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29-556 (2) Client#: 40056 CENTE4 ACORD,,, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYVY) 9/13/2012 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 CONTACT NAME: Carol Sherman Commercial Lines PHONE 413 781 - 8711 FAX 41 103 Van Deene Avenue _ (E- MAIio Ezt): (NC, No): 3 731 -8548 P. O. Box 339 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # West Springfield, MA 01090 -0339 INSURER A : The Travelers Cos. I NSURED INSURER B : A.I.M. Mutual Insurance Co. CENTENNIAL CONSTRUCTION LLC INSURER C : 11 KENWOOD PARK INSURER D SPRINGFIELD, MA 01108 INSURER E: INSURER F : C OVERAGES 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 POLI LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE I NSR POLICY NUMBER (MM/ (MM /DD LIMITS A GENERAL LIABILITY 1680201C582ATCT12 08/26/2012 08/26/2013 EACHO $500,000 X COMMERCIAL GENERAL LIABILITY PREMISES (Ea $ 300,000 CLAIMS -MADE , X, OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 500,000 GENERAL AGGREGATE $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS - COMP /OP AGG $ 1,000,000 POLICY X JECT LOC 1 $ AUTOMOBILE LIABILITY i Ea accideDtSINGtE LIMIT ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON-OWNED { PROPERTY DAMAGE I i HIRED AUTOS AUTOS (Per accident) I I $ UMBRELLA UAB I I OCCUR EACH OCCURRENCE $ I EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION WCC5007142012012 05/01/2012 05/01/2013 X �W p Y A T U - _ °TH - , AND EMPLOYERS' UABIL(TY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N E.L. EACH ACCIDENT 5100,000 OFFICER/MEMBER EXCLUDED? ` Y I N/A (Mandatory In NH) - E.L. DISEASE - EA EMPLOYEE $100,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION City of Springfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE tY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S54257/M54250 CAS Sille (904n/In0~-eaa � � Office of Consumer Affairs and usiness Regulation ' it 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Horne Improvement Contractor Registration Registration: 152965 Type: Ltd Liability Corpor CENTENNIAL CONSTRUCTION, LLC. Expiration: 10/18/2014 Tr# 232978 THOMAS SULLIVAN - 11 KENWOOD PARK SPRINGFIELD, MA 01108 Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card DPS -CA t it SOM- 04/p4- G1 // 0t2i6 y .J;ce 6r- Art 24/2 e/� - l[Q.: {7e-it fl.:ei Office of Consumer Affairs & Busi R egulation License or registration valid for individul use only �?; HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to . 7 , Registration: 152965 Type: Office of Consumer Affairs and Business Regulation 'i `. ' Expiration; 10/18/2014 Ltd Liability Corpor 10 Park Plaza -Suite 5170 Boston, MA 02116 CEWTENNIAL CONSTRUCTION, LLC. THOMAS SULLIVAN 11 KENWOOD PARK � SPRINGFIELD, MA 0110$ ���— 416771111/11: �'�� ...01<.–..r. : / // Undersecretary Not valid without signature Nl,t »achti tciti. - i)cpartu1 iii iii Public '‘afrti 9 Board of Builtlinu Re2olatiun. and'tandard. ;--•' Construction Supervisor License License: CS 37717 THOMAS C SULLIVAN JR a 11 KENWOOD PARK SPRINGFIELD, MA 01108 ' — "' Expiration: 10/20/2013 t i.n10 ' -- i,»i t Tr= 5089 City of Northampton Massachusetts * f. ` 1 DEPARTMENT OF BUILDING INSPECTIONS e 212 Main Street • Municipal Building tiJ Northampton, MA 01060 t� INS PECTOR Louis Hasbrouck Chuck Miller Building Commissioner i 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 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 a ` "` � 911"`1M Office of Investigations ' 4; .. 1 '. s 600 Washington Street - Tp!a , * f F .� � Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly ' Name ( Business /Organization/Individual): Address: City /State /Zip: Phone #: 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 I employees (full and/or part- time).* have hired the sub - contractors 6. n New construction listed on the attached sheet. 7. in Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub contractors have g. [] Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance. required.] 5. LI We are a corporation and its 10.n Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11.n 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. ❑ 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. XContractors 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 certify untie h • , ains an i ,r' allies ; p ry that the information provided abo e is true and correct. Si l ature: /i / / /,/ //.iii/ Date: .4-' ° c___,‘"_ Phone #: 1- 7/3 -- 5 — a 7 yo 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 , 1 8.1 Licensed Construction Supervisor: - ,/C101/ Not Applicable ❑ Name of License Holder : �' U License Number ... /VA/CV/ PO le/ //174" 3 7 7/ 7 Address /� f Expiration Date " , 025-0 -,a7 4,//1 Signature Telephone 7/ 9�'Regis'tered Hoi ie;linprovement Contractor , .; :_ _, ::: 7 __ ,a4 „ ,t' Not Applicable ❑ r Company Name Registration Nu ber Address Expiration D e / 6 7//4, e10 0/ /7-14V. it Telephone € ,2 5 -61 i t i r e. 7 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 ❑ 1 .1.� w Qw 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 • J SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) n Roofing IT Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [D Siding [O] Other [0] Brief Work: Description of Proposed� J ' _ /VO / �Ji r Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Y No Plans Attached Roll - Sheet sa f:. Whouse -and r aclditlon. #o ezis #inq 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 y BE COMPLETED- 'OWNERS / AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT . d A1" `� � � �'< as Owner of the subject property hereby authorize ArPi/ :f C % ' _ to act on my behalf, in all matters relative to wo authorize. • this building permit application. . .,., AI' . , 4 • �!w. Signature of Owner — 7 Date fo �l I ef/, , 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 und-r the pains and •- nalties • per'ury. f /1/ Print Name //' J Signat r;o owner/Agent Date ............ _ ~ . ^ Section 4. ZONING ALt Information Must Be Completed. Completed. Permit Can Be Denied Due To lncomplete Information Existing Proposed Required by This column to be fine Building Department Lot Size [ | | i! __ ^ --- - � r -�-- -- -- - - + Frontage '' - Setbacks Front 7 ( i , —� l { l Side L:' ' }t_- ` L:-___ }L___ . ' � ) i - 7 | � � Rear ` ' - Building Height } > ; , > l Bldg. Square Footage r i � Y6 } ( | � Open Space Footage ____ �- - --- �m��m��»u:&nmo � �--- Y parking) I --1 1 i i ! #ofy��ng Spaces Fill: ---1 (volume & Location ` '. ' A. Has a Special Permit/Variance/Finding ever been issued for/on the site? �� �� NO h�j DON'T KNOW �_� KNO YES m�� ' h | IF YES, date ., IF YES: Was the permit recorded at the Registry of Deeds? �� �� �� NO \~� DDNTKNOYV \�� YES w�� : l IF YES: enter Book | Page; | and/or Document # | y~ /�� D. Does the s�econtain abrook, body of water orwedands NO [� KNOW �~� 9 DONTKNO YES �~� , IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained «�� Obtained �~� Date �~� �~� , ' C. Do any signs exist on the propert »�~x e �� y7 YES �_/ NO h�� , IF YES, describe size, type and location: ; __ ____ D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 l NO v.� IF YES, describe size, type and location: / --- E. VWU the construction activity d��rb hng.g�ding.oxoovabun.m�|ing) over 1 ao�orisdpo�ofu common plan th��wi||diotudbover1aum? YES (0 NO 4 �� p~x i IF YES, then a Northampton Storrn Water Management Permit from the DPW is required. -', ','gg'.,' � 6 art ,Dg mO t „ uset-o !y $ i_ City of Northampton Sttus`��ermi ;- ' '� -- f - , \ Building Department C u tio. - 7 ; ay P... it fl : i 43. : - 212 Main Street S ewe J S Wp -i * g a ll Ili a -f -"4'` TM ,h,----,-J,,,,,',7,7-,,--7,b,„,--,v,-,-,,,R,,,,,,,„!,, ' 7 t ` ,° � v -� w� ` , � ; 2p Room 100 YYa er ,ei ailabill g c^ "q, :. ...� F � ` „ ,, 2a ig . 4 : � -r Q.-C-) (1-4' u • rx ” e ,” � ` fi b ,. . .1x1. * . O c �oN Nov ampton, MA 01060 w ee o tr ctu a J � c ,, ' ,- � � ' G t - ' 3- 587 -1240 Fax 413 - 587 -1272 Plofl l a 611S ` vEei. c\ cNP Other.Specify�` s i. .. • • PLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by offi 1.1 Property Address s /O N �� Ma p Lo ' s� U nifi : ..*//7//f• . rt' 5+ a *. 58x'': s�' x , B/e �r / O Zo Overlay Qists!tct EIm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT , . 2.1 Owner ecor�� / r / e a ISICil g°71//eX/ Name (Tint) C ent Mailing A. s. / a - _1 Signature ' 22 Authorized A• ent: f •/"' 0 Name (Print � ' Current Mailing Address: Signature Telephone 520. SECTION 3 -ESTIMATED CONSTRUCTION COSTS em Estimated Cost (Dollars) to be Official Use_Only completed by permit applicant 1. Building (a) Building' Permit Fee 2. Electrical s C4 (b) Estimated Total Cost , of ' . , La - 2 Construction froth .(6) 3. Plumbing 4a. a Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection ■2 " ,‘r- . - - - ' - -,- - - - ,, , iti - Iii‘ , 6. T 6I=(1+2+3+4+5) C heck Number _ ,5, q -;f6 .:. s .. This Section ForOfficial Use Onl Date Building Permit Number Issued.. ' Signature ' Buildin Commissioner /Inspector of Buildings Date File # BP- 2013 -0665 APPLICANT /CONTACT PERSON CENTENNIAL CONSTRUCTION CO ADDRESS /PHONE 11 KENWOOD PK SPRINGFIELD PROPERTY LOCATION 605 RYAN RD MAP 29 PARCEL 556 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out `GI � O � Fee Paid v ✓ Typeof Construction: REPLACE TUB & ADD STAIRLIFT & RAILINGS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 37717 3 sets of Plans / Plot Plan THE FOLLO NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION 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 Demol' on Delay / - Signature of Building 0 icial 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. 605 RYAN RD BP- 2013 -0665 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 556 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2013 -0665 Project # JS- 2013- 001101 Est. Cost: $4300.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CENTENNIAL CONSTRUCTION CO 37717 Lot Size(sq. ft.): 20037.60 Owner: MCDONALD DONALD & MARGARET BROUGHTON Zoning: Applicant: CENTENNIAL CONSTRUCTION CO AT: 605 RYAN RD Applicant Address: Phone: Insurance: 11 KENWOOD PK WC SPRINGFIELDMA01108 ISSUED ON:12/27/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE TUB & ADD STAIRLIFT & RAILINGS 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 12/27/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner