24D-309 VDAC
TRAVELERS WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (7PJUB- 0545N13 - 1 - 11 )
RENEWAL OF ( 7PJUB- 0545N13 -1 -10 )
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
NCCI CO CODE 13579
1.
INSURED: PRODUCER:
DELONG CONSTRUCTION LLC WHALEN INS AGCY
76 BANCROFT ROAD 71 KING STREET
NORTHAMPTON MA 01060 NORTHAMPTON MA 01060
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05 - 26 - 11 to 05 - 26 - 12 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
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 Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease: $ 1000000 Policy Limit
Bodily Injury by Disease: $ 1000000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
o
o
D. This policy includes these endorsements and schedules:
o —• SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 04-25 -11 WC ST ASSIGN: MA
OFFICE: DIRECT ASSIGNMENT 701
PRODUCER: WHALEN INS AGCY 28LKF
001404
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
F ate of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
is/her construction supervisor. The state defines "Homeowner" as, " Person(s)
ns a parcel on which he/she resides or intends to be, a one or two family
g, 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
home owner."
The _building department for the City of Northampton wants persons) who. seek to use
the home. owner eiemption, act as their own i zistruction 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 backfdl),
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
�ermits 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 DIELAY the project until such time as the proper permits and inspections are
made
1, understand the above.
.(Home owner /resident 9 's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date
Address of work
location
l � r
The Commonwealth of Massachusetts
Department of Indusftial Accidents
Office of Investigationg
600 Washington Street
Boston, MA 02111
www.mass gov1&a _
- Workers' Compensation Insurance Affidavit:. Builders / Contractors /Electricians/Plumb.ers
Applicant Information Please Print Le�ibIy
Name ( Business /Orgmizadon/individual): `zo•i eG
Address: 7 (o 4 - neo z
City /State/Zip: /, Io cr /� r✓ .� A - y Phoae. #: `/ / ' S^� 7 �� Y 3.7
Are you an employer ?. Check the appropriate'box: -Type of pioject (required):.
1. ® I am a employer with _1 4.. ❑ I am a general contractor and 1
employees (full and/or part tune).*
have hired the sub- contractors 6 ❑New coast ztciion ,
2- El I ani a sole proprietor or partner- listed on- the:attached sheet. 7. & Remodeling
ship and. have nQ e�loyees These sub-contractors have .8. ❑ Deiao;i#ion
working for -me iii an ?Ia- .Yecs__and have workers' 9 _ _:. $ a3dhon
y�v
(� , eon . msrNarrP # .:.. II ..- .. .
worlecrs- - iasrnance - cOmP - -
r ed 5. ❑ We_are a corporation and its 10.[� Electrical repairs or ons
1
of haveGercised their ❑ mg repairs ons
3. ❑ I am a homeowner doing a21 work 11. Plumb' r
myself: [No workers' comp. right of exemption per MGL 12. Roof" airs
: 152 1(4j, and'we have no -
insurance regoiied.] t c
- ' � 13.0 Other .
employees- [N wor
comp. insurance required.}.
'Any applicant Shat checia box #1 ==,also M out the section belowshowing d3eirworkem'-compensation policy vtformatiow
t Homeowner; -ho submit this a$idavit:mdicatm they are doing all work and rhea. hire outside contractors must subuui a aew affidavit indicating such.
IConuactms that check this box must =ached an additional shec showing the name. of the sub-conttactois and slat - whether or notthose-catities have
employees. ®Ployem they —= PrMde fficir workers' comp..policyanmba:
tam an employer that is providing workers' compensation insurance for. my employees Below & the policy and job: site
- 'information.
Insurance Company Name: _r_1 V E
Policy # or Self-ins. Lic. #: 7 !�T/r. - ° :S"�/S.c/13 - f // Expiration Date-
Job Site Address: __ t�3' 3x Inl YeoGr Je`7 •
C o iCilaArr ? 7•�� .
ity /State/Zip
Attach a copy of the workers' compensation policy declaration pae (showing the ppticy number and ez�iration date).
.. -_
Failure. for secure coverage: as rcgiiif d under Seatirni 25A ofMGL`c, 152 sari lead_fi the impositii n of criminal penalit<es of a
fine up to $1,500.00 and/or one- yearir3prisonment,1 as well as civil.penalties in the form of a STOP WORK -GRDER ard a fine
of up to $250 00 a -day agaiast the violator, Be advised that a copy of this statement maybe forwarded tQ the Oflice of , -
TnvestiQattons oftheIA for insiiraiurc coverage verification
Ido"kereb cerii under
P. -- fp�73' that the anlormationirovufednbavElslraie _gad carry __
• -1' -. fy-
S pours -gad enalttes o .
Si aatare: —�P �1 . �l.L —_ �� Gy & o it
Phone #:
Ocirrl use only. Do not write in this area, to be completed by city or town afficiaL
City or Town: - Permit/Llcense # - —_
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 i dm ,nXfd
License Number
7 Co 34 � /� . �� E� ��✓/ '�� ^ r4 S I zS - 12 0 ; z
Address Expiration Date
.-mot 12--- y t3 4-8 7 -0 Ll
Signature Telephone
& Regltstdrd[ei#pe lmgroelttfirrl r onttot w '� •_.x�, Not Applicable ❑
Company Name Registration Number
7& 6 -14
Address Expiration Date
_K1o2THH &rrr1 , ,,44 . 0 1,31 Telephone 87 „�c /3
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G L. c. 152, § 25G(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...... ❑
h j5 y
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 Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [] Addition ❑ Replacement Windows Alteration(s) ® Roofing ❑
Or Doors E3
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [O] Other [a
Brief Description of Proposed
Work: 1 "DZ 7�=p�wA1' 2eM•�Y� i ✓ Jte� c ��.¢c�s, s c' x.z /oSld
Alteration of existing bedroom Yes _� No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rolk het
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 Ta -OWNER AUTHORIZATION - T8 BE COMPLETEQ WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
X C r'.� �/, $ H as Owner of the subject
property C
by authorize
fo a n my beh If, i all matters relative to work authorized by this building permit application.
Signature of Owner Dat
n4 v.J as 9wAe#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.
J in lVd
Print Name
Signature ofawm /Agent Date
'
. �.
`
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete I formation
Existing Proposed Required by Zo ing
This coluumn to be led in b
L 'A0
Building Departm
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
010 Lr
Open Space Footage %
(Lot area minus bldg & paved L---j L—J
# of Parking Spaces
(volume & Location)
A. Has aSpecial Permit/ Variance/ Finding ever been issued for/mnthe site?
�� �� ��
N� «�� DONTKN¢YY x�� YES v��
IF YES, dateissue&
IF YES: Was the permit recorded at the Registry ofDeeds?
�.�
NO
»�� mun/ *nwv, 0 ,c»
IF YES: enter Book i Page and/or Document# �
B. Does the site contain a brook, body uf water orwetlands? NO 0 DONTKNOVV 0 YES 0
IF YES, has permit been or need tobe obtained from the Conservation Commission?
Needs tobeobtained »�� �btained �~� �ate�ssued'r---------
�_� . )
C. Do any signs exist on the property? Y[5 0 NO
|F YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES »�� NO »r�
^��
|F YES, describe size, type and location:
E. Will the construction activity d)utudb hng
�� .gnoding m�ion.or filling) over 1ooaor�itpa�ofo common p�n
that �8d���m�r1�� ��
? YES � NO ��
(F YES, then o Northampton Storm Water Management Permit from the DPW is required.
RECEI City of Northampton u
Building Departments
qz
212 Main Street` '
Room 100
Northampton, MA 01060
oFeuum►voursP ne
13- 587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Prooerty Address
� i�) n2 2� « ,
2� Ma Lot
8 p flnit
���o2T /�thri i� '� � +• /� � 4 Zgne ` Qverta Drstdct
'Ei St. District : CIS District
SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGENT!
2.1 Owner of Record /
�1?4 T!2 ! c' 04 CS �8 /34 -JCkQ'r
Nr A– P nt) Current Mailing Address:
i!
Ala — Telephone q / 3 – 5 - 1 7
Signature
2.2 Authorized Agent: `
� � ' s
�.Ja/: ./:{ .J - 76, � r�nJ'C•C'o <'� /27 . /�[ � r>' /¢6tn -r m err % Ga4 ,
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit amp
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
c7 c�� Construction from' 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5)
3� �°�q �_' Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings; Date
File # BP- 2011 -1097
APPLICANT /CONTACT PERSON ED LENNIHAN
ADDRESS/PHONE 76 Bancroft Road Northampton 587 -0437
PROPERTY LOCATION 88 BANCROFT RD
MAP 24D PARCEL 309 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out QQ 4 0 1:a
Fee Paid
Typeof Construction: ADD DOOR TO GARAGE & REMOVE INTERIOR WALLS
New Construction
Non Structural interior renovations
Addition to Existin
Accesso1y Structure
Building Plans Included:
Owner/ Statement or License 042506
3 se of Pl / Pl Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON T PPL ATION BAS
INFORMATION PRESENTED:
Approved Additional permits required (see below
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit Nth 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
Demolition Delay
Signature of Building Official 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.
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