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31A-316 (9) SEP -5 -2012 09:42A FROM :METRAS INS AGENCY 4135328522 TO: 5388753 P. 2'13 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYY) 09/05/2012 PRODUCER (413) 536 -1491 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Metras Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 2030 Memorial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chicopee MA 01020- INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A Travelers Olde Hadleigh Hearth & Home Center, Inc. INSURER B: 119 Willimansett St. INSURER C: _INSURER D' S outh Hadley MA 01075- 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, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER P D A TE ( PDATE CY (MMP DIYY) LI R DD'L LIMITS LT A GENERALLIABIUTY 16607910A718 08/30/2012 08/30/0201 EACH OCCURRENCE 0 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100 000 PREMISES (cooccurrence) a r 1 CLAIMS MADE © OCCUR / / / / MED EXP (Any one person) • 5,000 — PERSONAL &AOVINJURV i 1,000,000 / / / / GENERAL AGGREGATE 0 2,000,000 — . GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG - 9 2,000,000 7 POLICY n E1 LOC / / / / A AUTOMOBILE UABILITY BA2055C668 11/01/2011 11/01/2012 COMBINED SINGLE LIMIT _ ANY AUTO (Ea accident) 0 1, 000,000 ALL OWNED AUTOS / / / / BODILY INJURY X SCHEDULED AUTOS (Per person) 0 — HIRED AUTOS / / / / BODILY INJURY _ (Per accident) i NON -OWNED AUTOS -- PROPERTY / / / PROPERTY DAMAGE a (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ — ANY AUTO / / / / OTHER THAN EA ACC 6 — AUTO ONLY: AGG 0 A EXCESS/UMBRELLALIABILITY 2649Y614 08/30/2012 08/30/2013 EACH OCCURRENCE i 1,000,000 OCCUR n CLAIMS MADE AGGREGATE a 1,000,000 0 R DEDUCTIBLE / / / / ! i — RETENTION 510,000 a — A WORKERS COMPENSATION AND IEUB519712181 07/12/2012 07/12/2013 rAnklY0 FR EMPLOYERS UABILIIY ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT 0 100, 000 OFFICER/MEMBEREXCLUDED9 / / / / EL DISEASE - EA EMPLOYEE 0 100,000 If yes, describe under SPECIAL PROVISIONS below E L DISEASE - POLICY LIMIT a 500,000 OTHER / / / / / / / / / / i 1 / DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLE9 /EXCLUSION$ ADDED BY ENDORSEMENT /SPECIAL PROVISIONS CERTIFICATE HOLDER _ CANCELLATION ( ) - ( ) - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAR. DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT Jeff Green FAILURE TO DO 80 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 45 Ward Avenue INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE f3ruc&P T . e' Northampton MA 01060- {�[� ACORD 26(2001/08) C ACORD CORPORATION 1888 Pape or2 INS026 (0106).06 MA Construction Supervisor #CS'09989 / MA HIC #148198 / CT HIC,556609 Olde Hadleigh • Hearth & Home Center inc. 119 WIIlimansett Street, So'uth•Hadley, M • 01075 Tel (413) 538.9845, FAX (413) 538.8753 WOOD STOVE INSTALLATION CHECKLIST Permit A b u l l d i n g perm) t I s requI red for the I' s t a l t a t liOn of any sol I d fuel burning appl lance. The bur ld1ng permit and In ta11atIon inspection Are 11mited to the stove Instal.l'atIon and hot Co the .strive construction, Stove ,,,' A) Typc /radiant cir uleting 8) Nanuf•actur.er 'test label I ,, (after July 'T, 1979 only) Name /Model No, Col lar size Dimensions /HeIght Lenth Width - -,- . Chimney . A) New Exl'st Ing _ , 8) Size (flue area) C) Other appliances at tached to flue Dumber and f lue sIze)_ 0) Metal (Manufacturer —name and type) , E) Masonry /LIned Unlined • F ue IIner (type L nlnnufacturer) r) Heioht (refer to dIAgrams) cap f ,i N o.r log I 1L . j 1114 l'." . 4 . ... A , • , 1 .„://, . , / I �.l V ,...,. ^ I►�, r. IIEARTH CHIMNEY HE I'GHT Hearthemin, I hr, fire resistance) A) Materials e) Sub floor • cons.tructInn C). Minimum dlmenslorls (refer to diagram' Clearances and Wall• •Protection( stove Ins tnl'1At'Ion clearances chart) A) Type of wa 1 1 prot•ect1on'.pr..ovIded, 8) Clearances (refer to diagrams) I , l —,X, . o I . 1 . ,; . L . FIREPLACE CORNER WALL /CENTER • The Commonwealth of Massachusetts 1 nun n n r u r n i ��'t� 1 _ , $ _ Department of Industrial Accidents i z� � i Office of Investigations , 1 Congress Street, Suite 100 .' • -;; Boston, MA 02114 -2017 y y yr" www.mass.go /dia Workers' Compensation Insurance Affidavit: Bu lders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Olde Hadleigh Hearth & ome Center, Inc. Address :119 Willimansett Street City /State /Zip: South Hadley, MA 01075 Phone #:413/538 -9845 Are you an employer? Check the appropriate box: Type of project (required): 1. fil I am a employer with 8 4. n I am a general contractor and I employees (full and /or part- time).* have hired the sub - contractors 6. n New construction 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. ❑ 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 3.0 I am a homeowner doing all work officers have exe their 11.111 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), one we have no Install wood stove employees. [No workers' 13. Other comp. insurance -equired.] *Any applicant that checks box #1 must also fill out the section below showing their w rkers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then h' a outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name o the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' mp, policy number. I am an employer that is providing workers' compensation insuranc for my employees. Below is the policy and job site information. Insurance Company Name :Travelers Insurance Home Improvem nt Contractor's Liscense #148198 Policy # or Self -ins. Lic. #: Expiration Expiration Date: 7/12/2013 Job Site Address: « !7/�id &t'7 '' e Cit /State /Zip: ./l 1, !r/I T / 1 /W - 7 ! // ) fv 0 Attach a copy of the workers' compensation policy declaration p.ge (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 52 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 $250.00 a day against the violator. Be advised that a copy o this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certij under the , ains and I enalties o i er'u that the ' formation provided above is true and correct. Signature. • —__. -- -_ -_ Aria— ' Date 8/10/2012 Phone # : 538 -9845 CS SL #9878 _____ Official use only. Do not write in this area, to be completed by c or town official City or Town: Perm' /License # Issuing Authority (circle one): 1 Board of Health 2. Building Department 3. City/Town Cle I 4. Electrical Inspector 5. Plumbing Inspector 6 Other Contact Person: Phone #: _ SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / (4t- Not AApplicaable ❑ Name of License Holder : /0////[ d L 7 /-4.0/4y Si ` Fe, 4/4y /A License Num Addre Expiration Date Signs re Telephone 9. R istered Home Improvement Contractor: Not Applicable ❑ ad,! /kik 7$',9 4/ e dn/-7, 42(7. / w97 Company Name Registratio Nu ber //9 /r;27,7 '..fe#J73. 9 /3 1_3 Ad ess �yj� �/ ®�/ /� t /` Expira on D e ` pi## 4 ` 7 i /W em 7 Telephone 7�� ,�37 - 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 yt 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 an. - . oning 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 ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [p] Other Brief Description of Proposed -r- /.agr / ��► I Work: L// 5 �l � wile of .5 le 1 �z /121/�'P \/ o I ��l( ✓� - Y Alteration of existing bedroom Yes 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 Bathroo • 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 -tlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cel • 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, , as Owner of the subject property / /4 -,L hereby authorize 0! de // r/ / ///e to act on my behalf, in all matters relative to vb6rk authorized by this building permit application. Signature of Owner Date 1, J e t �R , as Owner /Authorized Agent hereby declare thal 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. c-rre G -r- e " 1 Print Name 9 / 3 - ?1 1 2 Sig f Owner/Agent D e Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied b e 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: 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 O DON'T KNOW 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O 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 O 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 0 NO O 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 O NO O I F YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only _ GENE City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit SEP 7 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability DEPT. OF WILDING fN$pECr10Nb Northampton, MA 01060 Two Sets of Structural Plans NoRmAMPT MA° a 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify % f1'11r0'kve 4- /me?' APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office y /44/7/ diftwwe Map Lot Unit A / 1 � » f , ,1 - 61/' Zone Overlay District �(� 7/ �� EIm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 6;?e,i «, < / rc /91/'ia /2 /( Name (Print) Current Mail A res �t #' s: - /9 Telephone Signature 2.2 Authorized Agent: w Jed- Gr-ee Name (P% Current Mailing Address: Si / Telephone S CTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Budding Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) ( 4 2-$(oi . DD Check Number 416( This Section For Official Use Only Permit Numbe • Date Building Issued: 9 - / 7\ Signature: / / / Building Commissioner /Inspector of Buildings Date 45 WARD AVE BP-2013-0301 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 316 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit # BP- 2013 -0301 Project # JS- 2013- 000492 Est. Cost: $2861.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784 Lot Size(sq. ft.): 15115.32 Owner: GREEN JEFFREY Zoning: URA(100)/ Applicant: GREEN JEFFREY AT: 45 WARD AVE Applicant Address: Phone: Insurance: 45 WARD AVE (413) 401 -5522 0 WC NORTHAMPTONMA01060 ISSUED ON: 9/17/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL JOTUL BLACK BEAR WOODSTOVE & LINER 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 9/17/2012 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck— Building Commissioner