The URL can be used to link to this page

17C-318 BP- 2011 -0241 GIs #: COMMONWEALTH OF MASSACHUSETTS M'apwBloc 17C - 318 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit # BP- 2011 -0241 Project# JS- 2011 - 000404 Est. Cost: $4308.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R K MILES INC 10388 Lot Size(sq. ft.): 12719.52 Owner: RECKHOW DAVID ALAN & WANAT CATHERINE GRACE Zoning: URB(100)/ Applicant: R K MILES INC AT. 45 HIGH ST Applicant Address: Phone: Insurance: 24 WEST ST (413) 447 -8300 WC WEST HATFIELDMA01088 ISSUED ON :911612010 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS 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 9/16/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner Department use only . City df Northampton Status of ^ Permit BGitding Department Curb CuUDrveway Permit lt . ,212 Main Street Sewer /SepticAvailabii Room 100 WaterlWell Availability Northampton, MA 01060 Two Sets of Structural Plans phor 16587 -1240 Fax 413- 587 -1272 Plof%slte Plans { Other Specify APPLICATION_TO- CONSTRUCT, AL7rER,_REPAIR, RENOVATE OR DEMOLISH_A_ON_ E_-OR.TW_O- FAMILY- DWELLING SECTION 1 - shPE INFORMATION 1.1 Property Address This section to be completed by office Map Lot Unit ' o ^ l J Zone Overlay District Elm St: District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record V Id Name 1 Current Mailing ,�, Xr Telephone �T Signature 2.2 Authorized A ent: • Name (Prir) � Current Mailing Address: Signatur Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only • completed by ermit applicant 1. Building $6, (a) Building Permit. Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee - - - .4. Mechanical (HVAC) 5. F ire Protection 6. Total =0 +2+3+4+5) Check Number This Section Fo Official Use Onl Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings 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 p arkin g) # of Parking Spaces Fill: volume &Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DONT KNOW O YES 0 IF YES, date issued:` IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW 0 YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES O 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 O 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 O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replac emeN mdows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [CJ Siding [0] Other [C7] Brief Description of Proposed Work: 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 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 7 as Owner of the subject property hereby authorize to act on y behalf, in all matters relative to work authorized by this building p rmit application. • 9 /r� /ra Signature of Owner Date I, 1 12A . Q G as Owner /Authorized Agent hereby dpclare that the statements and information on the foregoing applicatio are true and accurate, to the best of my knowledge and belief. Signed and r e ains and pens ies of perjury. t S Print Name Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable r ❑ f� p Name of License Holder / License Number ,> 1 Address Expiration bate Signature _ _ Telephone_ 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Addressff_ 1l jj�� j Expiration Date Telephon e - 4- 3 'A� 7- ?9 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 thejob 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 The Comm of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02:111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El iectricians(Plumbers Applicant Information Please Print Legibly 1l_ S 1\I3t11e (Bus inesslOrganization /Individual) - - - -- Address: �(/E5 - SI ` City /State/zip; ' ,q � � YA OVE Phone #: � P� � f 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 G. 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 S. ❑ Demolition worker for me in aci employees and have workers' g any capacity. �'• 9. ❑ Building addition [No workers' comp. insurance comp, insurance.' required.] 5. [] We are a corporation and its 10.[] Electrical repairs or additions q ] officers have exercised their 11. Plumbing repairs or additions 3. ❑ I am a homeowner doing all work ❑ g p � • myself. [No workers' comp. right of exemption per MGL 11❑ oof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required,] tt f�G/-�C *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 hie outside contractors must submit a new affidavit indicating such, i $Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. I f the sub- c have employees, they must provide their workers' comp. policy number. l ain an employer that isproviding workers' compensation insurance for nzy employees. Below is thepolicy and job site information. r — Insurance Company Name: I — vFe1R1q Policy # or Self -ins. Lic. #: (� � �� —' f/" Expiration Date: �' / d ��]f Job Site Address: 9�i/ /C� l City /State /zip: T - / + cl� I/J Attacha copy of the workers' c6dipensation policy declaration page (shovwW k the policy nilzn ber 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 o die DIA for insurance coverage verification. I do hereby ce d render zT i s and penalties of perl that the znforfn lion provided above is l e an correct -- - _ _.. -_ iA Signature: . ' .hf r Date: JU - av 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): Board of Health- 2. Building Department - 3: City/Town Clerk 4, Electrical-Inspector 5. Plumbing Inspector b. Other L„_ - Acadia Insurance WORKERS'CO ENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY SCHEDULE OF OPERATIONS MASSACHUSETTS Policy No. WCA 0240314 -12 Issued By Firemen's Ins. Co. of Washington D.C. Policy Period 01/01/2010 to 01/01/2011 NAMED INSURED AND ADDRESS AGENCY NAME AND ADDRESS 05111 R. K. Miles, Inc._ _.(802).362. - .13.11 618 Depot Street ___W.H Sha y.,_ _ Insuranee_Agenc__.Inc. P:O. Box: T125 — _ - _ - 135 Bonnet Street Manchester Center, VT 05255 -1125 PO Box 1067 Manchester Center, VT 05255 Premium Basis Total Estimated Rate Per Estimated Code Annual $100 of Annual Loc No. Classification Remuneration Remuneration Premium 4 8058 Building Material Dealer - new 169,000 3.45 5,831 materials only: Store Employees 4 8232c Lumber Yard - new materials only: 188,000 4.87 9,156 All Other Employees & yard, warehouse, Drivers 4 8742 Salespersons, Collectors or 44,000 .20 88 Messengers - Outside 4 8810 Clerical Office Employees HOC 71,000 .12 85 5 8058 Building Material Dealer - new 200,000 3.45 6,900 materials only: Store Em loyees 5 8232 Building Material Dealer - new 408,000 4.87 19,870 materials only: All Other Employees & yard, warehouse, Drivers 5 8742 Salespersons, Collectors or 309,000 .20 618 Messengers - Outside 5 8810 Clerical office Employees NOC 269,000 .12 323 5 5437 Carpentry - Installation of Cabinet 60,000 5.93 3,558 Work or Interior Trim Subtotal: Premium Subject to Modification 46,429 9807 Increased_ E_ L. Limits 1.00k 464 9898 Experience Mod Fctr 0.87 6,096- 0277 ARAP 1.00 0 Subtotal: Subject Premium 40,797 WC 00 00 01A Page 1 Original i Auldia Insurance WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI Carrier Code #27723 P—icy No. WCA 0240314 -12 Issued By Firemen's Ins. Co. of Washington D.C. Previous Policy WRA 0240314 - 11 One Acadia Commons Westbrook, Maine 04098 1 NAMED INSURED AND ADDRESS AGENCY NAME AND ADDE,BSS _ 05_.1.11 -_ -: X602 }362-1311 R. K. Miles, Inc. 618 Depot Street W.H. Shaw Insurance Agency, Inc. P.O. Box 1125 135 Bonnet Street Manchester Center, VT 05255 -1125 Manchester Center, VT 05255 F.B.I.N. 030141661 U.I.A.N. Bureau File No. 911735261 State: VT Entity of Insured: Corporation OCAT1$ See Attached Schedule of Locations 2. The Policy Period is from 01/01/2010 to 01/01/2011 12:01,AM Standard Time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA, NH, NY, VT B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily In ury by Accident $ 500,000 each accident Bodily In ury by Disease 500,000 policy limit Bodily In ury by Disease 500,000 each employee C. Other states.- Insurance: Part.Three.of - the - policy applies to the states, if any, listed here: ALL STATES EXCEPT ND, OH, WA, WY AND STATES DESIGNATED IN ITEM 3A OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedules: SEE SCHEDULE OF ENDORSEMENTS This policy is: X Direct Bill 12 Pay Plan Agent Billed WC 00 00 01A Page T Original i Acadia Insurance PRtI VM 4. the premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. SEE SCHEDULE OF OPERATIONS EST ANNUAL Minimum Premium $ 1,000 Subject Premium $ 129,790 Premium_ Discount _ $_ - - 13, 098- Expense.Constant $ 338 _Estimated Annual Premiuc0,..__$. __ _11.7,.Q3Q_._ Terrorism Rssk Insurance Act o 20 1 02 (Code 9740) $ 515 Terrorism (9740) $ 552 Catastrophe $ 552 (other than Certified Acts of Terrorism) (9741) Vermont_ Assessment _Fee - _ -,.$_ 764 MA D.I.A. Assessment $ 2,908 Total Estimated Annual Premium $ 122,321 r Authorized Signature WC 00 00 01A Page 2 Original I i Acadia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY ADDITIONAL LOCATIONS I- ..Lay No. WCA 0240314 -12 issued By Firemen's ins. Co. of Washington D.C. Policy Period 01/01/2010 to 01/01/2011 NAMED INSURED AND ADDRESS AGENCY.NAME AND ADDRESS 05111 (802) 362 - 1311__.. - R. K. Miles'_ 618 Depot Street — - -- W.H. Shaw _Insuranc.eleacy- , ..InC.. 135 Bonnet Street Manchester Center, VT 05255 -1125 PO Box 1067 Manchester Center, VT 05255 Location U.I.A.N. Name and Address Loc 1. 618 Depot.Street Manchester Center, VT 05255 Loc 2. 691A Depot Street Manchester Center, VT 05255 Loc 3. 88 Exchange Street Middlebury, VT 05753 Loc 4. 385 Cole Avenue Williamstown, MA 01267 Loc 5. 24 West Street Hatfield, MA 01038 Loc 6. No Specified Location, NH Loc 7. No Specified Location, NY We 00 00 01A 01/01/10 DAL 12/29/09 original __ SINCE 1940 rk MILE Ss BUILDING MATERIALS SUPPLIER Installed - ]Proi et Subcontractors Project: "A Subcontractors: If you have employees you must provide your Workers' Compensation Insurance Policy Number Subcontractor r .. Name: 3 C_ 07 Address: '519 A 7-,F/ f tD I- M Phone: y�13- ✓�� ' �� Policy #: Insurance Company: zfJcaq ('This form must be attached to Project Workers' Comp. Affidavit) Installed Project Subcontractors 2/12/2010 I