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37-108 (2)
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D > i O D (n z; O -Di o) O C a 3 w v m cn z r0- -< _ (n D O m ° m Q m m n c n m 0 = Z OD N �.v w w O r- X c' m N Cl) �� O O z > _{ O C co Z zr� p z .. !n O z = Z <n � 0 m .p z (n z OL C w Ori c m Q- U°, o n cn Z p m D co co 3 Cn' o co m o m K -� p3 r CD w A Z r N O v o °° Z ° X C/) y z p m( m ° v y W D co v o D Z� D D N v � v 7J _T7 OD ��—D m p p m o m 0 w m X o o _N p t _ ° C D C m 1 p O (D :7 'U OJ 0 v m w 3 ^6 m N w N CD (n m C m m o p o °° C7 I, w O W o m m o O v) O O p Cs CD Z5' N (D n (D m O M z O o a (0_0 z D C) � v m rn m D O a( O � m c .�,� �rnrrr rnnirrne+rl( r�<'.!"�irJJrrr�uJr(�' ffice of Consumer Affairs&Business Regulation_ g License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: " Office of Consumer Affairs and Business Regulation Registration: 148688 Type: 10 Park Plaza-Suite 5170 _ Expiration: 10/18/2015 Supplement card Boston,MA 02116_ LOWE'S HOMES CENTERS INC JAMIE SPOFFORD 136 TURNPIKE RD.SUITE 100 v-� SOUTHBOROUGH,MA 01772 Undersecretary `' "._vr. of valid without signature r ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: S Office of Consumer Affairs and Business Regulation Registration: 148688 Type: 10 Park Plaza-Suite 5170 Expiration: 10/18/2015 Supplement t .ird Boston,MA 02116 LOWE'S HOMES CENTERS INC WARREN COOKE 136 TURNPIKE RD.SUITE 100 - SOUTHBOROUGH, MA 01772 Undersecretary Not valid without signature Cowes 12345676910 >> loves 1916 ISO Massachusetts -Department of Public Safety Board of Building Regulations and Standards Con%truttion Supervi%or License: CS-103003 MICHAEL W BU$il; R 119 HTCH STREET 1 (t AGAWAM MA t loofa ✓.�..,.�.,6c . „ Expiration Commissioner 09/08/2014 ac CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD1YYYY) 9/27/131 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: Rejean J. Remillard Ins. Agy, PHONE —" FAX -- 23 Southwick St E-MAIL N ADDRESS: Feeding Hills, MA 01030 INSURERLSLAFFORDING COVERAGE NAIC# ENSURER A:National Grange-Mutual INSURED INSURER B:Acadia Ins Co Michael W. Burgamaster dba INSURERC:Main Street American Assurance Burgers Home Improvement INSURER _.�-._-.._D_:...... - --- --- - ..... — -- — --- ---- ----..._ 119 High St. 1st Floor IKMLLF RE: Agawam, MA 01001 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEILOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATE). NO-nN!THST.ANDING 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. iSR! {ADDL{SUBR! - POLICY EFF ! POLICY EXP TR TYPE OF INSURANCE i INSIR I POLICY NUMBER MIDDN MMIDD/YYYY • LIMITS C i GENERALLIABIUTY !MPK6213N 6/8/13 6/8/14 EACH OCCURRENCE $ 1 00010QQ OMMERCIALGENERAL_L LAB ILITY i I DAM4GETORENTED $ 500 000 {I (Ed CLANS-MADE OCCUR I PERSONA(48 AOV �) $ 10,000 � Xj _ _ INJURY �$ 1 000,000 GENERAL AGGREGATE- - $ 2 CLOO,00- GEN'L AGGREGATE LMITAPPLIESPER i PRODUCTS-COW IOP AGG $ 2,000,000 X POLICY PRO r ECT I I LOC E — $ AUTOMOBILE LIABILITY � ; INGLELIMIT v1 3385E 1 /1 — ANYAUIO i BODIL Y INJURY(Per person) $ _ _ 100.00 ALL OWNED SCHEDULED --------I '- -"IS AUTOS X NON OWNED { E I BODILY INJURY(Per accident). $_ 300,00_0__AUTC j PROPEf7fY DAMAGE X HIRED AUTOS X AUTOS I Peraccident $ 100,000 LL._- � -- { $ UMBRELLA LIAR OCCUR I _ . �EACHOCCURRENCE `— EXCESS LIAR— - CLAIMS-MADE! i ( — - — AGGREGATE $ I DED RETENTION 3 I r $ WORKERS COMPENSATION { 'WC-20_20_002804 '01 H- 0 AND EMPLOYERS'LIABILITY -- - ANYPROPRIErOR/PARTNER/EXECUT,/E YrN I 1 1 OFFICER,tAEMBEREXCLUDED� �iNI AI DEL EACH ACGDE tJT $ (Mandatory in NH) F E L DISEASE-EA EMPLOYEE $ if yes aesuioe unoer - - DESCRIPTION OF OPERATIONS be.- E L DISEASE-POLICYLIMIT $ 100 000 100,000 500,000 SCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Rermrks Schedule,if more space is requi red) )we, s Companies, Inc. and any and all Subsidiaries are named as Additional Insured as i aspects to General Liability and A-aLO Liability. Ii I RTIFICATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lcwe's Companies, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. j Attn: Install Sales Insurance AUTHORIZED REPRESENTATIVE P. O. Box 1111 N. Wilkesboro, NC 28656 — © 1988-2010 ACORD CORPORATION. All rights reserved. ORD 25(2010/05) The ACORD name and logo are registered marks of ACORD e: Fax: (877) 411-7129 E-Mail: r Den artment of 1ndus&ia1 Accidents Office of.Invemgaldorrs j s 600 Washington Street ,Boston, MA 02111 www.gas's got'/dia Workers' Coinpensation Insurance Affidavit: Huilde 4 licant-Info at irsl Contractors/]EleetriciBn /p om ens x : 'on Plante]Print L2 iblY Name t$usiuess/Orgamzation&wividual): Address: —City/state/Zip! AA Phone#: u� 6 .�- Are you an eiaployer?Check the appropriate:box:• 1: I am,a employer with „ 4• I am a general contractor and I Type of project(required): j employees (full.aad/or part-time).* have hired the sub-contractors 6. ❑New construction z 2.❑ 1 aril a,sole proprietor or partner- listed on the attached sheet, 7. ❑Remodeling f ship:and have no.employees These subcontractors have i working.for the in any capacity. employees and have workers' $ ©Demolition � fNo workers'.mx p. insurance comp.insurance.t g• ❑Building addition required.] 5. ❑ We are a corporation and its 10. Electrical repairs or additions 3. 1 am.a homeowner doing all work officers have exercised their 11- Plumbing repairs or additions myself.'[No;workets'comp. right of exemption per%4GL insurance required.] t c. 152,§1(0),and we have no 12.0 Roof repairs clnp10yees, [No workers' 11M Other comp.insurance required.] ay agpiicant that ohec 6 box#1 must also fill out the section below showing their workers°compensation,policy information, Homoownors who submit this affidavit indicating they are doing al!work and than fore Outside contractors must submit a now WTid;lvit indicating such. �Contamctors that;ahoek this box must attaohed aii addi6ona!sheet showing the name of the;sub-contractors and slate whether or not those ctrtiti os have ctnployacs. If thc.sub�eotlttactors have employees,they must provide their workers'comp.poiieynumbcr. f am an employer that rs pratvtdung workers'comp. atnorn insurance for my employees. Below is the policy and job size information. Insurance Company Name._ 14—n , T 12QM;llcad Tn Lxzvice �ce�t rtit, U Policy#or Self-ins.Lic. WG 2n.,Q0-04a$ON — 6 Expiration Date: Job Site Address: City/Staatc/zip: .attach a copy of the rvorkers' compeosation policy declaration page(showing the policy number and expirzdon da*.$). Failure to secure coverage as required under Section 25A of 1v1GL c. 157 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage'verification. I do hereby certify under th pains aloes of perjury at the information provided above i$trite and comet-. i T lure• Oat �D 32Ll Official use only: Do not write in this area,to be completed by city or town official 1. City or Town. Permit/License# �, ti Issuing Anthorliy(circle one): LLCOOttha rd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector $.Plumbing Jnspectog• si er ' ct Person: Phone#: t� LA d QS I ML Savo] << City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 11' 1 , S 150A. Address of the work: .SD -12�6 �4N The debris will be transported by: �,c�;mss ,Ef� er The debris will be received by:�rf ��/Wi .- sue �� Building permit number: Name of Permit Applicant Xt "g;oO Date Signature of Permit Applicant SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: I /f L 1U12CX e7,f/-5 Tx- C•S- A)3 00.3 License N tuber XI—C/ Address Expiration Date �'a Signature Telephone 9.Registered Home lmorovement Contractor: Not Applicable ❑ 5 �`#1 Jm E /S 7�`G. /Y? � F' y Company Name Registration Nu ber Address Expiration Da e Telephone3° 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 Mill SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Wipdows Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[p] Other[o] Brief Des ripti n of Proposed,,- Work: E f�L,4� d/x/%�%y [/�a2 //0 �77C,.-C 77a,24-t— Zu4 n K 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 I, 'iO/Va A/Z as Owner of the subject property hereby authorize O Kim to act on my behalf, in all matters relative to work authorized by this building permit application. =9' 19A2 Z221r- Signature of Owner Date 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. Print Name 6 Signature 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 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 Special Permit/Variance/Finding ever been issued for/on the site? NO (D DON'T KNOW 0 YES 0 IF YES, date issued:! IF YES Was t he permit recorded at t he Regi st ry of Deeds? NO 0 DON'T KNOW YES IF YES enter Book Page; and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW U YES IF YES, has 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 0 NO 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. � l City of Northampton Status of Permit: Department use only uilding Department Curb Cut/Driveway Permit • 6ct`o�s 212 Main Street Sewer/septic Availability. &Gaso\o o Room 100 Water/Well Availability Northam ton, MA 01060 Two Sets of structural Plans one 413-587-1240 Fax 413-587-1272 PlottSite Plans Other Specify.. F- 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 Pe A, Map Lot Unit Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current__ ailing Address: _ X113- 3,;L6 ° W .5'66 �'d/(.'� Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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 6. Total =0 +2+3+4+5) ,j Check Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date 50 ICE POND DR BP-2014-1178 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37- 108 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-2014-1178 Project# JS-2014-001988 Est.Cost: $1884.00 Fee:$35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LOWES HOME CENTERS INC 103003 Lot Size(sa. ft.): 12501.72 Owner: MILLER JONI S Zoning: Applicant: LOWES HOME CENTERS INC AT. 50 ICE POND DR Applicant Address: Phone: Insurance: 136 TURNPIKE RD SUITE 100 (413) 588-0270 WC SouthboroughMA01772 ISSUED ON.51812014 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE ENTRY 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 Siznature: FeeType• Date Paid: Amount: Building 5/8/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner