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35-258 (2) CERTIFICATE OF INSURANCE REQUEST TO: Finck & Perras Insurance Agency, Inc. PHONE: (413) 527 -3000 ATTN: Rebecca J. Kubosiak, CSR FAX: (413) 527 -5970 DATE: 6// //e COMPANY: Robert H. Dunn Jr. Construction Services, Inc./ PHONE NUMBER: (413)527 -2953 FAX NUMBER: ************************ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * ** Certificate Holder (Recipient): C% �� ���77 - / j° Attention: 734 c- ,0/.? n Sit) Address: Sir Address: AVe) ,-- Tf/f}fr1l77'1 in , 9 - 1/e c,C> City, State, Zip: Certificate is: URGENT " SAME DAY NEXT DAY Please Fax Certificate to (Enter Fax #): 4 /43 58 / ? ❑ Please Name the Holder as Additional Insured ❑ Please Name the Following as Additional Insured: ❑ Please Reference the Following Job: `T — ❑ Additional Description (If Any ): Pies . o . that the original certifica 1 be sent to the certificate holder even when faxed. Also a copy will be sent to you and th. insurance cony. - X A et- /Printed Name: n T ° ci o o - • _ a e of Person Requesti , , ertificate :- 1la..aciu .etts - Department of POOlit_ !Nafit. 1111P Bard of Builtlin�t Rc 2ul ttion..tnti St:ttttlartls - .rte• str -4ct cn Si,,D . ,...: r ..enSe License: CS 85846 Restricted to: 00 ROBERT H DUNN JR tf` 43 BURT RD A WESTHAMPTON, MA 01027 40 41 . "'",;',: �—e--- �`. c Expiration: 3/5/2011 ( , nnmi. sinner Tr •: 13540 am/ - - -- - -- - __...- --- - --- -- - - _____— s � ✓Ae - 6;mmoJuvea /( o /,- GG 1/ asiae% e,16. Office of Consumer Affairs & Business Regulation License or registration valid for individul use only k , si before the expiration date. If found return to: y HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation 1� g Registration: Expiration: 6/6/2011 133318 Tr# 700220 10 Park Plaza - Suite 5170 Boston, MA 02116 Type: Individual ROBERT H. DUNN, JR. ROBERT DUNN JR.' 43 BURT RD. 10 WESTHAMPTON, MA 01027 Undersecretary Not valid 6666✓✓✓✓ ut signature The Commonwealth of Massachusetts � _ --- Department of Industrial Accidents > E " 4 % Office of Investigations 600 Washington Street � � � = Boston, MA 02111 4 _•,,,,} www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business / Organization /Individual) ) , tT /- 1 • �� , \ r r S-Try CT / 6)1 ('. circi_ire- S� _4-- i'' 4-_. Address: 4/3 &csal p,p City /State /Zip: LUeS }I3-rn prni a) f Phone #: 4 (3 ac 7 q 3 6 Are you an employer? Check the appropriate box: Type of project (required): T am a employer with N) 4. 0 I am a general contractor and I ❑ employees (full and/or part- time).* have hired the sub - contractors 6. New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7)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 h 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. 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. . Insurance Company Name: iq C4 Oi A ) c a S v v t4-14 C 6 Policy # or Self -ins. Lic. #: WG- 20--2o -o6 73 L{ ` 00 Expiration Date: 10) g / 2 010 Job Site Address: I 1 -rem )1 121/ City /State /Zip: Th ft V) t0 i yn 1 Attach a copy of the workers' comp sation policy declaration page (showing the policy number and expiration date). 011.PO 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 Investi t . • t - ' the DIA for insurance coverage verification. 1 o hereby cert' under the pains a p nalties of perjury that the information provided above is true and correct. 4 ture: - a-1 ( Date: (J 1 kti f'0 Phone #: '-1 13 2 7 `i 3 Official u ' only. Do no 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 ❑ Name of License Holder : v 19 _,7 i-1 b , h J T , is ?.?-7 4-,--) f License Number � a 24-- 2. io we',5 ft MA 157 i r • . ress ExpiratDa - - ec. L. 4 7(3 S. • atur• Telephone 9. Registered Home Im ement Contractor: Not Applicable ❑ ..---- r � a Cr /-1- , r b c w - n C d s r . ucii co St; rJle....e s , / -3" --33i F Company Name Registration umber - car T �- �).�S'i� � e-z�7 Al A &" IC, 2n ( I ( Addr s 7 Expirati n D e t' [QCZV 2--- Telephone L ((3 237' c SECTION 20- WORKERS' C ,) SATION 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 buil ing 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 ❑ Replacem Bows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [0] Other [0] Brief Description of Proposed Work: ? Cla277 L-''/ e-p /A-C c.- R A'Sm i-,r CX�� 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 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 1, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, Ob c� /-) . C 0,4 n , 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. (,,, d under the pains and enalties of perjury. o €6'22- / . v► Pr' ame I / . .�L�` G '�L, / /0 ■ Signa e o 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 Sp- ial Permit /Variance /Finding ever been issued for /on the site? NO el DONT KNOW 0 YES IF YES, • ate issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 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 O NO dQ 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, ex vation, 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: ^ r-S Building Department Curb Cut/Driveway Permit, 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability JUN 1 6 2010 Northampton, MA 01060 Two Sets of Structural Plans phone 413 -t87 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify s APPLOtibii.'f'(_CIINSLRUCT, 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 9/ 4 i< �� ' / /� r � Map Lot Unit / Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Dr. Timothy Parsons 91 Turkey Hill Rd. Northampton MA 01060 Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: /�, / ° v n r► J � >��2 p `3 iri -i'1 /O'er i i/ - / t) Current Mailing Address: ✓ O /0 Z 7 -,4 /2 — • X13) 3 7 Si. r . ur• Tele hone SEC ON 3 - ESTI TED ONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 2-0 7? S-2_ (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 y�` 6. Total = (1 + 2 + 3 + 4 + 5) -1 070. -2" Check Number 7 of ;Le, This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date : a # BP- 2010 -1154 GIS #: COMMONWEALTH OF MASSACHUSETTS ' i kf 35 - 258 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- 2010 -1154 Project # JS- 2010- 001690 Est. Cost: $2070.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT H DUNN Lot Size(sq. ft.): 79714.80 Owner: PARSONS TIMOTHY V Zoning: RR(100) //WP Applicant: ROBERT H DUNN AT: 91 TURKEY HILL RD Applicant Address: Phone: Insurance: 43 BURT RD (413) 527 -2953 W ESTHAMPTONMA01027 ISSUED ON ::6/17/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE FRONT & BASEMENT DOOR 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 6/17/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo