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22B-047 JONES -1 OP ID: JR A L,_i IEr CERTIFICATE OF LIABILITY INSURANCE I DATE 07 /27 DiYYYY} 07127!12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CON 413 - 737 -5359 NAME: J Raymond Lussier Ins Agcy Inc PHONE FAX 181 Park Avenue, Suite 8 413 - 732 -2027 (NC. No Ext): (PJC. No): PO Box 499 E -MAIL West Springfield, MA 01090 -0499 ADDRESS: J Raymond Lussier Ins Agcy Inc INSURER(S) AFFORDING COVERAGE NAIC # INSURER A Travelers 39357 INSURED Robbin D. Jones INSURER B: 21 Deveau St Springfield, MA 01151 INSURER C: INSURER D : — INSURER E : SURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS • LTR !Hsi; IV wvn POLICY NUMBER (MMIDDIYYYY) (MMIDYYVY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 6804834B154TCT11 11/10/11 11/10/12 PREM PREMISES (Ea E occurrence) $ 300,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,00C _ PERSONAL & ADV INJURY _ $ 1,000,000 GENERAL AGGREGATE $ 2,000,00C GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,00C — 1 POLICY ' PRO- I LOC - $ ,1R AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) _ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY D • MAGE $ HIRED AUTOS _ AUTOS (Per accident) _ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ _ DED RETENTION $ _ $ WORKERS COMPENSATION WC STATU- 1 10TH- AND EMPLOYERS' LIABILITY YIN TORY LIMITS I ER ANY PROPRIETOR /PARTNER/EXECUTIVE n E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CARPENTRY CONTRACTOR JOB SITE: 2 FLORENCE RD, NORTHAMPTON, MA FOR ATIS TASNEEM CERTIFICATE HOLDER CANCELLATION WELLSFA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE WELLS FARGO HOME MORTGAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 171 PARK AVE WEST SPRINGFIELD, MA 01089 AUTHORIZED REPRESENTATIVE ' I {• © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Office*Silmer Biiiiefregu 11 HOME IMPROVEMENT CONTRACTOR !InTilep- Registration: 123245 Type: Expiration: 1/13/2013 DBA Rsai IN D. JONES HOIVIE IMPROVEMENT ROBBIN JONES DEVEAU STREET INDIAN ORCHARD, MA 01151 Undersecretary "I '111215 3 ( 1,11s tt tik non ',two ■ :en se CS-066433 ROBBIN D JONES 21 DEVEAU ST INDIAN ORCHARD MA 01151 12/11/2013 The Commonwealth of Massachusetts Print Form Department of Industrial Accidents . 1 1 , s-. Office of Investigations ,� 1 Congress Street, Suite 100 Boston, MA 02114 -2017 's www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organizati on/Individual): Robbin D. Jones Address:21 deveau Street City /State /Zip: Indian Orchard, Ma 01151 Phone #:413- 575 -3479 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 1 employees (full and /or part- time).* have hired the sub - contractors 6. ❑ New construction 2. 0 1 am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling ship and have no employees These sub - contractors have 8. n Demolition working ca employees and have workers' g for me in any capacity. y 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10. 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 12.0 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. 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: City /State /Zip: 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 un r the ains a ° I p • alties of perjury that the information provided above is true and correct. Signature: I l Date:1111MMANIIIIII Phone #: "I/ 3 '' 59 s 3 7 / 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su erv Not Applicable ❑ Name of License Holder : (C � ) ✓ \ J . s License Number 5 12d • t'-� �- 0 11,5 I 006 Address/ Expiration Date 411K . Z1/3 3q 7 ` /fill 3 Si. ature Telephone 41, 9. Registered Home Improvement Contractor: Not Applicable ❑ Com an a Registration Number 1 066,1 ` b■ J as a 3 2 , �s Address �„ Expiration Date j 1� S 1— O I S Telephone '/r3 J`�7S ^3`/) 1 /13/13 — 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 [E] Siding [0] Other [0] Brief Description of Proposed , RQ fkiCC 'A4 1-616 (tit \S) Reeks -'C (v Wf/!c, (15,, replace .k ( i ct tt'•�`ryl . „ Work: Replace hand railings on front porch, replace 6 wind on 2nd floor and repair 3 broken panes in basment. Replace missing trim in rooms and replace broken ceiling fan and baseboard heater in bathroom. f-- y Alteration of existing bedroom Yes X No Adding new bedroom Yes X No FY' 4 ds�� Attached Narrative Renovating unfinished basement Yes X _No Plans Attached Roll - Sheet 4 « -41 h 4e a- 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 /9 r/ ?4" S/v4 ti711 , 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 ( / g/ 1 , CR 1 ..j itQ 5' , 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. - 1 - Print Name /6 f/ 2 Signa re of 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 0.26acre Frontage Setbacks Front Side L: R: L: R: Rear Building Height 20 Bldg. Square Footage 2093 Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces 4 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 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 0 YES 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 ® 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 ® 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 O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. _ Department use only REC rt City of Northampton Status of Permit: _ Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability OCT 1 8 a 12 Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans DEPT 4tNG SPEC ne 13- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans ON MA ()Iwo 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 rLO� Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Atif Tanseem 2 Florence Road Name (Print) Current Mailing Address: 2 Florence Road Telephone Signature 2.2 Authorized Agent: Robbin . , ones Robbin D. Jones Name (P Current Mailing Address: Robbin D. Jones Sig -ture Telephone SECTION 3 - ESTIM D CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 2500 (a) Building Permit Fee 2. Electrical 75 (b) Estimated Total Cost of Construction from (6) 3. Plumbing 250 Building Permit Fee 4. Mechanical (HVAC) 0 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 2825 Check Number / 3 y $35 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0466 APPLICANT /CONTACT PERSON ROBBIN D JONES ADDRESS/PHONE 21 DEVEAU ST INDIAN ORCHARD (413) 575 -3479 PROPERTY LOCATION 2 FLORENCE RD MAP 22B PARCEL 047 001 ZONE NB(100)/WP(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out x �' Fee Paid /✓� $36" Tvpeof Construction: REPLACE FRONT HANDRAILS & 6 WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 066433 3 sets of Plans / Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I F ATION PRESENTED: Approved 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 ;U - /7 Si je of Building a ffic '1 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. 2 FLORENCE RD BP-2013-0466 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22B - 047 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit # BP- 2013 -0466 Project # JS- 2013- 000746 Est. Cost: $2825.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBBIN D JONES 066433 Lot Size(sq. ft.): 11107.80 Owner: TANSEEM ATIF Zoning: NB(100)/WP(100)/WSP(100)/ Applicant: ROBBIN D JONES AT: 2 FLORENCE RD Applicant Address: Phone: Insurance: 21 DEVEAU ST (413) 575 - 3479 INDIAN ORCHARDMA01151 ISSUED ON:10/23/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE FRONT HANDRAILS & 6 WINDOWS 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 VIOOLATION OF ANY OF ITS RULES AND REGULATIONS. 1 Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/23/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner