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29-429 (4) - l 11 -2@1@ 1444 • • f F I NO< & PERRAS INS 1 413 527 54?@ P. @it@ So` %.ASUt Limy it !I' = *I! . E C. %JA },.IA *.D11. 1 ■ ■ algw+.ea.ar In......�. ZouctiR (413)527-5520 FAX (413 527 -597 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 'inck & Perras Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TItIS CERTIFICATE DOES NOT AMEND. EXTEND OR a CBANI8 lane • LTER It • - _ . E • • .t • - 3t BY TH POLICI .. B . • :asthempton, MA 01027 iebecca Kubusiak INSURERS AFFORDING COVERAGE ila Zinn ' • • rt H. twin r. ons - ruction rv , - nc. 11'46Q A Travelers 43 Burt Road nos: Westhampton, MA 01027 • M>IStORERc: Ell INSDPIERO: INSURER E 1 ;OYERAGI6 x....... THE POLICIES OF INSURANCE !ATM BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NODMTHSTANDING ANY REQUIREMENT, TERM OR CONDTTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE E MAY RE ISSUED OR MAY KRTAirl, TrIE Ii4URANCE Arl ormo 8Y TM P DESCRIBE) HEREIN IS SU$JECT TO RLL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _..--_,.._..-..._ 11 r_j4. TYPE L INSURANCe p(MI,IyW NUM6BR EFF y,r �- .' +�+ GENERAL LIABILITY 68004731 04/ 19 100 0/19/019 EACH I f s 1 Z 1,000, 1 - I 1-i MMERCIAL CO CAMERAL LIABILITY HAM - tD t 500 111 . 1 CLAIMS RAVE M QCCu• HES FxP IAA? one I,err+o,I) $ 102001 A PERSONALS AW 1 1 *AMY I , 000.0 I • GENeRALAoessMATe $ 2,000, I ! t rr : e r rs LIMIT A P! as ? I PRODUCTS • COLEVOP AGG 5 2 000 • I Milo? :e•r LOC ALTIOSTOSILE LIABILITY COMBINED SIHCf!.E L!Mrr $ { VW AUTO j icn art ib:w !) II ALL OWNED AUTOS BODILY moor e 4 ouiEn AUTOS 1 ,Par Rer59n) s c HIRED AUTO$ I BODILY MARY I AUTOS (Pet ammo . $ I M rya i f I `MAOv; (Peraoddant) $ LiR T3'1 AL!TQ ONLY - e.,* A ACCIDENT $ I AMNY A!.ITO OTHER THAN EA ACC $ AUTO ONLY AGE $ EXCESS/UMBRELLA LWBIL fl EAt m occukRENC$ S OCCUR CLAIMS MADE AGGREGATE $ I DE H RETENTION $ 1 1 —ma-- I $ t WORKERS CORPENSATION AND 1 EMPLOYERS' LIABILITY 1 . ANY PR1 OPRIETORIPAR'>'I�£WE%ECUTNE �E.L. L EACH ACCIDENT $ 071ir. OFFICE_TMINE 1SER OCCLUDED? I..°_ L- DISEASE • EA ROL I `` ° s °G_w+L +x 1 E.L. OI - POLICY UW $ . _ 1 VE9 fi OF OP[RA71ON$ I LOCATIONS /VEHICLES I EXCLUSIONS Abbile BY ENDORSEMENT /B -`RO`OVONS leference: Golaski- Golden Drive ',corkers compensation certificate of insurance to follow directly from the carrier. GsERTIPICATE HOLD CAN ELLATION - I 'IMMD ANY OF TIE ABOVE oeSORIBED POLICIES BE CANCELLED IEPORE THE EXPIRATION GATE THEREOF, TEE IMMO MEURER WILL ENPBAIO TO MAIL City of Northampton 1 XL_ rum *mum NOVICE. TO EMIIRCATE HOLDER NATSr.e. TO THE LE€T, Attn; Buil ding Dept- 1 BUT PULSES TO ieiA L Ira NCTCE0 -A L IMPOSE , NO OBLIGATION OR LIABILITY } 212 Main St. I o f A N Y KIND W 1 M'! HE PESLIP.PR. ITS ABORTS O Pri ,SOH ATIVES. NOrtha,7ctOn, MA 01060 AUTHORIZED REPRESENTATIVE E, _ _ 7o (!).• Rebecca Kubosiak/BgRY j I AGORD 25 (2001/08) FAX; (413)5S7-1272 RIACORD CORPORATION 1985 • = Nla.atclttiwtt. - Department of Piiahlit +,it 13o and of Builthn�o R DUI ttiom anti `+tantlards ,. _..r str c,_ c r ,, 1 s : 7.->0__ License: CS 85846 Restric.ted to: 00 ROBERT H DUNN JR ,� , 43 BURT RD � , WESTHAMPTON, MA 01027 , g7L- -- -/'. Expirat ?on: 3/5/2011 ( ,uumi..i.m +•r Tr -t: 13540 ✓fe eammonaleald of ila sackwe - Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to j Registration: 133318 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Expiration: 6/6/2011 Tr# 700220 Boston, MA 02116 Type: Individual ROBERT H. DUNN, JR. ROBERT DUNN JR. 43 BURT RD. ���' — C WESTHAMPTON, MA 01027 Undersecretary Not valid with ut signature , • The Commonwealth of Massachusetts --- - Department of Industrial Accidents >70 i Office of Investigations s fe _.. F-- 600 Washington Street ` = t Boston, MA 02111 .4. www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information ++ Please Print Legibly Name ( Business /Organization/Individual): t ►- 0 . �-1 , ,x 77 ,. "- Address: (4 3 ' ti_ ," r 7J City /State /Zip: (IBLS' i i -1 L vYA -ti WA Phone #: L A 1 3 5 7 LCS 0 Are ou an employer? Check the appropriate box: Type of project (required): 1- am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7.0 ship and have no employees These sub - contractors have 8. ❑ Demolition working employees and have workers' g for me in any capacity. P i tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 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 ��� I A C e. comp. insurance required.] Of i.;i d in c\O *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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: e'��0eii 4' [ye 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. 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 certi 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction.au , ,• Not Applicable 0 Name of License Holder :!�_�rvt~ 2 T �' ,`1 +^ r' �" `� License Number l0c3 4-1'►1 i 7-771 Address- -- Expirat n D Signatur r Telephone :e • istered H • m Im • r - � i t Contractor: Not Applicable ❑ ' i 1 04 �_ �,. -� d / 3 -A / Company Name Registration Number 93 - 8 r" s i2 i ' l r-t-j < ,7f. "L t� o f Address Exit tion ate e ` i 4 Telephone s SECTIO 10- WORKERS' COM F . ATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Wor ers 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 108.3.5.1. 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 lj$dows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [0] Other [d] Brief Description of Proposed Work: ft t � '71(�C G , i n E; l E= 1, i 6. , D c. .3 ✓ . Alteration of existing bedroom Yes No Adding new bedroom _ Yes No Attached Narrative Renovating unfinished basement Yes " Plans Attached Roll - Sheet sa. 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 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 f I, Ks.6 be rT 0 , bi) > I ✓N air , 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. i ned under the pains and penalties of perjury. H ;Print Nam: 1�y / / ///6 Sig o 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 0 YES 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 , I DONT KNOW © YES 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 ® NO "4 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, gradin• ex •vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO ► :4 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. `- Version1.7 Commercial Building Permit May 15, 2000 itiS Department use only Ns\ \ \ ' City of Northampton Status of Permit: - ''`` , Department Curb Cut/Driveway Permit ' 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit f.-4/--e i2 a Zone Overlay District Eim St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C: iii 6c 1 S ,c> err /oe. t� . r t ., e-- Name (Print) Current Mailijj�g Address: Signature Telephone y/_ 54'5 cl cia.-3 2.2 Au d Agent: ,, fh4 ub - ,e. ; l -/ • J.A.,,1,1 '/3 glc) Name (Print) Current Mailing Address: t- 'c .5 ^ TH A ✓ ii 4- /Y) A it 27 Sig ature , . L 2 T elephone 7 �3 s 74 ,c": SECTION 3 - E (MATED CONSTR ' N COSTS Item mated Cost (Dollars) to be Official Use Only •.mpleted by permit applicant 1. Building C . (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) 2. - Oz.). Check Number lira 5.- This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date • . 6614 3R €` BP-2010-0660 GIS #: COMMONWEALTH OF MASSACHUSETTS Map :Block: 29 429 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 -0660 Project # JS- 2010 - 000959 Est. Cost: $2000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT H DUNN 085846 Lot Size(sq. ft.): 11412.72 Owner: GOLASKI KATHLEEN L & WILLIAM J Zoning: URA(100) / /WSP Applicant: ROBERT H DUNN AT: 68 GOLDEN DR Applicant Address: Phone: Insurance: 43 BURT RD (413) 527 - 2953 WESTHAMPTO MAO 1027 ISSUED ON:1/12/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOW 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 1/12/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo