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'' a^ | ru ! ... � � �� / | �� ' ! ~.. 6 ,» `` CERTIFICATE OF LIABILITY INSURANCE S DATE QMDOtYYYY) 06/18/10 PRODS THIS CERTNICATE IS ISSUED AS A MATTER OF NIFORMATION Pioneer Valley Automobile Club ONLY AND CONFERS NO RIGHTS UPON THE CERTWICATE Insurance Agency, Inc. HOLDER. TINS CERTIFICATE DOES NOT MEND. EXTEND OR 150 Capital Drive ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. W. Springfield MA 01089 Phone:800- 622-9211 Fax:413- 205 -2319 INSURERS AFFORDING COVERAGE NAIC# INSURED HVBFER A Travelers INSURER B: Scott Callahan INSURER c No or Ntthh Hatfield MA 01066 ° INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED) TO TIE INSURED W WED ABOVE FOR DE POLICY PERIOD MDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRAST OR OTHER DOCUMENT WITH RESPECT TO VH#CH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAI 1W INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICES. AGGREGATE MATS SHOWN MAY WAVE BEEN REDUCED BY PAID CLAIMS. LIR NSRG TYPE OF INSURANCE POUCY NUMBER DA (MAIDD/YY Y)) DA (MNDD/YYYY) UNITS GEERM.LIABILI Y EA HOCCURRENCE S1000000 A COomazCIALGETERALLIABLm 680- 2377N464 ACJ -10 03/03/10 03/03/11 PRr�U` sES(Enoc ice) *300000 I CLAIMS MADE I I OCCUR aED EXP (My one person) $ 5000 X Business Owners PERsoNa_ s any INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GENL AGGREGATE LOOT APPLIES PER PRODUCTS - COMP/OP AGG S 2000000 POLICY n F irgi n LOC AIDOMOBIL.E IJAB LINTY COMBPED SINGLE LIMIT Y AUTO (Ea accident) $ AN ALL OWNED AUTOS BODILY INJURY person ScWDLLED AUTOS (Per ) HIRED AUTOS BODILY !MIRY NO .OWFIBD AUTOS (Per accident) $ PROPERTY DAMAGE (Per ) GARAGED ( AUTO ONLY- EAACCIDENT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: — $ EXCESS I UMBRELLA LIABIJTY EACH OCCURRENCE S I OCCUR I I CIAPAS MIADE AGGREGATE S $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION 10RY L I ER AND EMPLOYERS' UABLnY Y/ ANY PROPRIETOR/PARTNER/EXECUTIVE I I E.L. EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NN) E.L. DISEASE - EA EMPLOYEE $ If yyaems describe t SPECIAL PROV der below EL DISEASE - POLICY I-BIT $ OTHER PROPERTY 5000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS subject to policy conditions, provisions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRBED POLICES BE CANCELLED BEFORE THE E)PIATTON DATE THEREOF, TIE TSSUANfs INSURER vol. ENDEAVOR TO MAIL 10 DAYS vow NOTICE TO TIE CWTFTCATE HOLDER HAWED TO THE LEFT. BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UABLITY OF ANY KIND UPONII E INSURER. ITS AGENTS OR Richard Marsh REPRESENTATIVES. 9 Northampton MA 01060 No N 9:040 rtham ACORD 25 (2009)1) 01988 -2009 ACORD CORPORATION. MI rights reserved The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Q ... 1 ,,,=. ( Office of Investigations M 1 — = 600 Washington Street ., '" 1 41111101 P w Boston, MA 02111 . x ww mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): S LJnr C ` 1..kCv Address: Up a A �e -c):.� 3 e z t vAits. 0 tt(,,e, City /State /Zip: Phone #: 1.A \ - 3, (c p'r 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. ❑New construction 2. I`: 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 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' 13.0 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: a tJ Pt. CY\ - . - City/State /Zip: ) O$L h , #AV OA) 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 nd enalties of perjury that the information provided above is true and correct Signature: Lti' - Date: 6 ` iC(-/ o m 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): I. 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 ❑ ( CiL 3o7 Name of License Holder : l l7� C9-t, ` �Cto(\ � � :7 � / License Number 1 r, N p : T 2; n3 : \- P T 01b is Sidi/ /0 Address i Expiration Date Li( 3- v S'. na ure Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ C' Tt G� kVt,,c A r62 2 Q 7 Company Name Registration Number t)- A v -i -0 -CY of c kt � 3�� r f Address Expiratio Date _ ite 7 Telephone '7! ' v 9 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 (51--• 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 Windows Alteration(s) n Roofing 0 Or Doors 0 Accessory Bldg. ❑ Demolition . o New Signs [D] Decks [p Siding [m] Other WA i 4,r; - f � /►^� i. - � 1 i j Brief Description of Propos W Replace small section of rotted siding on front of the house. Replace the roof oo first floor font porch. Replace the ceiling of the first floor porch. Replace the floor of the second floor porch. Alteration of existing bedroom Yes k No Adding new bedroom Yes 1( No Attached Narrative Renovating unfinished basement Yes ,( No 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, Ali as Owner of the subject property hereby authorize <SC. 0 ' it C /Q C L/91y/9A( to act onm behal i II matters relative to work authorized by this building permit application. / c/-2-/-/, Signature of er Date I Cc0 " t- \cfOAta. , 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. Print Name Signat - '`."-• -r /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 Q 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 Q DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O ,Date Issued: C. Do any signs exist on the property? YES ® NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 © NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only �` c City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability r "L O Room 100 Water/Well Availability 0 2 L Northampton, MA 01060 Two Sets of Structural Plans ,phone 413-587-1240 Fax 413 -587 -1272 Plot/Site Plans A 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 Q t.1 i ,c)r1 S'S P o� A A , %Aix Map Lot Unit 0% Ccw o Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT *- 2.1 Owner of Record: Richard Marsh 9 Union Street Northampton,Ma Name ( Current Mailing Address: 1 ‘ Telephone Signature 2.2 Authorized Agent: Name Print) "„, _ ...., Current Mailing Address: CA C {�rr> j 2 y -— ti, ? -- � _ & oI s Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 3,800 (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 / #55 6 Total = (1 + 2 + 3 + 4 + 5) Check Number / 5 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -1172 APPLICANT /CONTACT PERSON SCOTT CALLAHAN ADDRESS/PHONE P 0 BOX 134 NORTH HATFIELD (413) 320 -6269 PROPERTY LOCATION 9 UNION ST MAP 32A PARCEL 074 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out `9 0gs Fee Paid / Typeof Construction: REPAIR PORCHES & SIDING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 97309 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IM IZMATION PRESENTED: A pp r oved 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 4 2Z E0 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. 9 UNION ST BP-2010-1172 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 074 CITY OF NORTHAMPTON Lot: -001 PERSONS COIF TRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -1172 Project # JS- 2010 - 001708 Est. Cost: $3800.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT CALLAHAN 97309 Lot Size(sq. ft.): 4094.64 Owner: MARSH RICHARD P Zoning: URC(100)/ Applicant: SCOTT CALLAHAN AT: 9 UMON T Applicant Address: Phone: Insurance: P O BOX 134 (413) 320 -6269 NORTH HATFIELDMA01066 ISSUED ON:6/23/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR PORCHES & SIDING 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: (r Rough Frame: 7,---.8' .- v-/ ; (2 ()k C /l n& Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: 7_13 / o c' f, c THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE , :TON., s AA 1'40044 Certificate of Occupanc ,/ Signature: FeeType: Date Pai : Amount: Building 6/23/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo