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STATUS OF EMPLOYER GEORGE DANZIGER DBA THE DATA FOUNDRY 000775972 Individual 31 TARA CIRCLE FLORENCE, MA 01062 COVERAGE GROUP 0812601 Coverage under this assignment The Waiver of Our Right to applies to Massachusetts Recover from Others Endorsement operations only. For coverage is available on Pool policies. outside of Massachusetts, contact Contact your agent for details. the appropriate Pool or Plan for that state. AGENT ALEXANDER W BORAWSKI INS INC INSURANCE COMPANY: OR 88 KING ST HARTFORD UNDERWRITERS INS CO PRODUCER: NORTHAMPTON, MA 01060 MS CINDY MAROWITZ P 0 BOX 4903 ORLANDO, FL 32802 -4903 (800) 453 -9843 AGENCY FEIN: 042222073 CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED CODE TOTAL ANNUAL PREMIUM REMUNERATION BUILDINGS - OPERATION BY CONTRACTORS 9014 $5,000 2.50 $125 EMPLOYERS LIABILITY 100/100/500 9845 STANDARD PREMIUM $125 LOSS CONSTANT 0032 $20 EXPENSE CONSTANT • 0900 $159 TERRORISM CHARGE 9740 $2 TOTAL POLICY MINIMUM PREMIUM $267 TOTAL ESTIMATED PREMIUM $306 DIA ASSESS. 6.3% $8 TOTAL EST. PREMIUM PLUS ASSESSMENT $314 INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $314 THIS IS NOT A BILL COMMENTS Coverage effective 12:01 AM on 09/19/08 DATEOFNOTICE: 09/19/08 PREPARED BY: Paulette Hoffman EXT 514 * * VOLUNTARY DIRECT ASSIGNMENT * * LETTER ID: 2611569 COPY: EMPLOYER The Workers' Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street • Boston, MA 02110 (617)439 -9030 • FAX (617)439 -6055 www.wcribma.org r PI -PLSP -001 111% Philadelphia Insurance Companies One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 Olt TIM 610.617.7900 Fax: 610.617.7940 Cover-Pro IX Philadelphia Indemnity Insurance Company L Philadelphia Insurance Company DECLARATIONS Policy Number: PHSD359711 NOTICE: THIS IS A CLAIMS MADE POLICY. PLEASE READ THIS POLICY CAREFULLY. THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR INVESTIGATION AND LEGAL COSTS. FURTHER NOTE THAT AMOUNTS INCURRED FOR SUCH COST SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT Item 1. Named Entity and Address: George Danziger dba The Data Foundry 31 Tara Cir Florence, MA 01062 -3446 Item 2. Policy Period: From: 09/15/2008 To: 09/15/2009 (12:01 A.M. Standard Time) Item 3. Premium: $ 887.00 Item 4. Limits of Liability: (A) $ 250,000 Each Claim, including Claim Expense (B) $ 250,000 Annual Aggregate, including Claim Expense Item 5. Deductible: $ 2,500 Deductible per Claim Item 6. Retroactive Date: 09/15/2008 Item 7. Continuity Date: 09/15/2008 Item 8. Additional Premium for Supplemental Extended Reporting Period: Refer to PI -PLSP -176 Page 1 of 2 ] -.- The Commorrwealt /i of Massachusetts �,. Department of Industrial Accidents f ,- t � Office of Investigations _` 600 Washin Street " Boston s-- _� www.rnass_gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information - Please Print Letzibly Name (Business/Organization/Individual): c .. I� J a n , - .0 ,i yil., _UN0R, Address: 3 t -1'r4 Rp CrRcC,t' City /State /Zip: p/ rN <.6' 04A 0 /062 Phone #: ill '2-1 / oo V Are iou an employer? Check the appropriate box: Type of project (required): 4 _ I am a general contractor and I 1. I am a employer with 2 - 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. fl Demolition working for me in ca employees dud have wutkers' g any capacity. �'• $ 9. ❑Building addition [No workers' comp. insurance comp. insurance. red. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions q ] ocers have exercised their 3. ❑ I am a homeowner doing all work ffi h id hi 11.❑ Plumbing repairs or additions myself. [No workers' co right of exemption per MGL Y comp. 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 #I trust 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 him outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the nann 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information — - Insurance Company Name: a. ,¢. 6 ea tv a i ` lo v r aA c_c C• • et • Policy # or Self-ins. Lic. #: 6 5 6 0 C( ) -16 q 2 L - O -Q 6 Expiration Date: 99' / y/ Loo S Job Site Address: 3 1 /3.3 - C/ l [.e _ GHQ / City /State /Zip: r 4 v cC /'-fA7 0 /QCZ J 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 $750 00 a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA:fnr incur ace coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: i dJn �,. p �. Date:" 7/2-5/ Phone #: q 1 3 / 1 0 0 g - Official rise only. Do not write in this arca, 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other i Contact Person: . Phone #: 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 cones and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfilI), 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 / 7 471- e(enei et► nce( I, v(E `Jcc n 3 icel understand the above. _(Mame: owner /resident's signailre requesting exemption) I - ill call-to schedule all required building inspections necessary for the building permit issued to -me - — — Date_ — 7/2 - gl 2 e Address of work �✓n�✓0 C 2C CC ovation __ �� M /1 0 /0 Z_ SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor -.? Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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 -H ome Owner L "ce ion 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 ail 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 a peisuii(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 )o�- Q..0SP¢- car c Q/llQ( Ilya ,1 O * SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition ❑ Replacement Alteration(s) Roofing n Or Doors Lnl Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks l/ tg,[ Siding [p] Other [p] GI' l l a c 100 CI ' A/ Q.(4 Ss Brief Description of Proposed r vm ,� ti I VO cer + re �`✓ Work: Whim 6 / st«(a.� 144/ 6-o k 3-( C<�avdow . � �(a CP Z-2 k6 r;�rc4t («� („�2 - 8)4 - B IW rt C4c9 r', 46u t, t I( A w/Z X3 -u t�,rNdow, Ade( SouNd60. d -5%g oc'�cr .� W � Alt of existin bedroom 1/ Yes No Adding new bedroom Yes V No J ,y Attached Narrative Renovating unfinished basement Yes ,� No Plans Attached Roll - Sheet 6a. If New house and or additi 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, / _ _ „ ulthil"J_82N11111:10Z IPS1 , 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 I, W=Ur - e . f,r ir tL d � c Ro.wvc,dp , as Owner /Authorized Agent herby declare th at 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. R / c, .fl r■ b 0. r tC �\ @ IJU ^ ✓/1LLIt I Print Name / 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 fiJ]ed in by Building Department 7 - ---- -- --- ----- Lot Size Frontage Setbacks Front ---- �� ,---` _ � �� � _^~ Side L: B: L: [Z-{}, D:L /�� -� � �� Rear � �� Bui|dingRoigb/ � �3F 'v��* o . \d Square Y� Bldg. quur Footage 1��� [--� F--- ~�c~ " ` �4 Open Space Footage �^�� < ^--�~ ^=�^�~ �-� ---� d»� .4, rc ' � �� � la v �o area F��l �� ��� �� � u��~ ` ^ �v�_^ °� '�^_ parking) #uf Parking Spaces Fill: (volume &�mu�) */s / /v�«/� A. Has a Speciat Permit/Variance/Finding ever been issued forion the site? �� �� 0 NO \_� DONT KNOW �� YES \~� IF YES, date issued:` IF YES: Was the permit recorded at the Registry of Deeds? NO � ] DONT KNOW YES ,� IF YES: enter Book � Page ) and/or Dncument � �� � 0 B. Does the site contain a brook, body of water or wettands? NO � ��� DONT KNOW \_� YES \_/ IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tobeobtained x-� Obtained Date ------7 v�� ' ' L_'__ - ___ - _---1 �� C. Do any signs exist on theproperty? YES *� �� � NO � n�� IF YES, describe size, type and location: y ` �------------------------___ D. Are YES /—� NO /�� � �_p ��' IF YES, describe size, type and tocation: / L_ - E. V\fiII the construction activity disturb ring, gradinggrad excavation, or fifling) over 1 acre or is it part of a common pian that will disturb over 1acre? YES � NO K�� �� �� IF YES, then a Northampton Storm Water Management Pemiit from the DPW is required. Department Use only City of Northampton status of Permit Building Department Curb,Cut/Driveway Permit 212 Main Street Sewer/SepticAvailabii Room 100 Water eH - i bi '\ Northampton, MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 o ens t; .tber'Speci } ` t APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DE II OLIS A ONE OR TWOfA ILY DWELLING SECTION 1 - SITE INFORMATION � 0c` 1.1 Property Address: V_, Shie-section to be completed by office Map Lot Unit 3 1 7 3 / /3A4 CtAc( L oa e__c M / OIc� Zone Overlay District Elm St District - CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: R G L o ^ c- r C,+^ d 1 2 (e n� A ,JO<viUef'i.� 7/QIZA ( ) Name (Print) J Current Mailing Address: / r(c,es t7.1 <c ✓Lff Jlv( r .. v r' r elephone (J 2../ / 1. J E Signature — / ( 3 g 2.2 Authorized Agent: Name (Print) Current Mailing Address: 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 7001 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) 7 0 00 Check Number 5d "' This Section For Official Use Only Date Building Permit Number: Issued. Signature: Building Commissioner /Inspector of Buildings Date • File # BP- 2010 -0099 APPLICANT /CONTACT PERSON DANZIGER GEORGE & MELENA BONNELLO ADDRESS /PHONE 31TARA CIR FLORENCE (413) 218 -1008 0 PROPERTY LOCATION 31 TARA CIR MAP 29 PARCEL 515 001 ZONE URA(100) / /WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 06 7 � �© Fee Paid Typeof Construction: CONSTRUCT 10 X 10 DECK,SLIDER W/WINDOW,ADD SOUNDBOARD TO PARTY WALL, REMOVE PARTIAL DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQVIATION PRESENTED: i /Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission _ Permit DPW Storm Water Management Demolition Delay 3 Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. f BP- 2010 -0099 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 -0099 Project # JS- 2010- 000116 Est. Cost: $7000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 15333.12 Owner: DANZIGER GEORGE & MELENA BONNELLO Zoning: URA(100) / /WSP Applicant: DANZIGER GEORGE & MELENA BONNELLO AT: 31 TARA CIR Applicant Address: Phone: Insurance: 31TARA CIR (413) 218 -1008 0 FLORENCEMA01062 ISSUED ON: 7/31/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 10 X 10 DECK,SLIDER W/WINDOW,ADD SOUNDBOARD TO PARTY WALL, REMOVE PARTIAL DECK 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 7/31/2009 0:00:00 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo