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22-013 ' > MCCLURE INSURANCE Fax 4137318548 Aug 10 2009 09:52am P001 L; I Ienro: 4u "I oxi . ........ 1 — ACORD„, CERTIFICATE OF LIABILITY INSURANCE LE OWDD/YYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION McClure Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERT1Fa'CAT.c. 103 Van Deene Avenue HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P_ t)_ Box 339 West Springfield, MA 01090 _ INSURERS AFFORDING COVERAGE NAIC 10 INSURED INSURER A. Acadia Insurance URBAN & SONS INSULATION CO., INC- INSURER B: AIM. Mutual Insurance Co. 385 LIBERTY STREET ....., . INSURER c The Travelers Cos. SPRINGFIELD, MA 01104 INSURER O; INSURER E: COV RAGES 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 TC WHICH THIS CERTIFICATE MAY BE ISSUED CR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SuSJECT TO ALL THE TERMS, EXCLUSIQNS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION ),YR INskC TYPE OF INSURANCE POLICY NUMBER • :TE MM /DDlYY .: MMIDD LIMITS A GENERAL LIABILITY CPA018807913 08/01/09 08(01/10 EACH OCCURRENCE f1 r:0 a 00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED i5II 0,00 u CLAIMS MADE X OCCUR MED EXP (Any ons parson) $5,000 X BI /PD Aed:1,000 PERSONAL & ADV INJURY £1'000,000 GENERAL AGGREGATE 301.10, GEN'L AGGREGATE LIMIT APPLES PER: PRODUCTS - COMP /OP AGG 42;Cf00,000 POLICY PRO- r LOC _ aG C AUTOMOBILE LIABILITY BA7180W7380$SEL 08/01/09 08101 COMBINED SINGLE LIMIT $C000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY a n ers Per person) X SCHEDULED AUTOS ( X HIRED AUTOS BODILY INJURY (Per Karl sent) ,a X NON -OWNED AUTOS — ----.. X Drive Other Car PROPERTY DAMAGE .� (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT , '$ W... n 1ANYAUTO OTHER THAN EA ACC ;'$ — AUTO ONLY: AGG '$ .: - A EXCESS /UMBRELLA LIABILITY CUA020840712 08/01/09 08/01/10 EACH OCCURRENCE $1,090,000 X I OCCUR 1 CLANS MADE AGGREGATE 'S3 4 0000 r DEDUCTIBLE M— RETENTION S. (, $ „� B WORKERS COMPENSATION AND WMZ8005556012009 01/01/09 01/01/10 WC STATU- Cr114 ; EMPLOYERS' LIABILITY TORY LIMITS I FR -1 ANY PROPRIETOR /PARYNERJEXECIJTIVE E.L. EACH ACCIDENT ,; $5011 OFFICERJMEMEEREXCLUDED? E_4. DISEASE - EAEMPLOYE$ 00,000 If yes, describe under E.L. DISEASE - POLICY LIMIT 000 SPECIAL PROVISIONS below „_ OTHER DESCRIPTION OF oFERATIONS / LOCATIONS ! VEHICLES! EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS Proof of Coverage . CERTIFICATE HOLDER CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED E EFUR' THS EXPIRATION To Whom It May Concern DATE THEREOF, THE ISSUING INSURER WILL ENCEAVOR TO MAIL , 30 • DAYS WRITTEN NOTICE 10 THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE'. O DO 50 SHALL IMPOSE No OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSUREk ITS, AGENTS OR REPRESENTATIVES EPRESENTATIVES, AUTHORIZED REPRESENTATIVE . • ACORD 25 (2001/08) 1 of 2 #$44136/M44093 ., CA$ cia ACORD C(R;IORATION 1988 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 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 state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, whic i alive, /fuotings- (before- baekfih1), 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 worms caii 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 alI required blinding necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents • 4-4, .0 Office of Investig,ations t' 600 Washington Street F mk Boston, MA 02111 -`' www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians/Plumbers Applicant Information Please Print Le6ibly • Name ( Business /Organization/Individual): �� 1/�. �' . ��� �� t' v , Address: �- (\ .n �r'�`Y '/� ' col /O City /State /Zip: F 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. ❑ 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 officers exercised their . Plumbing repairs ❑ i am a homeowner-doing-all-work have id - - - - -- - - -- - - - - -- 11 - - - -- airs or additions Plumbing P 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: (0 A' l W -S., _ Policy # or Self -ins. Lic. #: K --_ 6° 1 00 C A. Expiration Date: / � U yi L Job Site Address: 6 1 ( QC City /State /Zip: n C1-`\h u i nc © /06 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, 50:00 and/orone- yearimprisonment, s 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. /do hereby certify under the pains and penalties of perjury that the information provided above isti °tie and correct. Sio 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. Ber- d-of -I ea th - - -2. Building Depa- t-rnetit 3. CityfTuwu Cler 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 : l c v ti9 Tb' v' �l 7 License Number st Address Expiration Dat Signature Telephone 9_ Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number L� er *y Sf 6 ice( [ 0 /0 Address Expiration Date Telephone 3 ? , 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 ❑ IL 1-; orne er Ei It 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) n Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [E] Siding [O] Other [p] Brief Description of Proposed Work: Q I vv►✓\ C \'15 e Th V1 b. L ct Ind ,sc-' i V' P4't 1--C , Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached RoII - Sheet sa If New =louse and or addition to existing housing, completelhe 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT . .... __.........___ ...... _ ....... -.. 11 / t ( , as Owner of the subject prope i hereby authorize U. *) h A--S0 I1 % -"k�L3 c1C 0 V to . on my behalf, in all matt elative to work authorized by this building permit application. mitut. II_ Sign iYr Date I � . ' Pi 4 1 0 kis (C\ VI t- , as Owner /Authorized Agent hereby declare 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. Derr /1 c! I /a n y Print Name r oc Signature 6 Owner / A Kent Date I 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 �i (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 M1 YES 0 _.... IF YES: enter Book Page; _ and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended #or the property ? YES 0 NO 0 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. �attrrient use only City of Northampton S1 t enn�t Building Department Main Street �' � x ' 212 Sewer�$epttc`AVatiabilitjr t.E Room 100 tivater Ava�lahihry `Northampton, MA 01060 T Sets o f S tn cturaJ Flans phon 41 587 -1240 Fax 413- 587 -1272 Piet/S to flans der S epI ty 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 C (_, Map Lot Unit .06 v WlC-. - "14 o / o6 Zone Overlay District E1111" St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: -- ��? INP1 I \0 Ck _ C 1'LJc ., Rd Name (Print) Current Mailing Address: Telephone Signature �\/ -a-3787 2.2 Authorized Agent: Name (Print) Current Mailing Address: Sig ature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars)-to be - Official Use Only completed by permit applicant 1. Building ial-[ V\ ' 06 (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) Check Number 3 5 :;)- _. _. .-This Sectian`Fer"OfSciarUse -Only Date Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date LA f BP- 2010 -0224 GIS #: COMMONWEALTH OF MASSACHUSETTS 1 :22-013 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2010 -0224 Project # JS- 2010- 000150 Est. Cost: $1332.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: URBAN & SONS INSULATION CO INC 101878 Lot Size(sq. ft.): 27007.20 Owner: MULLANE JEREMIAH J Zoning: URA(100) //WSP Applicant: URBAN & SONS INSULATION CO INC AT: 67 SPRUCE HILL AVE Applicant Address: Phone: Insurance: 385 LIBERTY ST (413) 732 -3922 WC SPRINGFIELDMA01104 ISSUED ON:8/27/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:BLOW IN CELLULOSE INSULATION 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 8/27/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo