44-016 (6) Office of Consumer Affairs&Business Regulation
H?� -OOME IMPROVEMENT CONTRACTOR
registration:
135204 Type:
xpiration: 3/13/2016 DBA
dV am
.'
CAMPS CONSTRUCTION CS_OS2531
STEPHEN CAMP NEB p Lp
46 EAST ST. STEP
EASTHAMPTON,MA 01027 46 E lar Mp 41027
"�— Easthamptt on
Undersecretary
� � 1112312015
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE CUVEKAGE AI-FUKUEU BY i Ht PULKALb tlt_LUYY.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR PRODUCER.AND THE CERTIFICATE
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(iss)must be endorsed. if SUBROGATION IS WAIVED,subject to the
terns and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
JAMES J DOWD&SONS INS PHONE FAX
226 RUSSELL ST SUITE B (A/C,No,Ext): (Arc,No):
E-MAIL
HADLEY,MA 01035 ADDRESS:
769WG INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY
CAMP,STEPHEN P DBA CAMPS CONSTRUCTION INSURER S:
INSURER C:
INSURER D:
46 EAST STREET INSURER E:
EASTHAMPTON,MA 01027 INSURER F:
COVERAGES 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 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MMI)DIYYYY) (MMIDDIYYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
rl COMMERCIAL GENERAL LIABILITY
CLAIMS MADE OCCUR. PREMISES TO RENTED $
PREMISES(Ea occurrence)
ED EXP(Any one person) $
PERSONAL&ADV INJURY ;$
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $
POLICY [::]PROJECT LOC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY is
SCHEDULE AUTOS (Per person) j
HIRED AUTOS BODILY INJURY is
(Per accident)
NON OWNED AUTOS PROPERTY DAMAGE {$
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE AGGREGATE Is
DEDUCTIBLE Is
RETENTION $ is
A WORKER'S COMPENSATION AND X WC STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-58909720-15 04/04/2015 04104/2016 LIMITS
ANY PROPERITOR/PARTNER/EKECUTIVE N/A E.L EACH ACCIDENT I$ 500,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
THE WORKERS'COMPENSA'170N POLICY DOES NOT PROVIDE COVERAGE FOR CAMP,S'T'EPHEN P.
CERTIFICATE HOLDER CANCELLATION
C{f*(*EA9 PTO UIL NG D )AR NT , SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
A PAY�doi f / BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELIV D
r IN ACCORDANCE WITH THE POLICY PRO
'� i �� AUTHORIZED REPRESENTATIVE
EA�31-1& IP'I4JN, '0102
ACORD 25(2010!05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP r ghts reserved.
Stephen Camp Construction
46 East St.
Easthampton, Ma 01027
(413)527-7124
Submitted To : Eric Stahlberg Phone- 584-2160
Address : 115 Old Wilson Rd. Date - 3-31-2015
Northampton, MA 01060
We hereby submit this bill for- Roof Job
The roof job will start with stripping the whole roof down to the sheathing.
I will install ice & water shield over the whole roof along with new drip edge and pipe
flashings.
There will be new step flashings for the chimney and against the back garage wall.
I will install new 30 year architectural shingles, color to match existing.
There will be new ridge rent installed to finish the job.
Building permit and trash removal is included in my price.
Materials= $ 4500.00
Labor= $ 4250.00
Dumpster= $ 800.00 Total Cost= $ 9550.00
Contractor Supervisors License number 082531
Home Improvement contractor Registration number 135204
I propose to supply materials and labor-in accordance with above specifications.
This proposal may be withdrawn
By us if not accepted within 30 days Authorized i tajel ;.
Acceptance of proposal Signatur '
The Commonwealth of Massachusetts
-x Department of Industrial Accidents
Office of Investigations V
r 600 Washington Street
_ Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 4 IQ Please Print Leaibly
Name(Business/Organization/Individual): 4-f G�l 6,44
Address.
City/State/Zip: *, ' ?4\t--,/ /2 _. Phone#: '< 2-7 �21 Z
Are you an employer?Check 7e e appropriate box: Type of project(required):
I am a employer with 4. ❑ I am a general contractor and 1
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.El 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'
comp.insurance.$ 9. ❑Building addition
[No workers' comp. insurance p•
required.] 5. ❑ We are a corporation and its 10.7 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 1;.HRoof 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.
+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:' tl e A)dl e✓t
—
Policy#or Self--ins.Lic. #: �? G } ���!�2 j Z Expiration Date:
Job Site Address:_//�' �°7/ �L/in• City/State/Zip: G��' `�Y"r�►✓ r�/� C�%L� �)
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 and the pains and p, alties of perjury that the information provided above is true and correct.
Signature: Date: 4-1
- -
Phone#:
Of 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):
L Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Other
ntact Person: Phone#:
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW.(780 CMR 110.11) ;.
Independent Structural Engineering Structural Peer Review Required Yes w No
SECTION 11 -OWNER AUTHORIZATION!_30:BE COMPLETED WHEN`
OWNERS AGENT OR CONTRACTOR APPLIES`FOR BUILDING:,PERMIT
as Owner of the subject property
her y tho ize I "1!
a on my eh f in m ers relative to work authorized by this building permit application.
Senaturb4i caner Date
I, _.......... 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.
t
Signed under the pains and penalties of peg ry, � q__ _� _ q ........
Print Name .
Signature of cane Date
SECTION 12-CONSTRUCTION:S RVICES L'
10.1 Licensed Construction Supervisor: t Not Applicabl e
Name of License Holder..____... ...�_ __ -... -'••�-• ..••. �,. .� _._,._ __ ._._
License Number
Address ,
Expiration Date
Signature,,/ J Telephone
SECTION'1:3--WORKERS.'COMPENSATION INSURANCE AFFIDAVIT(M.p 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 0
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE --
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofingj Change of Use❑ Other❑
Brief Description =Enter a brief description here. 5+, �� �v`J .S
Of Proposed Work: .
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ -- - : .-< 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use F-1 Specify:
SSpecial Use ❑ Specify:.w.,.._,...w...,-.....�..,.......M,w_-.V�.._,...�.a.....................�. .�..A..-.�......._�.,,. .....,_.� _....y.,...,w _.__.�_m �_�-,
COMPLETE THIS SECTION IF._EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS:ANDIOR CHANGE IN USE
Existing Use Group. Proposed Use Group.
Existing Hazard Index 780 CMR 34) _..,_.,•., •. Proposed Hazard Index 780 CMR 34)
SECTION.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
so
Floor Area per Floor(so
1st €
nd . ,._..............._._.,,�M._.._._._,.,. _
2nd __..... .,__.,._.,.. __._. ...: _..,._.._._... 2
3rd 3rd
4th _....._.__. ___ ,..___ ._..... 4m
Total Area(sf) Total Proposed New Construction s
ti ns
................. _
Total Height(ft)
---------- —.------ Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private Zone Outside Flood Zone E] Municipal ❑ On site disposal system[—
Versionl.7 Commercial ilding Permit May 15,2000
Departure t use+onlX
of Northampton `' status of Permit
APR 3
20 5 Iding Department curb C�ut/DrlveWay Perm�f� 36'
.i 12 Main Street Sewer/SepttcAvatlabr►rty
Elects
F i Room 100 lhlater/tNeII.Avaltablhf
y:
= _
hampton, MA 01060 Two Sets of Structural Plans
phone 87-1240 Fax 413-587-1272 Plot%SitePlans� . .
r ,
Other.Spemfy
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address:
This section to be completed by office
/ I l L� b✓I 1�LYb•� l� a Map Lot Unit
/ 1 1 �`
/ i Zone Overlay District
District`. CB District
SECTION 2-PROPERTY OWNERSHIP/AUTH'ORIZED AGENT
2.1 Owner oLaecpr d:
Name(Pri ) _M. Current Mailing Address:
Signature `� `� Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address
_.
Signature .F Telephone
SECTION 3-ESTIMATED CONSTRUE ON 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) Check Number
This.Section Foe Official Use Only.
Building Permit Number Date
Issued
_Signatur-e:__
Building Commissionerlinspector.of Buildings Date
115 OLD WILSON RD BP-2015-0956
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:44-016 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-2015-0956
Proiect# JS-2015-001847
Est. Cost: $9550.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: STEPHEN CAMP 082531
Lot Size(sq. ft): 30796.92 Owner: STAHLBERG ERIC&GAIL
Zoning: Applicant: STEPHEN CAMP
AT: 115 OLD WILSON RD
Applicant Address: Phone: Insurance:
46 EAST ST (413) 527-7124 WC
EASTHAMPTONMA01027 ISSUED ON:411012015 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 4/10/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner