23A-125 I ' L
viv i
e?
6 , 1 69 c 9 . Q ‘,./
'j i ( ji
, c "c _______ i . „ )}..49 , ri , ( 4 ) ,_ i „......,...,
� , t 4
/ # L <.,
1 I '
1
i
I" ji
i
i,
i
t
I t
c4.- Peerless
RENEWAL P. ' Insurance®
Mcmbcrof tUbcrty Mutual Group
Forming a part of
Policy Number: CBP 5943880
Coverage Is Provided In PEERLESS INDEMNITY INSURANCE COMPANY
Named Insured: Agent:
WILLIAM GEMMELL DBA WSG KING & CUSHMAN INC
RENOVATIONS
Agent Code: 6200791 Agent Phone: (413) - 584 -5610
TOTAL ADVANCE PREMIUM FOR ALL LIABILITY COVERAGE PARTS $ 8 8 0. 0 0
COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS
LIMITS OF INSURANCE
Each Occurrence Limit $ 1, 0 0 0, 0 0 0
Damage To Premises Rented To You Limit $ 10 0 , 0 0 0 Any One Premises
Medical Expense Limit $ 15 , 000 Any One Person
Personal and Advertising Injury Limit $ 1 , 000 , 000 Any One Person or Organization
General Aggregate Limit (Other Than Products/Completed Operations) $ 2 , 000 , 000
Products/Completed Operations Aggregate Limit $ 2, 0 0 0, 0 0 0
LOCATION OF PREMISES
Location Number Address of All Premises You Own, Rent or Occupy
0 01 100 CARDINAL WAY
HAMPSHIRE
FLORENCE MA 01062
PREMIUM
Class Classification Description
Code Rates Advance Premium
Premium Territory Prods/ All Prods / All
Base Code Comp Ops Other Comp Ops Other
MA
LOCATION 001
91340 CARPENTRY - CONSTRUCTION OF RESIDENTIAL PROPERTY NOT EXCEEDING
THREE STORIES IN HEIGHT
28,600 017 $ 14.161 $ 14.875 $ 405 $ 425
PAYROLL
PER $1000
22 -19 (12/02)
INSURED COPY
02/25/2012 5943880 NPC650P 2812 PGDM060D J27765 PCAOPPN 00034837 Page 25
- Office of Consumer Affairs and usiness Regulation
_.,_(= 10 Park Plaza - Suite 5170
- Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165392
j Type: Individual
Expiration: 2/8/2014 Tr# 221094
WILLIAM S. GEMMELL
WILLIAM GEMMELL - — -------------------- _�.. - - - -_
100 CARDINAL WAY - _________ .______ — ___ _______________
FLORENCE, MA 01062 _ . - _ __ ______________._.________.
Update Address and return card. Mark reason for change.
7 Address [] Renewal p_, Employment . Lost Card
DPS -CA1 C) 50M-04/04-G101216 ,, /r�
,Z' Officeff o umer'�' rsffiginess' eg a on License or registration valid for individul use only
a -- HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
, .Registration: 165392 Type: Office of Consumer Affairs and Business Regulation
T _ f Expiration: 2/8/2014 Individual 10 Park Plaza - Suite 5170
i k'4k,' = Boston, MA 02116
- AM S. GEMMELL
WILLIAM GEMMELL / //
100 CARDINAL WAY 4:2 f , 1 x
FLORENCE, MA 01062 Undersecretary No vali i ithout signature
The Commonwealth of Massachusetts Print Form j
Department of Industrial Accidents
��. L ; ��•�� Office of Investigations
- 711 11 .--%% ) . 1 Congress Street, Suite 100
�ter,, =0 r � Boston, MA 02114 -2017
~` y www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Plleas Print Legibly
Name ( Business /Organization/Individual): WLL)o�ivi ( - 'jar) m (SL. L ,)1/9 V W 4, foy//6) -Fa ✓f
Address: / 0/9112-Pf n// i 0
City /State /Zip: (,!&/C /?4 plc &Phone #: L// Ord
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
employees (full and/or part- time).* have hired the sub - contractors 6. El New construction
2.g 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'
g Y P h 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 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. 6'O / POs;
comp. insurance required.] r 2-0 ���
*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: 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 + ain and + enalties of I erju that the information provided above is true and correct.
Signature: T`4 ' Date IWIMI
Phone #: LI13 10)/Y
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 Supervisor: Not Applicable El
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable CI V � S 6- e"� aVA -/ O,•! -( / is' g 7---
Company Name Registratio N tuber
) o 0 C4 N4 W Z 1
Addres (A 3 Expirati D e
h -011-67v / -6,- -- MA 01 0 L>2.--- Telephone s — cer
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 108.3.5.1.
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" 'fees and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, St... • 4 Local 7 ing La s d St e of �i % Massachusetts General Laws Annotated.
Homeowner Signature
P /` �.c
t, .
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) J Roofing ❑
Or Doors I]
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [Q Siding [O] Other [0]
Brief Des t}pn of PrjRpposed , / ,� �P�i
Work: �1 f-- & T� Drn f �r `7 I I C acrf wH J9/44 'kW
Alteration of existing bedroom Yes 1X 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L mo
I, t/ 1 L/4 , as Owner of the subject
property �/�� Dig/9
h- y authorize r �" i LL/ `- /� �GZ L---' 0 -7 o,il
on my behal in a afters relative to work authorized by this building rmit application.
Signature of Owner Date
I, Ii41f ' L - AJJG j � , 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.
Si . ned under the pains and penalties of perjury.
� 'i✓ /ham M CI-Ai " ; / /—
;/L
Pri e
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 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ® YES C
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW ® YES Q
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 :1
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO
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 ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
20I2 Department use only
City of Northampton Status of Permit:
L Building Department Curb Cut/Driveway Permit
DE FEL.
NCFrr;a 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, 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
2 Map i?.7A Lot 'l 2- Unit
) P S
Zone Overlay District
j./C 1/114 O ) Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ( `
N nnt) Current Mailing A ddress:
5 Telephone 3 d /4 — 0 -
Signature
2.2 Authorized Agent: ar7/1-)wwi,c_ D / / 6 00 ; "�� \A// t - t '} Lf4 ico9$, ,ar✓J 7 Vc c� `" tr7A- o vt
Name Prin / 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 t , (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) a~ 2/ Check Number
This Section For Official Use Only
Date
Building Permit Number: j Issued:
/ /1/0'
Signature: 2, 2, .--/
Building Commissioner /Inspector of Buildings Date
24 MIDDLE ST BP- 2012 -1159
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 125 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- 2012 -1159
Project # JS- 2012 - 001982
Est. Cost: $1200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM GEMMELL 165392
Lot Size(sq. ft.): 7797.24 Owner: SEILER MARGARET L & LEONARD MELNICK
Zoning: URB(100)/ Applicant: WILLIAM GEMMELL
AT: 24 MIDDLE ST
Applicant Address: Phone: Insurance:
100 CARDINAL WAY (413) 585 -8024
FLORENCEMA01062 ISSUED ON: 6/25/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: Repairs Porch Posts
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 6/25/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner