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32A-115 (2) The Commonwealth of Massachusetts Department of Industrial Accidents 5 Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information N (' ( (� Please Print Legibly N Name ( Business /or , J f s �ihL Address: 7 C. l ✓ C icA 1 �, /A City /State /Zip: (9.°s .4 ( DI UI 0 \ 6 5 Phone #: L/ ( 'CU} - (o 3 Are you an employer? Check the appropriate box: Type of project (required): 1p I am a employer with 4. 0 I am a general contractor and 1 employees (full and /or part-time).* have hired the sub - contractors 6. 0 New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' g Y p ty 9. 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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 12.0 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 #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. tContractors 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: "�✓'t' i 5 t �r^( V V Policy # or Self -ins. Lic. #: 7/ H f` b Expiration Date: Job Site Address: g9 I" lu!k - f S v Cit /State /Zip: NA T\ 61 . 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 certify and th ins and penalties of perjuty that the information provided above is true and correct. Signature: r Date: 1 5 / 0 t~ • Phone #: > 3 C 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 #: &O\,tt the Co Fully ,Li,used and Insured n Petitio n r 7 Philip Cir Granby, MA 01033 M Reg " #:20 - 2015718 Phone: 413-563-6354 MA Lic #: 147961 specializing in Roofing Fax #: 467 -9748 MA CSL #: 99565 NICHOLAS BERNIER Authorized GAF/ELK Roofing Contractors (Owner) ®..®�::- www.n- bexteriors.com EXTERIOR HOME IMPROVEMENTS, Inc. www.nrbexteriors.com ROOFING & SEAMLESS GUTTERS Windows - Siding - Decks Residential - Commercial Proposal submitted to Phone# h: c: Special requirements Street City,state,zipcode Proposal to furnish and install the following ❑ Re -roof ❑ Tear -off ❑ Gutters Complete Roof Preparation ❑ Home exterior to be protected by tarps and plywood • Shrubs, landscaping, trees to be protected, roofers buggy used ❑ Entire existing roofing material to be removed to existing decking, including flashing, ect • Site to be cleaned on a daily basis with roll magnet, debris to be removed at project completion by dumpster ❑ Deteriorated existing decking to be replaced at $50.00 per sheet of plywood O New flashing installed where necessary • Install new pipe flashing to waste vent stacks Complete roofmg system O Install ice & water barrier along bottom 3ft of all roofs O Install ice & water barrier around penetration, in valley's, and all critical areas ❑ Install 151b reinforced saturated felt paper to entire decking ❑ Install breathable synthetic deck protection to entire decking O Install 8" perimeter flashing to all edges of all roofs 0 white ❑ brown ❑ Install pre cut starter shingle to bottom and rake edges of all roofs ❑ Install GAF Prestigue High Def Shingles to manufactures specs ❑ using six nails ❑ using four nails ❑ Install Cobra snow country ridged pvc ridge vent to all peaks in heated areas ❑ Install GAF ridge caps to hips and over ridge vent O Install new lead counter flashing to chimney Warranty options O We guarantee our labor for 15 years GOOD ❑ GAF -ELK 10 yr smart choice roofing system warranty for 100.00 BETTER 00 Upgrade GAF -ELK 15 yr weather stopper roofinsystem plus warranty for 200.00 BEST ❑ GAF -ELK Prestigue High Definition — color: 0 30 year ❑ 50 year Acceptance of Proposal: The above prices, specifications, and conditions are satisfactory and hereby accepted. Payment will be ''A down upon signing and balance due upon completion. Total sale price: down payment: upon completion: Customer signature: date: phone #: Authorized signature: date: ACORD CERTIFICATE OF LIABILITY INSURANCE " " "'" '°LOY " M ( 06/19/2010 PRODUCER ' 413'. 536.0751; FAX 413.536.9182 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Chaffee Hell iwel1 Ins. Agcy. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 17 Coll ege Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Hadley, MA 01075 —___, ! INSURERS AFFORDING COVERAGE NAIC # N R B Exteriors Inc. i INSURED INSURER S. H. Smith & Co, , Inc. 7 Philip Circle INSURER Travelers Insurance Company Granby, MA 01033 INSURER C American Zurich Ins. Co. INSURERD Connecticut Underwriters 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 T HE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGOREGAI E LIMI 1 S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1R S 1 - POLICY EFFECTIVE POLICY — - - LT IN SR INSR TYPE OF INSURANCE i POLICY NUMBER (DATE (MMlOD/YYYY) 1 DATE E (MM /DD/YYYY) ' LIMITS GENERAL LIABILITY ' WS053135' 11/03/2009 1 11/03/2010 FACHOCCURRENCE +$ 1,000,000 DAMAGE TO RENTED X ; COMMERCIAL GENERAL LIABI!_ITY + PREMISES (Ea occurrence) $ 50,000 CI AIMS MADE ' X OCCUR { . MFD EXP (Any one person) $ A X ' Subject to PERSONAL & ADV INJURY $ 1,000,000 $500.00 deductible I ! , GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE 1 ow' APPI IFS PER ! I PRODUCTS - COMP /OP AGG $ 2,000,000 : 1 " ICY P R O LOG a AUTOMOBILE LIABILITY BA6953N101'i 06/23/2010 06/23/2011 COMBINED SINGLE t !MIT $ AN n;rl0 (t accident) Ala OWN! 0AUIOS P0011 Y INJURY $ B X sk',i,? Dot 1 All 1 OS - Wet person) 100,000 X 1{)R! 1)AUiOS BOD11 Y INJURY X (Per accident) + $ NON OWNf D AU i05 300.00 - ! I PROPERTY DAMAGE $ (Per accident) 100,000 GARAGE LIABILITY ! { AU O ONLY - EA ACCIDENT ; $ ANY AUTO S EA ACC i $ 1 OTHER THAN _._ AUTO ONLY AGG I $ I EXCESS 1 UMBRELLA LIABILITY 1 I EACH OCCURRENCE + $ OCCUR CLAIMS MADE i AGGREGATE I $ ' !)t l)UCIIBLI i $ R( IL N I ION $ ! $ , WORKERS OOMP 6ZZUB-0347N31 -1 -10I 01/30/2010 01/30/2011 TORYLIM1TSj 01 P ANY PROPRI! I ORIPAR I NER/LXICUI NE Y - -- P FOLLOW DIRECTLY FROM] ! E 1 EACH ACCIDENT $ OFFICER/Mt.WEIR L XCI UDED "� 1 -" _- - "-- - " —' - C �' (Mandatory in NH) THE COMPANY) I C Ell L DISEASE - EMPLOYEE i $ I if yes descr be .:nder SPECIAL. PROVISIONS below F 1 DISEASE - POLICY l IMII + $ I_ now Plowing Liability MAX0124000037161 11/13/2009 1 11/13/2010 2,000,000 General Aggregate D ' 1,000,000 Each Occurrence I 1 Subject to $500.00 Deductible DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS Siding, Window Installation, Roofing and Carpentry Snow Plowing 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 DO SO SHALL Pioneer Contractors Inc . IMPOSE NO OBLIGATION OR L OF ANY KIND UPON THE INSURER, ITS AGENTS OR P.O. BOX 1145 RESENTATIVES. Northampton , MA 01060 O ED REPRES TAT ACORD 25 (2009/01) FAX: 413. 527. 5099 ©1988- 009 tl • D CORPOR TIO . All ri is eserved. The ACORD name and logo are registered marks of AC rT s • • r \lassachusett, - i)cpartmcnt of Public �afct� I Board of Buildim.) Rt::;ulatinns anti standard License: CS SL 99565 Restricted to RF,WS NICHOLAS BERNIER x` 7 PHILIP CIRCLE GRANBY, MA 01033 Expiration: 5/28/2012 Tr-: 99565 tivte -60/inzino 4 ,nuui•�" Office of Consumer Affairs an B usiness Regulation • =__ 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 147961 Type: Private Corporation Expiration: 8/23/2011 Tr# 287520 NRB EXTERIORS INC NICHOLAS BERNIER 7 PHILIP CIRCLE -- ------ - - - -__ GRANBY, MA 01033 -_ -_- Update Address and return card. Mark reason for change. DPS -CA1 0 50M-04/04- 0101216 C Address El Renewal ❑ Employment r1 Lost Card ✓fte jno'in'no7ta+ea - o/,,/lgaddacftu6e1i Office of Consumer Affairs & Business Regulation License or registration valid for individul use only expiration date. If found return to: before the ex WO HOME NOME IMPROVEMENT CONTRACTOR P e `tn ' ` � Office of Consumer Affairs and Business Regulation _ Expiration: 8!23! 3/147961 20111 1 pi ration• Registration: Tilt 287520 10 Park Plaza -Suite 5170 Boston, MA 02116 Type: Private Corporation NRB EXTERIORS INC NICHOLAS BERNIER 7 PHILIL CIRCLE GRANBY, MA 01033 Undersecretary Not valid without signature SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 1 ° s L ‘ ` Sc2D Z f 7 License Number Ad pti � ," tA — �� ') dress J Expiration Date � C ( f ` ) -- 5 4 3 - ) Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ r 1�� Q�� V�� � � L t � `� Company Name Registration Number Address Expiration Date Telephone ! T (Li-Of 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 ❑ 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) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [0] Other [0] Brief Description of Proposed r • 11 Work: 6 -t. tr^ J v e ��� S 1 jr L "� v)., I ( �'v {1,J Ct N. ? • (_e Sc Alteration of existing bedroom Yes e ' _ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes ?" 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? N P 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 ii /Aa ',� ■ /4 : j _ z■Il eA A ri G { " as Owner of the subject property i hereby authorize ' /� " g'J 'CY �> J "�S _-fLti l to act on my behalf, in all matters relative to work authorized by this building permit application. ,'"" Signature of Owner Date I, I to 5 \ ^ , ✓ "'t- {1 U ✓S , 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 Print Name Signa ure of Owner /Agent Date ti 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 DON'T KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW 0 YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ® YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 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 0 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 City of Northampton Status of Permit: Bu Department Curb Cut/Driveway Permit • 212 Main Street Sewer /Septic Availability `O�0 Room 100 Water/Well Availability n ; � N MA 01060 Two Sets of Structural Plans phon 413 -S67 -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 (C^ ) J, k S Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) pp ` _ Current Mailing Address: SRC c1kc l C T Teephone 1 0' Signature 2.2 Authorized Agent: Name (Print) z e Curre Mailing Ad ess: Si ature 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 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection _ A #35 6. Total= (1 +2 +3 +4 +5) t]U "- L) Check Number p _ This Section For Official Use Only Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date BP- 2011 -0138 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block :. 32A' 15 4 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- 2011 -0138 Project # JS- 2011- 000232 Est. Cost: $8800.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: NRB EXTERIORS INC 99565 Lot Size(sq. ft.): 6403.32 Owner: FEDERMAN PAUL Zoning: URC(100)/ Applicant: NRB EXTERIORS INC AT: 84 MARKET ST Applicant Address: Phone: Insurance: 7 PHILIP CIRCLE (413) 563 -6354 WC GRANBYMA01033 ISSUED ON:8/19/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP,PLY & SHINGL 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 8/19/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner ''AGNOLI SIGN COMPANY;' INC.' `• 722 WORTHINGTON.I STREET, '5PG RINfIELD, MA 011().5 0 TEL. (413) 732--5111 u FJ\X ( 41 3 ) 7£37 -2169 �s r ,� : � +e �� z . mr '' - i',1 P ',. ' em u , {o''T` it � rs z ab � • ce ' v ,�. .: � � � € � P R� 'i � �` z't � d�k� y ;��3: �� ?.;a, � � ., - - C t o � e-" '' 4 'ta �* i ce . SCIENCE & ? A ` { LEARNING - �� P _ ,. _ . . .., a ... t , _ P R t .. I 3 , •4.. i, tZ 1 2' • { ,a4i', ,i g 4' X ICI DOUBLE FACE INTERNALLY ILLUMINATED CABINET PAINTED BLUE. I LETTERED WITH PRINTED AND CUT VINYL GRAPHICS. INSTALLED ON A 6" DIA. STEEL POLE PAINTED TO MATCH CABINET. BOLIAPDS INSTALLED TO PROTECT SIGN FROM TRAFFIC. SCALE: ' /. " =1' -0 rP, �•• .-v R F, 3 S £ Iw. , us , CUSTOMER: LOCATION: CONTACT: JACK FINN DRAWING CODE: ORIG. 10 -26 -09 REV. 0 -0-08 SCALE 1/2 1' -0" A2Z SCIENCE AND LEARNING STORE A2Z SCIENCE AND LEARNING STORE SALESPERSON P.SURRERIA X: /CDR /A 2_Z.CDR DRAWN BY: DRAWN BY: THIS otd l IS THE eixu nt rcwwtt OF 57 KING STREET 57 KING STREET DRAWN ELY K,BRICK — REV. 0 -0 -08 REV. 0 -0 -08 AGNaL:aN ,E wr °' NCGNP: RY RAl nnn �u ® RKMi3 NORTHAMPTON, MA 01060 NORTHAMPTON, MA 01060 DRAWN B. DRAWN BY � ' �� n MRSER�