
5 8810 Clerical Office Employees NOC 269,000 .12 323
. 5 5437 Carpentry - Installation of Cabinet 60,000 5.93 3,558
Work or Interior Trim
Subtotal: Premium Subject to Modification 46,429
9807 Increased E. L. Limits 1.00% 464
9898 Experience Mod Fctr 0.87 6,096-
0277 ARAP 1.00 0
Subtotal: Subject Premium 4Q,797__
WC 00 00 01A Page 1 Original
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
+YIH
Office of Investigations
w- 600 Washington Street
*-. SIN - = Boston, MA 02111
S ° www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization /Individual): A . � � 1 " `-' � c , '
S
Address: 2'1 /) T C?
` r
City /State /Zip: /1/0 / FI D /•%/7 P /L/ Phone #: ^).� , /c? .1/ — ON )( //a
Are you an employer? Check the ap b x: Type of project (required):
1. ❑ 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. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
for me in any capacity. employees and have workers'
working Y P ty. 9. p Building addition
• [No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions
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 12.0 oof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. ther G()J�I/f�l�Gi P�
comp. insurance required.] / t f �i9 C- ' ../V
*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: ACI h (//A ! A S?LRA CE
Policy # or Self -ins. Lic. #: W('4 0240,3 /4° — / 2 Expiration Date: J / �. -Oil
Job Site Address: / 4 1 LLL A V f City/State /Zip: / Y d FM/ t 7 2 T / 0/ 0 n
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration datee
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 ti under a pal s and penalties of perju that the in orm /lion provided above is true and correct:
Signature: ` if / 1/3(`c'lCie . Date:
Phone #: 4/3 "2`f" 7 - /J sl/e) >e AQ
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
ConfacfPerson: — -. - - -- — _ _..._ Phone #.
_.:
„, ,..),
_,.._,, g -6204,....a.,a , , 4 ' / 4
_,I°
I Office of Consumer Affairs and usiness Regulation
wa° 10 Park Plaza - Suite 5170
=� Boston, Massachusetts 02116
•
Home Improvement antxactor Registration
a Registration: 165435
, _ -; I Type: Private. Corporation
i717--- _ Expiration: 2/17 /2012 Tr# 293477
R.K. MILES, INC. z�
DAVID NORRIS _ _
24 WEST ST ROUTE 5I NORTH 7 - 72 :
WESDT HATFIELD, MA 01088- -
Update Address and return card. Mark reason for change.
0 Address 0 Renewal 0 Employment El Lost Card
DPS- CA1 0 50M- 04/04-0101216
gge 6 )72o. 0/._ ackweta
t ,� Office of Consumer Affairs & Business Regulation License or reg valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
office of Consumer Affairs and Business Regulation
L. Registration 165435 10 Park Plaza - Suite 5170
Expiration 2/17.12012 Tr# 293477 Boston, MA 02116
Type : E_ Priijate
R.K. MILES, INC?” i
DAVID NORRIS s s. M tssat husetts Department of Public Saco
24 WEST ST ROUTE 5-NORTti 4e- e3 -- '
., (�'� � � �" Board of Buildin!� Re��ttlutions and Standard
WESDT HATFIELD, MAC- 0 Undersecretary Not valid witho t sr nature Construction Supervisor Specialty License
g
License: CS SL 103888
Restricted to WS
DAVID NORRIS
195 CHESTNUT ST
BRATTLEBORO, VT 05301 M
��- iy�—. Expiration: 11/2(2013
( omniissioner Tr#: 103888
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /A\ imeis Not Applicablle ❑
Name of License Holder : 4 V i� / v /031.4
/9S tC1".N i ST, /3317 t �`-�cR I / License Number 2 4 .)3
)
Address Date te`
/(. Expiration 0 4/3-r317- 1 -1 /i
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Com an Name / Registration Number
a 1 (-67 5z-7- jv, 47F/60 l' O/Yfi ?- /7 ZiD ) ,
Address J �f/� Expiration Date
� / 13
Telephone `7 217 Q "
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 ❑
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 108.33.1.
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 ❑ Replacemendows Alteration(s) r7 Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [Q Siding [El] Other [0]
Brief Description of Proposed AP/4 C t /27 t , 0 .� 0 � J vT Work: G /�.� __.1 ( f C /J
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes X. 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 S ENT /3 OR CONTRACTOR APPLIES FOR Q UILDING PERMIT r
I, /'f /nUl'�-� OA() �J E, // 2) �/;,/ ) T6/ , as Owner of the subject
property , ( / �
hereby authorize _� t /[ � �AY.I 6 T /-/ / �LE 5 r- ik) t
t i ct on my behalf, in all m tters relative to tters relative to wor�autlyorized by this building permit application.''
Signature of Owner Date
1 � j\b / ,q , t .1
, � �1,�� .�h0 c , as Owner u on .�
ig_ent tereby declare that the statements and information on the foregoing application are true and accurate, to the best of owledge
and belief.
Signed under t
Print Name pains and penalties of perjury.
/JA 1 / e7/9. s
i
1 ()Aq / D - / -/ d
Signature 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 DONT KNOW ¢ YES C
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW 00 YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO p..) DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , 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 O
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.
Ir ' r-r . t''', Department use only
}• , _ .___._._.. City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
NOV 3 0 2010 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
4 Northampton, MA 01060 Two Sets of Structural Plans
ph 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
\ �) Map Lot Unit
/ i //A le IN() A V P Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
AAwc B PA,1).ggid 1rr DATWO 4! fRS 14 AR L o t 4i/ . /U. (-16 thofo�)
Name rint) Current Mailing Address:
ct ' X13 �8� 9�r�
Telephone
Signature
2.2 Authorized Agent:
OW #,,N� D5 R'.1'11Y; . N�. ,24 lJ T - A47-D r(7) /`-)lq
Name (Print) Current Mailing Address:
�� , 443 2 -97 -73(k;
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building
/ ` /,,v 24 (a) Building Permit Fee
2. Electrical J � (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection yy /U
6. Total = (1 + 2 + 3 + 4 + 5) /5� / if 2'f Check Number -+3F / S-
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: t / J / // - 3 6 /V
Building Commissioner /Inspector of Buildings Date
t
c
BP- 2011 -0504
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- 2011 -0504
Project # JS- 2011- 000826
Est. Cost: $15618.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: R K MILES INC 10388
Lot Size(sq. ft.): 6185.52 Owner: BROADBRIDGE ANNE F & DAVID A PETERS
Zoning: URB(100)/ Applicant: R K MILES INC
AT: 14 HARLOW AVE
Applicant Address: Phone: Insurance:
24 WEST ST (413) 447 -8300 WC
WEST HATFIELDMA01088 ISSUED ON:12/1/2010 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:
FeeTvpe: Date Paid: Amount:
Building 12/1/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner