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29-439 ACORD TM CERTIFICATE OF LIABILITY INSURANCE l DATE E1/ M /2 D/ PRODUCER Phone: (413) 781 - 2410 Fax 413 - 9539 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER OF NEW ENGLAND ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P 0 BOX 1175 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR WEST SPRINGFIELD MA 01090 - 1175 ALTER THE COVERAGE AFFORDED BY THE POLJCIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Peerless Insurance Company 24198 Prospect Builders, Inc INSURER B: National Union Fire Ins Co (PMC) 660 Prospect St INSURER C: East Longmeadow, MA 01028 fi 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 POUCIES 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 ADM TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION UNITS LTR I RE DATE RAM/BONY) DATE (MMVWYY) GENERAL LIABILITY CBP8532362 10/31/10 10/31/11 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIAEI LFrY DAMAGE TO RENTED $ 100,000 IS PREMES (Ea occmance) CLAIMS MADE I X I OCCUR MED. EXP (Any one person) $ 10,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPUES PER PRODUCTS - COMP/OP AGG. $ 2,000,000 PRO- . 7 POLICY n JECT n Loc AUTOMOBILELUwILITY BA8535262 10/31/10 10/31/11 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Par accident) GARAGE UABILT Y AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ _ AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY CU8537054 10/31/10 10/31/11 EACH OCCURRENCE $ 1,000,000 • — TIC OCCUR I J CLAIMS MADE AGGREGATE $ 1,000,000 A $ DEDUCTIBLE _ $ X RETENTION $ 10,000 $ W 10/31/10 10/31/11 ITORY WORKERS COMPENSATION AND LIMIT rrs OTHER UM EMPLOYERS' LIABILITY B ANYPROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT $ 500,000 OF'RCERIMEMBER EXCLUDED? E.L. DISEASE-EA EMPLOYEE $ 500,000 Wyss, (were* under SPECIAL PROVISIONS pilaw E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER: DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /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 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE To Whom It May Concern TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE J / Attention: i ruQ ACORD 25 (2001/08) Certificate # 52849 © ACORD CORPORATION 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 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 jermits 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 Date Address of work location , . ' The Commonwealth of Massachusetts –•---- Department ofindus A6cidents Office of InVestig,ationg , • • —,-, -1_=-- ; 600 Washington Street • • =3 . monr.' Boston, MA 02111 . - -=_,,-/- ,...... . . , , www.mass.gov/dia ' .. ..... -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers - . - Applicant Information Please Print Legibly • -' , -- Name pusinesS/Organization/IndiviriTIRD: ,a,e...p /3 .- .... . • • Address: /0 Jo ki .3c ,z_ City/State/Zip: ,4_ Phone.#: czc - - 3,2 2 ? - . p Are you an employer? Check the appropriate box: • -Type of project (required): - • 1.D-ram a employer with .,:f '... 4• 0 I am a general contractor arui I • 6 El New co 'on have hired the sub-contractors employees (full and/or part-time).* 2.0 I ari a Sole proprietor or partner- listed on the attached sheet." 7. 0 Remodeling • ship oixl have nci .}loyees These suh-contractors have .8. 0 Deniilition • working for me in any capacity. craggy:es workers' 9.. .. tf [ workers' comp-. insurance - 'cl:m13P-3411112ncell: - • - -------- — : - • required.] s . 5. 0 We are a corporation and its 10.0 Electrical repairs or adclitions 3.0 I am a homeowner doing all work officers haVe4xerCised their . 11.0 Plumbing repairs or additions . myself [No workers' comp. right Of exemption per MGL r--/ 12.0 Anor repairs . • insurance required.] t ' • . c. 152, §1(4), and we have no • • 13.0 Other r . 2 ea [No workers' . . - . ccrull insurance =Tilted-1 • . • . Any applicant that checks box an:list also fill out the section belawshowing their compensation policy information; : Homeownera who submit this affulaVitinclicating they are doing all wont and then hire outside =traitors must submit anew affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the =Me of the sub and state witerher•ornotthose entities have enmloyees lithe sub-ccauraitorshave eraployeea, they must provide their wOriors' comp policy number. . ... . . • . • lam an employer that Ls providing workers' compensation insurance for my einpleyees. Below is the po tiCyand job site information. : . Insurance Company Name: P- - A.)I- - Z/44 0 1.1 1:- , • . s . . . . . _ . ____ Policy # or Self-ins. Lic. #: ./(...- t.:)o "7 '7/ 3 f Expiration Date: - /07 3,/ /1 • ___,_ Job Site Address G' - -(..-.ZZ--/.e4.: ti),C.-- ie_ P . Crty/Stafe/Zip:' i .:- ife • - Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). . . . • , Failure to secure Coverage as reqiiire Miler .Sehtiiiir 25A 152 can lead to the iiiiioiltiOri Ofaiiining penalties of a frne up to S1,500.00 and/or one-year imprisonmen4 as well as cl penalties in the form of a STOP •Nsipo.RDER.ancla fine of up to S250.00 a day against the yiolatOr. Be adyited that a copy Of this statenient may be forwarded to the Ot5ce of , , .• , . Eire oftlie Du foi'itisiiraticeCOVeir;iill'eatioii. .. ' . . . 7. - 7.7 ..,:-.77.=7„......,..:.: _ I herehysertifil under the pains penalties ofperjray that the in:firmationprovided_abovii.rizoriPcz _ S _,., ignatin .. <.,.. ...:•-&--:-L. - ' • Date: :• • , –.- Phone • • it: ,_ 5 3 — - 3,2 (---' ' - - 2 •' . . . . - • • . . - Official use only. Do not write in this area, to be completed by city or townOfficiai • • • City or Town: '. Permit/License # • Issuing Authority (circle one): :1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector • 6. Other , • • Contact Person: Phone #: • • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : /��)� l� ,7‘i G License Number ` _3� :; G e. P1 f - / / e' /l Address Expiration Date �. 2 -32,74 Sign. r• Telephone 9 . "Registered.Hame` oiritracttir .. „..,, 4t5 :n a.... ; . = Not Applicable ❑ / 4 5 Pe Company Name Regiisttra on Nu ber Address Expiration ate Telephone 9 27 1.) 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 Er No ❑ 11. , Home #, WnefElt ioi 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 shalt 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) ❑ Roofing [/ Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [1:1] Decks [C'j Siding [0] Other [CA Brief Description of Proposed Work: /!'ehL Alteration of existing bedroom Yes 'll o Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa ` {f le it #to s= stir x w adi i iv�tc exist q iouslnri a tips+ e. #lii folk wih : a. Use of building : One Family f/ 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 , as Owner of the subject property hereby authorize to act "n y behalf, in all matters relative to w. authorized by this building permit application. :r, Signature .f ner Date I, /2 �/ . f72 � � / , 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. ./2 = / 1 �� Print Nam- /'� ■0�,;>, / 7 Si. n - re . Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information `. -1 Existing Proposed Required by Zoning This column to be filled in Wtiit Building Department Lot Size i .. ._ _ L ;4`' Frontage _ _. ____ Setbacks Front 1 1 i Side L.� R 3 L: R:' ' I Rear = ' — 1 Building Height [ I Bldg. Square Footage I i I I % ~? I Open Space Footage % (Lot area minus bldg & paved ..,,a,_ ,—, , parking) , # of Parking Spaces Fill: 1 (volume & Location) ? , — — ---- - -- A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:; i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 3 I Page' i and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q ,Date Issued: C. Do any signs exist on the property? YES 0 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 IF YES, describe size, type and location: E. Wilt 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 Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. E EIVI ? of N.rthampton ® ,� „ � "4 Y��, Buildi g 1 epartment u• I LU I M. n Street at4 • , ; � " 00 100 4itlf ► • pt. , MA 01060 . • 1v L OF IID41G ' _. .,., �:, =124 Fax 413 - 587 -1272 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 767L/vls% 0A/ ,, Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Na � - rint) Current Mailing Address: Telephone S e 2.2 Authorized Agent: /2 ,r 1 <3) £ 302_ Name (P ' t) Current Mailing Address: 7/3 - 5z " --3 22 - Signatur 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 i f a 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) / D1 40(..) Check Numb 5 Bog e J This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings, Date 67 ELLINGTON RD BP- 2011 -0957 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 439 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2011 -0957 Project # JS- 2011- 001563 Est. Cost: $10000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PROSPECT BUILDERS INC 76106 Lot Size(sq. ft): 10018.80 Owner: FINLEY JAMES A JR & MICHELLE G Zoning: URA(100) //WSP Applicant: PROSPECT BUILDERS INC AT: 67 ELLINGTON RD Applicant Address: Phone: Insurance: P 0 BOX 302 (800) 486 -4976 Workers Compensation EAST LONGMEADOWMA01028 ISSUED ON:5/19/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP,PLY & SHINGLE ROOF 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 5/19/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner