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50-003 514 PARK HILL RD BP- 2010 -1060 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 50 - 003 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cafegoly: BUILDING PERMIT Permit # BP- 2010 -1060 Project # JS- 2010 - 001562 Est. Cost: $1950.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN CAMP 082531 Lot Size(sq. ft.): 25264.80 Owner: MOLITORIS THOMAS M & JOAN M TRUSTEES Zoning: SR(100) / /WSP II Applicant: STEPHEN CAMP AT: 514 PARK HILL RD Applicant Address: Phone: Insurance: 46 EAST ST (413) 527 -7124 0 WC EASTHAMPTONMA01027 ISSUED ON: TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE PORCH 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 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo Version1.7 Commercial Building Permit May 15, 2000 S. NORTHAMPTON ZONING Existing Proposed I Required by Zoning This column to be filled in by Building Department Lot Site 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: volwme & Location) A.. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO fl 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, grading. excavation, or filling) over 1 acre or is it part of a 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. Version1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Acdress Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor �.r �,: _ ._ .... .... ... .. Not Applicable ❑ Company Name: � t a Responsible In Charge of Construction Afilir Signature Telephone Versionl.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 WaterlWell Availability Northampton, MA 01060 Two Sets of Structur Riaas phone 413 -587 -1240 Fax 413 -587 -1272 Plott.Sa#eP1 s 'Other APPLIG t s , _ i _ . t :_. -= P}g�lATR s .: - 1 it = 6eeUPAN"C t`-@ , - NfOLISI -tANY BUILDING OT HEST- HA A — OR- . * a i,! ,NP � it�,� SECTION 1 - SITE INFORMATION ; • x 1.1 Property Address This section to be completed-b ffice Map Lot Unit ( p I t74, . /` /L<= Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Signature Telephone 37y— 2_1/ & 2.2 Authorized Agent: Name (Print) Current Mailing Address er 2._ 0/ o z, 2 Signature �(0 - .ago, Telephone 2 7/ 2_y SECTION 3 - ESTIMATED CONSTR CTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. 9 /� a® (a) Building Permit Fee 6 2. Electrical i (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) . 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5 } - -- Chesk- Number j _ 3 This Section For Official Use Only Building Permit Number Dote Issued Sionatitre- Building Commissioner /Inspector of Buildings Date Stephen Camp Construction 46 East St. Easthampton, Ma 01027 (41 3)527 -7124 Submitted To: "rom. Molitoris Phone- 584 -2916 Address a 514 Park Hill Rd. Date 5-20-2010 Northampton, Mass 01060 We hereby submit this estimate for- Roof job This price is for stripping all old roofing materials off the porch roof. 1 will strip back the wood siding and shingles necessary. Customer will supply trash removal. The plywood edge and fiber board will be installed. We will install all new drip edge (lashings needed. The rubber roof will be installed . We will flash as needed and re- shingle. 1 will install the wood siding to complete the job. 1 will supply the building permit Price = S 1950.00 Contractor Supervisors License number 082531 Horne improvement contractor Registration number 1 35204 1 propose to supply materials and labor -in accordance with above specifications. This proposal may be withdrawn 13y us if not accepted `ti-ithin 30 Days Authorized Signature Acceptance of proposal Signature The Commonwealth of Massachusetts Department of Industrial Accidents rr� x Office of Investigations 600 Washington Street 1: 1 6 . ...10111■1111 1=r 7 Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Indivi p _ � Address: City/State/Zip: / tY P� _ � _ - ti Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. n 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. El 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 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. - 1 I am a homeowner doing all work officers have exercised their 11.(1 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ®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: I c l 1 C 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. 1 do hereby certify under the pains and ofperjury that the information provided above is true and correct. $ierlature: � � f ._ , , 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub- contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self - insured companies should enter their self - insurance License number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617 - 727 -4900 ext 406 or 1- 877- MASSAFE Fax # 617- 727 -7749 Revised 4 -24 -07 www.mass.govfdia . P. CERTIFICATE OF LIABILITY U��U U�»�� DATE ��~x� o nx n��n u~ ��o nx��o�»~�»��— 04/05/2010 ACOR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE James J. Dowd and Sons Insurance age�o�. Inc yo�osn THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ' � s evr*spnuo�sasLovv PO Box 10300 | ��Ten7oscove��osxppnno o . . |wsogsnoxppono/macovsn�ss Holyoke MA 01040 INSURED m xon�*»wrm�n z000ra ooec�� Stephen P. Camp INSURER ft.: 46 East Street /ySURE* iNSURER o Easthampton MA 8IO27 wsuREn COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEL' TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD /wo/cArso wo`wI/HorAwomoAwv REQUIREMENT, TERM onCowomowoF ANY CGNTRACT OR OTHER DOCUMENT VTH RESPECT TowmcHrmoceRrmcArs MAY as ISSUED oR MAY p*nrmw. THE INSURANCE AFFORDED BY THE POLICIES osscR!aeo HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND cowomows OF SUCH POLICIES AGGREGATE UMTS SHOWN MAY HAVE BEEN REDUCED 95' PAD CLAMS IN»n| TYPE opINSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS oR / DATE ,wm/DowY/ I o^rs(Mmmmvv) ' GENERAL LIABILITY EACH OCCURRENCE S i GENERAL AGGREGATE GEy'LAGC.;REGATE tiMir APPLIES PER: PRODUCTS - COMP'CP A S { | pn'vx| /Jcrr | !uC ■ ! ' 1 ANY AUTO ' / i 1 ALL OWNED AUTOS BODILY INJURY ! , SCHEDULED AUTOS (Per pef son) IS GARAGE LIABILITY { ^m^oro -- ---- EXCESS LIABILITY EACH ODSURRENCE 1 s' i OCCUR i I CLAIMS MADE ! AGGREGATE 4:_-; -- �� | , _, , DEDUCTIBLE --- - , ! , � |nszem.nx 5 / i s � | � mw arWc131305 1 04/04/2010 04/04/2011 zf6�/i��o � EMPLOYERS' `-- EACH o znn.000 s�� s L. DISEASE 'c^ � 100.000 ---- u-mseASE poL ICY LIMIT |o son'unn OTHER ( � i DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS � | CERTIFICATE HOLDER |�|� om��/^��n�� CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE | ' EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOT TO THE CERTIFICATE HOLDER NAMED TO SHE LEFT, BiT FAILURE TO 00 SO SHALL MPOSE NC OBLIGATION OR LABILIr( OF ANY SIND UPON THE NSURER, ITS AGENTS OR REPRESENTATIVES. . " ` � AUTHORIZED REPRESENTATIVE O ■ . ` --- «onnoz5-a(7/97) �AConoconpon� �i' 1988 fit„- |wS0zso«mw ELECTRONIC m, e��ryuw* INC LASER (bsS,0)327-0545 Page ',1z ' // e c »P ..friz nt,1P.(GC {J r,., ifaiJ<6f'1 e,Jel d a Of�ic ®f Const?mer Affair§ do k sihes s ° f3` eg ial on �1 `' HOME IMPROVEMENT CONTACTOR �� , Registration:., 135204 ` `, E pir'ation: 311312012 Tr# 242i37 TIpe: lndividuiel CAMPS CONSTRUCTION STEPHEN CAMP 4.-4 EAST ST. 4. - :.�_ -. EASTHAMPTON MA 01027 ' Underscretary >3.;i. 1r 111 :.1 - kli,,i lrn 'alt ni, 't hhc `+,a:fel� vt Board of ; anal 1”12, Wt4ttlatioro, and Stand ar( Comoruction Supervisor License License CS 82531 Restricted to: 00 y # STEPHEN P CAMP `' 46 EAST ST ° r EASTHAMPTON, MA 01027 „ : , 7; `' "' "�` Expiration: 11/23/2011 ( ,qnr i,r,i„nc nts. 8573