30C-045 Date'1/14/2015 1:10.26 PM Paoe:2 of 2
URBA&SO-01 CMASCIADRELL
ACI�A 0 DATE(MM/DDYYYY)
CERTIFICATE OF LIABILITY INSURANCE 1/14/2015
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:
McClure Insurance Agency,Inc. PHONe----- ----- — FAX –
103 Van Deene Ave. Lc,No.Ext)_(413)781_8711 _ _ �ac NoL, (413)731-8548
West Springfield,MA 01089 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAI_C 0
INSURER A:Acadia Insurance
INSURED INSURER B:A.I.M. Mutual Insurance Co.
Urban&Sons Insulation Co., Inc. INSURER c
385 Liberty St. INSURER D: _--
Springfield,MA 01104 INSURER E:
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.
ILT R TYPE OF INSURANCE _POLICY NUMBER (MMIDD YYYV MMIDDIYYYY LIMITS
LTR
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00(
-�CLAIMS-MADE Al OCCUR CPA0188079-18 08/01/2014 08/01/2015 PREMISES(Ea occurrence) $ _ _ 250,00(
MED EXP(Anyone Person) S 5,00(
PERSONAL&ADV INJURY S 1,000,00(
GENT-AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE. $ 2,000,00(
POLICY PE�- L_I LOC PRODUCTS-COMP/OP AGG $ 2,00000(
OTHER.
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00(
Ea accident)
A ANY AUTO MAA0352971-14 08/01/2014 08/01/2015 BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 1,000,00(
AUTOS AUTOS _ _
NON-OWNED PROPERTY DAMAGE S
X HIRED AUTOS X AUTOS (Per accident
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00(
A EXCESS LIAB CLAIMS-MADE CUA0208407-18 0810112014 08/01/2015 AGGREGATE S 1,000,00(
_ DED RETENTION$
WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS'LIABILITY _ STATUTE ___ER
C ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N WMZ80080055562015A 01/0112015 01101/2016 E.L.EACH ACCIDENT S 500,00(
.
OFFICER/MEMBER EXCLUDED? _N.. NIA - ---
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE S 500,00(
If yes,describe under 500,00(
DF SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S _
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) A
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
Property Address: 3 Rls S RI�71
Contractor
Name: 1'� �v cr tIN
Address:
City, State: �� 1
Phone:
Property Owner
Name: �`�•
1
--- - t --------------- - ---- -- - ---
City, State: � G \� 1 �?
i, (contractor)attest and affirm that the building 1 intend
to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavit.
Contractor signa
Date.
OWNER AUTHORIZATION FORM.
lowws Name)
oyfiM of the pMp8dy kKgW at
top"Address)
hereby auftrize (Subcontractor)
an authored suboontrador for RISE Engineering,to act an my behatf to obtain a building
pennit and to perform work on my
Owner's Signature
p
Date
-443
.................... .............
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:
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 v5 � s���{•
- DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building •�!. 'L'.
` Northampton, MA 01060 'ss �ti1
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
Faccessory f Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
n supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
des or intends to be, a one or two family dwelling, attached or detached structures
o 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
l 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
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le M
Name (Business/Organization/Individual): -�
Address:-Zs ���� Y S1
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. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. E]Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp, insurance comp.insurance.$
required.] 5. We are:a corporation and its 10.0 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 12.0 Roof rr a s
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13 .Other V
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, l
Insurance Company Name: �C 1�
Policy#or Self-ins.Lic. ����� �► Expiration Date`
Job Site Address�o L� �J +� C \�1� City/State/Zip:�I� cE r_
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 her rtify under the pai dpenalties ofperjury that the information provided above is true and correct.
Si ature: Date: v
Phone o-�_A�
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 Su ervi or: Not Applicable £
Name of License Holder
License Number
ress Expiration Date
Signature Telephone
9 Reaisteced Homeamprovement Contrac or Not Applicable £
�3� a - -�� S�_T►O.� _.-._ - - X00
Company Name Registration Number
Ci
Address Expiration Date
Telephones <J��
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§26C(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 YesDk £ No...... £
11 .. .Home Owner_Egempt><on
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinss 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,
I
i
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 1771
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [C]] Oth r[+ 9]
Brief Description
Wok �_\G ���5�� "�\Q�► Q `r `�J�D�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 New house and-._or addi:t>on to exisfing houslng;-cornplete the followlna:
a. Use of building:One Family It>Z,_ 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 ff. 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
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1 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.
igned un r the pain nd penalties of perjury.
5 Ll---1 L��
tName
Signature Owner/Agent Date
- ^
Section 4. ZONING Att Information Must Be Completed. Permit Can Be Denied Due To IncompLete Information
Existing Proposed Required by Zoning
This column to be fille�-in by
Building Department
Lot Size
Frontage
Setbacks Front T.
Rear
Building Height
Bldg.Square Footage 5".
Open Space Footage
(Lot area minus bldg&payed
of Parking Spaces
^ .
A. Hasa Special Permit/Yariance/Rnchng ever been issued for/on the site?
O ���. ' ^ ' YES
_ �~�
IF YES, date issued.,
-. . . '
IF YES: YYaxthe permi recorded at the of Deeds? -
VON
NO
IZN DON / ^nup/ 0 YES
IF YES: enter Book Pag it and/or Document#
B. Does the site contain a brook, body of water orwetlands? NO 0 DON7KNO\Y 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needstobeobtained x-
� Obtained «~� Date |ssue6.
'
�~� �~� '
C. Do any signs exist on the property? YES �-� NO uQ%
IF YES, describe size, type and location:
D. Are there any proposed changes toor additions of signs intended for ilile' roplyrtv? YES - NO
IF YES, describe size' type and location:
E. Will the construction activity disturb(clearing, grading, excavation, orfiUing)over 1 acre orioit part ofa common plan
' that will disturb over Iacre? YES � � NO
��
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
-
^ ~
!
/
/
/
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'
i f]epartment use ORIy
rElect City of NorthamptonBuilding Department 212 Main Street SewerlS__ Room 100 a6rllty'�@C1iOnS Northampton, MA 01060 Two Sefs'Q .S#ructri>al Pfa 60 e 413-587-1240 Fax 413-587-1272 Ptof/Srte Plans°, ",�;
ClrNORT1iAllfON
N TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to rbe completed by office
c i t
Zone:- - Overla p►stnct -
4
y
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT::
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
me(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) Check Number
This Section For Official Use'Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissionerllnspector'of Buildings: Date
File# BP-2016-0335
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD01104(413)732-3922
PROPERTY LOCATION 388 BURTS PIT RD
MAP 30C PARCEL 045 001 ZONE SRO 00)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existinp -
AccessoKy Structure
Building Plans Included:
Owner/Statement or License 101877
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
�pproved 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
apfficiall y /
ureof Date
N ote: 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.
388 BURTS PIT RD BP-2016-0335
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C-045 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cater,-: INSULATION BUILDING PERMIT
Permit# BP-2016-0335
Project# JS-2016-000543
Est. Cost: $3947.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sa. ft.): 31232.52 Owner: KESSLER ALEXANDER
Zoning: SR(100)/ Applicant: URBAN & SONS INSULATION CO INC
AT. 388 BURTS PIT RD
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON.911612015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
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 9/16/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner