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38B-176 VDAC TRAVELER WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (7PJUB- 0545N1 3 -1 -1 2 ) RENEWAL OF (7PJUB- 0545N13 -1 -11) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 1. NCCI CO CODE: 13579 INSURED: PRODUCER: DELONG CONSTRUCTION LLC WHALEN INS AGCY 76 BANCROFT ROAD 71 KING STREET NORTHAMPTON MA 01060 P 0 BOX 478 NORTHAMPTON MA 01060 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 05 -26 -1 2 to 05-26-13 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA 0 B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1000000 Each Accident INIMONEM Bodily Injury by Disease: $ 1000000 Policy Limit Bodily Injury by Disease: $ 1000000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A 0 D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 0 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY . DATE OF ISSUE: 05 -07 -12 WC ST ASSIGN: MA OFFICE: DIRECT ASSIGNMENT 701 PRODUCER: WHALEN INS AGCY 28LKF City of Northampton . Massachusetts / - ' ',t cz ii's,.. `�, DEPARTMENT OF BUILDING INSPECTIONS `: ,k `, 2 12 Main Street • Municipal Building y "b' } + Northampton, MA 01060 36; INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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 11114 ' 600 Washington Street _ # • Boston, MA 02111 www.massgov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly 4 , Name (Business /Organization/Individual): 7) Cc 444- A.S-fiwc 4 i, e C ( Address: 7 G. 734 Aftw lc ,, . City /State /Zip: o2 rrra -v • 0/3,6 Phone #: K03 Se7r y 37 Are you an employer? Check the appropriate box: Type of project (required): 1.Z I am a employer with 4. n I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. El New construction 2. ❑ I am a sole proprietor or partner listed on the attached sheet. 7. El Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition g for me in any capacity. employees and have workers' working Y P Y 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. n We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.n Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.© Other 7oaz keac4 6.'4/ ,i.-7 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: T /? ` ' s • Policy # or Self -ins. Lic. #: 7 7 -%v3 '-0 S YJ "/ �- �3 / — �L Expiration Date: �, C � 16 � 2 0 /3 Job Site Address: ,s, e-r- 5 City/State /Zip: 1 _ c - / - 7/41P7a ✓, i4 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: "")' .12 Date: /2 /z /IL Phone #: / / 3 7 - o 4 o . V 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 Supervisor: Not Applicable ❑ • Name of License Holder : t c_ 'V? v.J/ L F�/•vi/ -/ �I C S 0 ( 2 5 License Number 7 d„reec, C /1v /Hr /)ra -r/, at4 o/- 03 /1 12 0i 4 / Address Expiration Date . > c /l3 S8 v37 Signature Telephone 97Registeed. Home.lriiproveinent °Contractor 7;7: , Not Applicable ❑ 3 o [ C'ov5 e% �id1/ CC /S767/ Company Name Registration Number - 76 3,44rc ; ,z . 6, //S /l o r y Address Expiration Date r7 -lA>14 1'1 ✓ "14 0 io ° Telephone 4/6 'S87 -‘) �/ 3J 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 ig 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 • a 4 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) .. , New House n Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors El Accessory Bldg. ❑ Demolition n New Signs [D] Decks [Q Siding [D] Other [D] Brief Description of Proposed Work: /� P �t.► C - 4tBrA1 - %)oa e Alteration of existing bedroom Yes )( No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes / No Plans Attached Roll - Sheet sa_ If- "New house and ' addition to existing housing; complete vie 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 7i- OWNERAUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT /-/d/14 2)1 4 -, e"(t c , as Owner of the subject property hereby a thorize f G / E•v4 i /44 V to a m behalf, II ers relative to work authorized by this building permit application. /2/2// Signature of Owner Date 1, e d Z Ev✓v , M 4 J , as.Awrier /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. Print Name -1 ) .. ay %L lL //L Signature of-9woer./Agent Date • Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by'Loning This column to be filled in by Building DepartmentS%Q ]aa+stt,,ii Lot Size Frontage Setbacks Front Side L: R: L:. R: Rear L_ Building Height Bldg. Square Footage % Open Space Footage o (Lot area minus bldg & paved parking) � � 3 # of Parking Spaces Fill: (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 Q YES 0 IF YES: enter Book Page: and /or Document # 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 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO Q 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. .4I 4 Department use only a fi s -__ ._._ it of Northampton Status of Permit �^``'" `gam, y. , t uilding Department Cu C ut � Dnveway �erm� _ 212 Main Street Sewer1SepticAvailabtiY i fEC 4 2z Room 100 Wa # erlWeli Avaaabll�ty , No ham, 01060 Two o f'S � ,uctur�ai Plans 4 .� I N 1tc. • 13 587 -1240 Fax 41 3- 587 -1272 Piot/Site Pians h , ,,, 4. NORTHAMPTON, MA 01060 Other $peCl 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 fo 2 7 5� Map Lot Un - ,L / , A , o IO 63 /p l i /�/1"M Zone ` � � Overlay District Elm St. District '' CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ` / � /L /Q J1 !'l�i�' r ST . i z�-I , /�.4 Nam s: � / � , TelephCurrent one / `f C /� Signature ��Mailing Addres�0 ' ` �`� 2.2 Authorized Agent: ■ Name (Print) Current Mailing Address: 0 / p(,?L) u¢ y /3._ s -3 6EL Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use. Only , , completed by permit applicant . 1. Building 3 (a)' Building Permit Fee 6 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)j 0 - Check Number Section For Official Use Only Building Permit Number: • Issued: Signature: Building Commissioner /Inspector of Buildings 3 FORT ST BP- 2013 -0626 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 176 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT DOOR BUILDING PERMIT Permit # BP-2013-0626 Project # JS- 2013- 001014 Est. Cost: $600.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ED LENNIHAN 042506 Lot Size(sq. ft.): 2439.36 Owner: PARKER HOMER D SR Zoning: URB(100)/ Applicant: ED LENNIHAN AT: 3 FORT ST Applicant Address: Phone: Insurance: 76 Bancroft Road 587 -0437 WC NorthamptonMA01060 ISSUED ON:12/5/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE FRONT 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 12/5/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner