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29-014 (2) Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/Y14 L..�� 11/20/2014 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: Christine Sullivan Aquadro & Associates PHONE (413)586-7373 FAx (413)584-0859 355 Bridge St. , P. 0. Box 357 E-MAIL INSURERS AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURERA:Main Street America Insurance 29939 INSURED RONALD KEITH INSURER B: DBA KEITH CONSTRUCTION INSURERC: 5 BIRCHMEADOW DR INSURER D: INSURER E: >AMLEY MYA 01035-3554 INgW!ER F: COVERAGES CERTIFICATE NUMBER:CL1461605656 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 L POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER M / N /D Y Y GENERALLIABILITY EACH OCCURRENCE $ 500,000 X COMMERCIAL GENERAL LIABILITY PREMISES E occurrence $ 500,000 A CLAIMS-MADE a OCCUR KPF3699Y 12/17/2013 12/17/2014 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 r POLICY PRO LOC $JECT AUTOMOBILE LIABILITY COMBINED INGL LIMIT Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED HIRED AUTOS AUTOS ED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS N PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $� _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- Y LIMITS OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE� N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in Nil) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF NORTHAMPTON ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET NORTHAMPTON, MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD 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 111, S 150A. Address of the work: I,! 1)� The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant City of Northampton Massachusetts 4 t, DEPARTMENT OF BUILDING INSPECTIONS ` Sts 212 Main Street • Municipal Building \ .✓` ` Northampton, MA 01060 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 1, 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 F 600 Washington Street 1 Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): h,u_nu Address: Wc:o"G i nti City/State/Zip: W,6,pu,W,6, Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2:V I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. []Demolition working for me in any capacity. employees and have workers' 9 Building addition comp. insurance.$ [No workers' comp. insurance 5. � We are a corporation and its 10.❑ Electrical repairs or additions required.] 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 12,0 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. tHo meowners 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 certify under the pains and penalties of perjury that the information provided above ' true and correct. Date: Zo / Signature: 'rte--yam Phone#: 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:-.. Q o wr L( L5- ns, �ol License Number _ l� 1� 1:(�t f`"�[�liL�'] i71�• �Jf'�`zi .a.-)- !'jl Address Expiration Date Signature Telephone 6. Registered Home Imarovement Contractor: .. _ Not Applicable £ Company Name,, Registration Number Address Expiration Date Telephone 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 Dwellines 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 51 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 Alterations) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[0] Other[0] Brief Description of Proposed , Work: „r\ i�aut" t e'�c� �^, rt"o dt:w,F� SW— —P 0k "x q+L Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. If IVew house andoraddition to existing.h"ousna, 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, A-6 L. LA�/\l-A u'r as Owner of the subject property hereby authorize` "U Uc r �� to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner / Date 0� 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 Date Signature of Owner/Agent Section 4. ZONING AU 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 Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved L---------J1 #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO \�� DONTKNOW �~��/ YES �~�� |F YES, date issued:| > IF YES: Was the permit recorded at the Registry ofDeeds? NO �� D �_/ u/, / m,uvv 0 YES IF YES: enter Book I Page and/or Document# �� B. Does the site contain a brook' body uf water urwetlands? NO ��, DON7KNOY/ «�/ YES �=y IF YES, has a permit been or need tubp obtained from the Conservation Commission? Needs tobeobtained x~� Obtained v~� Date � �_� x_� ' C. Do any signs exist on the property? YES 0 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 0 NO 0 IF YES, describe size' type and location: ' �� E. Will the construction activity disturb(clearing, gradingexcavation,orfi||ing)over 1 acre nrisit part ofa 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, '— 4 � e Us on Y. epartmenii o i City of Northampton StatusofPermtt 4 r ' a, � `'i Building Department Ctrr6CutlDn�teuvayPeirrft# x t. . 212 Main Street Viewer/SepticAVait"ab�lrfy � �-' ' Room 100 3lVater/tltfeliA�a�la5111ty -' ection N hampton, MA 01060 Two Sets of Structurai Pups F ,q 6 o e 413-587-1240 Fax 413-587-1272 Plof/Site.f'ians E Nf Othei'z5pectfj(t} +� ,s '`� APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Th s section to be completetl by off,ice 1.1 PropertV Address: j 1111 t�(\ Map Lot Unit 1� Nic.C6 •i 1GS�e,�c Zone Overlay Disfric3 V. Elm St District CB District SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: ' t a Telephone Signature -i 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 l U Construction`from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection :70 X7 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector'of Buildings Date r 16 HICKORY DR BP-2015-0585 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-014 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2015-0585 Project# JS-2015-001116 Est. Cost: $11000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RONALD KEITH 085204 Lot Size(sq. ft.): 18556.56 Owner: WARAWKA EUGENE E&JULIA M Zoning,: Applicant. RONALD KEITH AT. 16 HICKORY DR Applicant Address: Phone: Insurance: 5 BIRCH MEADOW DR (413) 584-5589 HADLEYMA01035 ISSUED ON.1112012014 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 11/20/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner