32A-238 ISSUING COMPANY �/��
I ACE PROPERTY &CASUALTY INSURANCE Workers' Compensation
2254ARRIERCODE and Employers Liability
Insurance Policy
_ Information Page
POLICY NUMBER New X Renewal Rewrite
Symbol: NWC Number:C4 63 88 21 5
PREVIOUS POLICY NO. X Individual Partnership
Symbol: NWC Number: C45823337 Corporation
Item 1.
WILLIAM J MITCHELL Inter /Intrastate ID No.:
Named 72 TEAWADDLE HILL ROAD
Insured LEVERETT MA 01054 Federal Employer ID No.: 042809179
Mailing
Address
L_ Employer's ID No.:
PIIC CODE:89999
For other named insured see Extension of Information Page- Schedule of Named Insured, WC 99 99 99 A
For other workplaces see Extension of Information Page - Schedule of Other Workplaces, WC 99 99 99 B
Item 2. Policy period: From 11 -11 -2010 To 11 -11 -2011 12:01 A.M., standard time at the named insured's mailing address.
Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here:
MA
i• Item 3B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT
ND,OH,WA,WY,
AND STATES DESIGNATED IN ITEM 3.A
Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information
required below is subject to verification and change by audit.
SEE EXTENSION OF INFORMATION PAGE CLASSIFICATIONS
If indicated here, interim adjustments of premium will be made: Minimum Premium collected in MA $ 500.
❑ Semi - Annually adjustments
Quarterly ❑ Monthly Total Estimated Premium $ 8056.
Deposit Premium $
This policy includes these endorsements and schedules:
SEE SCHEDULE OF FORMS AND ENDORSEMENTS WC999999D
PRODUCER NAME AND MAILING ADDRESS
TPA INSURANCE AGENCY INC
10 NEW ENGLAND BUSINESS CENTER
SUITE 303
n Kinn /CD MA 01810
10 Niasswtc busctts - Department of Public Sat'ct's
Board of Duildititt Rct ttlatit nr and Ststntl. °dk '"'' Offieeift ohu the egu a`flo
Construction Supervisor License ., HOME IMPROVEMENT CONTRACTOR
License: CS 6457 7 Registration: . Type:
Restricted to: Op ' � - ' ; 3) Expiration: 7/9/2012 Individual
WILLIAM J MITCHELL WIL J. MITCHELL
72 TEEWADDLE RD
LEVERETT, MA 01054 William Mitchell
72 TEAWADDLE HILL RD. Q � -,A E
LEVERETT, MA 01054 Undersecretary
Expiration: 8/14/2011
t "ouniv ..i.mer Tr#: 916 tl Councl
,NSUREC --
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
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
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 me.
Date
Address of work
location
. ,
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
- www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/IndivirInno: (.),) (( (y&^ I IA I
Address: 72-- et_uvertiA (\( ( -
C i t y / S t a t e / Z i p : Le kin! C- M D () (OS4' Phone.#: “3
Are pu an employer? Check the appropriate box: Type of project (required): 1 "
1.1E1 am a employer with • 0 I am a general contractor and I ,
6. u New construction
have hired the sub-contractors
employees (full an.d/or part-time).*
listed on the attached sheet. 7. 0 Remodeling
2. 0 I am a sole proprietor or partner-
These sub-contractors have
ship and have no. e,...loyees 8. 0 Demolid.on
working for me m any capacity. employees and bave workers 9. EIBuilding additiOn
[No workers' comp. insumince _ comp.insurance
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have4xercised their .
11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL .
12.14(.1coor repairs
insurance reqrthiredi t c. 152, §1(4), and we have no
employees. [No workers' 13 112 / Other (c vt
comp. insurance require-di ‘..E •
*My applicant -that checks box #1 must also fill out the section below showing their wcnicers' compensation policy information.
t Homeowners :who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that chre+ this box must attached an additional sheet showing the nan of the sub-contractors and state whether or not those entities have
employees If the sub-contractors have employees, they must provide their worimrs' comp policy number.
/am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 1-4 c .116) \)e-i 1 6,
•
Policy # or Self-ins. Lic. #: S5 2 5 Expiration Date: - 1 11 1 1 11(
Job Site Address: 17 Po \AP a 0 Art. bter City/StaiziZip: 0 m 01€6°
7 r crki 1. AU11
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under SectiOrf 25A ofMGL c 152 can lead to the in 'position of Criminal penalties of a
fme up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of g STOP WORK-ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of las statement may be forwarded to the Office of
IfifeliiiitiMis - of the DIA for insurance coverage venficaiion.
_ /do Iterebycerti57 under the." 'amities of perjury that the infonnation ,provided_above_is.true_and_correci
Signann \- k) : - Z /
Date
Phone# •
• Official use only. Do not write in this Irea, to be completed by city or townOfficial.
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: I�1 Not Applicable ❑
Name of License Holder : /✓�`\} Gt1 - 1 ' Il �� , ((✓7
License Number
�-- (x. 64)0(0 (e 14 - L,,ektnt'4M
010 � �' I It
Address A IL Expiration Date
Signature Telephone
S. ReclrsteredtHomel ov@IYletit Cariii'icti .,.
a �� s a '......'.,_, Not Applicable ❑
UPS c. � t 775"
Company Name Registration Number
S cl ikv ° cte -7 17 /P..
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.152,i§ 25C(6))
Workers Compensation Insurance affidavi must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the build' g permit.
Signed Affidavit Attached Yes No ❑
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 p Replacement Windows Alteration(s) ❑ Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [0] Other
refst f 4'6C
Brief os
n ofpro ti
Description ) a r
Work: p , - e CP P e- d U 0 f J u r oa ' (z91 . i]� rtd 1' 4- t] � c4 ".a e trt�i's
Alteration of existing bedroom Yes V No Adding new bedroorh Yes / No
Attached Narrative Renovating unfinished basement Yes 4 �No
Plans Attached Roll - Sheet
s l:it iiii home to i tai c iiiifi lititi iq ..h iiiii Eir iai fre t it6Mi :
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 e iv. oLvtAe• , as Owner of the subject
property !
hereby authorize W �! U ( r;( llln tit :11\ C
to act on my behalf, 'n all matters relative to work authorized by this building permi a plication.
-\.._- 5 1 /
Signature of Owner Date
1, k)3‘1 �� (CL-V� / r ( , as Owner /Authorized
Agent hereby declare that he 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.
l 1((a NI OA f1
Print Name
WA Pik 514/
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete In ormatior
Existing Proposed Required by Zon g
This column to be fil d in by y
Building Department libt ;r
Lot Size I 1 ; : _ r ,,.„
Frontage ; I x.
Setbacks Front L
Side L: R: Li R:` ' mm i
Rear a
Building Height
Bldg. Square Footage % [
Open Space Footage %
(Lot area minus bldg &paved 3 ___ .
parking)
# of Parking Spaces I ,
Fill: ,_......n.��..�..... _ _.. , .. ...,. _1 i � ,
� _ 4
(volume & Location) ��
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I p Pagel I and /or Document ft,
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
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 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
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
�& a ,.. '"� ® 9 'f d 0 k 5 ya `t 0-0,11
RECEIVED City of Northampton Y - = ,, ,
Building Department 1� ` „,,,,I.,-,,,, "
212 Main Street - x -
MAY / 3 2011
Room 100 . . =E
Northampton, MA 01060 ; . �, . & ` °= s
DEPT. RT BUILDING INS one 413- 587 -1240 Fax 413- 587 -1272 , x '
NORTWMiPTON MA Ot ', ”'
gy,
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
/ 1 C live ay 1;d'1, Map -Lot Unif.
rI 14 1111 1" 0 (a 6; /d Zone Overlay A�str�ct
A/ O r 0
t Elm StD istrlct° ! CB District
SECTION 2: PROPERTY OWNERSH1P /AUTHORIZED AGENT
2.1 Owner of Record:
e) (ton CO ,nom C o y i v ►.J T t s F -0 r )rr7/1Q/ iPr° j
Name (Print) Current Mailing Address:
{ - . .66 7.> 8
— '
1 Telephone
Signature
2.2 Authorized Anent:
W "( ( j CL/AA. : t ‘ (- ,\ 1 7 TQa - t(Cfe_. t'q - Le_ - 6, 0
Name ( lint) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
0 (� (a) Building ''Permit Fee
1. Building 915-
i
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection #6113
6. Total= (1 +2 +3 +4 +5) j'+ 15 0 e Check Number 71.59
f This Section For Official! Use Only
Date
Building Permit Number: Issued:
''', e, -5.--/ /
Signature: s
Building Commissioner/Inspector of Buildings Date
6 POMEROY TER • BP-2011-0947
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 238 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 -0947
Project # JS- 2011- 001548
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM MITCHELL 000457
Lot Size(sq. ft.): 14287.68 Owner: JAMES BENJAMIN G & OONA M COY
Zoning: SC(3)/URC(97)/ Applicant: WILLIAM MITCHELL
AT: 6 POMEROY TER
Applicant Address: Phone: Insurance:
72 Teewaddle Hill Rd (413) 548 -9526 Workers Compensation
AM H E RSTMA01002 -9805 ISSUED ON: 5 /17/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAI R POSTS & REPLACE 2 PORCH ROOFS
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 5/17/2011 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner