Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
24A-081
A °R°® CERTIFICATE OF LIABILITY INSURANCE /2;0 5 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 WANED,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 NAME•oNCT Barbara Van Mourik TA Finck & Perras Insurance Agency Inc. PHONE (413)527-5520 FAX 0:(413)527-5970 6 Campus Lane E o1a .bvanmourik @finckandperras.com INSURERS AFFORDING COVERAGE NAIC It Easthampton MA 01027 INSURERAMain Street America Assr Co 29939 INSURED INSURERB:NGM Insurance Company 14788 ASAP Painting, Inc INSURER C: P O BOX 241 INSURER D: INSURER E: ,Hadley MA 01035-0241 INSURER F: COVERAGES CERTIFICATE NUMBER:CL14103001137 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-WLTH-RESP-ECT 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. IN SR TYPE OF INSURANCE ADDL BR POLICY NUMBER MMMIDD EFF MMND E%P LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 500,000 DAMAGE TO RENWD X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 500,000 A CLAIMS MADE OCCUR B49466 /5/2014 JS/2015 MED EXP(Arty one n $ 10,000 PERSONAL SADVINJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 1,000,000 JECT X POLICY PRO LOC $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea acrident ANY AUTO BODILY INJURY(Per person) $ 100,000 B ALL OWNED SCHEDULED 9B49466 6/20/2014 6/20/2015 AUTOS X AUTOS BODILY INJURY(Per accident) $ 300,000 X HIRED AUTOS X AUTOS WNED PROPERTY DAMAGE $(Per I Uninsured motorist BI split lenit $ 20,000 UMBRELLA UAB OCCUR EACH OCCURRENCE $ r+EXCESS LIAR CLAIMS-MADE AGGREGATE $ ED RETENTION$ $ B WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY Q' FJL ANY PROPRIETORIPARTNERIEXECUTIVE N NIA E.L EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? CB49466 1/31/2015 1/31/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE9$ 100,000 If es,describe raider CB49466 1/31/2014 1/31/2015 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS!LOCATIONS f VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Proof of coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ASAP Painting, Inc ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 a www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lelzibly Name (Business/Organization/Individual): ASAP Pa i n f incjf I n r, Address: 117 Russell Street / PO Box 241 City/State/Zip: Hadley, MA 01035 Phone #: ( 41 3) 586-8010 Are you an employer?Check the appropriate box: Type of project(required): 1,®I am a employer with 4 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.M I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑ 10 E] Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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: NGM Insurance Co — Policy#or Self-ins.Lic.#: Expiration Date: 1 /11 /2 016 Job Site Address: 88 Jackson Street City/State/Zip: Northampton, MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 nd penalties of perjury that the information provided above is true and correct. Signature: Date: 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: Jim R. Boyle CS-107689 License Number 117 Russell St- / PO Bc)x 241 ., HadlP)zr MA 01035 10/25/2017 Address Expiration Date ( 4111 586-8-010 Signature Telephone 9.Registered Home mproyerrent Contractor: Not Applicable ❑ ASAP Paintincl Tnc- / .Tim R Bn)Zl P 132074 Company Name Registration Number 11 /09/2016 Ad ress Expiration Date Telephone( 41 3) 586-80 0 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....... 10 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 SignatureG —� - , SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[l�j Brief Description of Proposed Work: Kitchen Remodel 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, Andy or Karen- Pacicarek as Owner of the subject property hereby authorize Jim R. Boyle to act on my behalf, in all matters relative to work authorized by this building permit application. Signature f Owner Date I, _,Ti m R Br)3Z1 e 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. -T i m x l e Print Name April 1 , 2015 Signat 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 W DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW Q YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO � DON'T KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q 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 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 Q NO IIQW IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only y of Northampton Status of Permit: ilding Department Curb Cut/Driveway Permit APR -3 2015 !� 12 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Electric, Plumbina&Gas InspLld ampton, MA 01060 Two Sets of Structural Plans Northampton, 7-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1 A Property Address: This section to be completed by office 88 Jackson Street Map Lot Unit Northampton, MA 01060 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Andy & Karen Paciorek 88 Jackson Street Name(Print),} Current Mailing Address: -__ Q�!!�''yL ✓ " (� Z� �� Telephone 1 3 -T—�84-0666 Signature 2.2 Authorized Acient: PO Box 241 , Hadley, MA 01035 ame Pnnt) Current Mailing Address: ( Z - ,/f ( 413) 586-8010 Signa06 Telephone SECTION 3-ESTIMA ED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building $10, 000. 00 (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of 1 , 500. 00 Construction from 6 3. Plumbing Building Permit Fee 750. 00 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0933 APPLICANT/CONTACT PERSON JIM R BOYLE ADDRESS/PHONE P O BOX 241 HADLEY01035 (413)586-8010 PROPERTY LOCATION 88 JACKSON ST MAP 24A PARCEL 081 001 ZONE URA(104)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid -- Tyneof Construction: REMODEL KITCHEN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 107689 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 99M*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 Demo ' ' elay Signa of ui mg O 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. 88 JACKSON ST BP-2015-0933 GIs#: COMMONWEALTH OF MASSACHUSETTS MW:Block:24A-081 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: renovation BUILDING PERMIT Permit# BP-2015-0933 Project# JS-2015-001803 Est. Cost: $12250.00 Fee: $73.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JIM R BOYLE 107689 Lot Size(sq.ft.): 12632.40 Owner: PACIOREK ANDREW F&KAREN C Zoning.URA(104)/ Applicant: JIM R BOYLE AT: 88 JACKSON ST Applicant Address: Phone: Insurance: P O BOX 241 (413) 586-8010 WC HADLEYMA01035 ISSUED ON.•41712015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN 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 4/7/2015 0:00:00 $73.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner