17A-097 (2) •
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EYh€ ((J - 1114160/ltuieac'/ or ✓g i
iJci ibccoG'e6-
k,;; Board of Building, Regulations and Standards
=� = One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Construction Supervisor License
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License CS: 55333
Restriction: 00
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Expiration: 5/21/2010 Trl1 25290
LAWRENCE A JUBB JR
PO BOX 429
GREENFIELD, MA 0'1302 — — - - -. - --
U ttdale Address and r'etur'n card. 51ark reason tur change.
t:OM•Urro1•rcuauu 171 Address 1 _-i 1tetie vat 1: Lust Card
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One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Registration: 100001
Type: Private Corporation
Expiration: 6/8/2010 Tiff 267161
The Jubb Company, Inc.
Larry Jubb . .
P. O. Box 429 • - - -----
Greenfield, MA 01302
Update Address and return card. Mark reason fur change.
60M•07r07•rc04e0 Ci Address (_1 Renewal rj Emplo Lust Card
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Nlassacbusctls - Department of Public Safct■
Board of Building 12c�ulalions anll Slantlarlls
Construction Solwrvis()r I ic:e
License: CS 55333
Restricted to: 00
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LAWRENCE A JUBB JR w'L � .
� �.r �.7f4 19;
PO BOX 429 y„:
GREENFIELD, MA 01302
Expiration: 5/21/2012
( cnnmi..i me r Tr#: 24599
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The Commonwealth of Massachusetts
tr =w= Department of Accidents
Office of Investigations
_ 2 . 600 Washington Street
' Ifi 1-
Nor
Boston, MA 02111
y..
''.*'ley tvwvtt. mass.gov /dim
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): `J t✓) }� I � } v��C�) `I v1 __
Address: p 0. g„,
C �
Cit /State /Zip: C-3-, C. r � � ) a_ N'1 Phone #: 7
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 6. ❑ New construction
employees (full and /or part- time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We arc a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box ill must also fill out the section below showing their workers' compensation Lion policy information.
t I lomeowners 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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: � C C r ' - .l ) 0 ( Q.
Policy # or Self -ins. Lic. #: j (e' L f CI Expiration Date: 5 /3 I )
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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 044= —. -- Date:
Phone #: —] 7 (_ ('o2 f 7
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 #:
A5/07/20111 15:5'2 41:3863%58 AHRI'ST PAGE 1=11/A1
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CO ry r :I.. 4' T M D,). (' Y;
` l YYr L " / - / ` L •' _ CERTIFICATE OF LIABILITY INSURANCE 05/07/2010
PRODUCER rho 413- 803.4373 Fax, 413•BE3AG5U THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
A.H. RIST INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
159 AVENUE A HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. BOX 391 ALTER THE COVERAGE AFFORPEp BYTHEe .. =__O
TURNERS FALLS MA 01376 INSURERS AFFORDING COVERAGE IIM
INSURED INSURER A; PEERLESS INSURANCE COMPANY
THE JUBB COMPANY, INC. INSURER 9! -
P.O. BOX 429 INSURER C: IIIIIIIII
GREENFIELD MA 01302 --
INSURER D:
INSURER E'
COVERAGES
THE POLICIES" CF INSURANCE LISTED EEELOVJ HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INb NCrvITI/STAND; \D
ANY RECUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT ', RESPECT TO WHICH THIS CERTIFICATE MAY 13E, I;SL:RrJ OR
MAY PERTAIN, THE INSURANCE AFFORDED I3Y THE POLICIES CESCRIRDO HEREIN IS SUO.ECT TO ALI.T•IE TERMS, EXCLUSIONS AND CONDIT'.DNS OP S!_:_7'H
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS
INSP. ADR T YPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
L'F. ,'NSF/: TYPE pATa$11,1i110rrr) LIMITS
• GENERAL LIABILITY CE3P 8661749 05/03/10 05103/11 EACH OCCURR 5 1,000.000
X COMMERCIAL. GENERAL LIARILITV L,41u. r!E TO RENTED T 100,000
PREMISE 3 (Bn owurcn.n
CLAIMS MADE X OCCUR MED, F.XP ;Any ono po�'e�n1 'i 1
-.�, 15,000
A - PERSONAL S ADV INJURY T 1,000,000
GENERAL AGGRE_GATF. , 2.000,000
SRN'/_ AGGREGATE LIMIT APPLIES, PER: rRODUCTS - COMPrOP AGe °. 2,000.000
- . POLICY n JL- a 1 -- . — „or.,
AUTOMOBILE LIABILITY CA 8669247 05/03/10 05/03/11 COMDINE.D 31NOLt LIMI I ,? 1,000,000
ANY AUTO (ER RCCICI9n:)
ALL OWNED AUTOS
BObILY INJURY
X SCHEDULED AUTOS (Rol' pSrnon)
A X HIRED AUTOS
ROq!f -Y INJURY
X NON -OWNED AUTOS (Nor accidam)
PROPERTY DAMAGE
r'or eccldonl )
GARAGE LIABILITY N/A AUTO ONLY - LA ACCIDENT -
ANY AUTO OTI IER THAN EA ACC s
AUTO ONLY AG(}
EXCESS /UMBRELLA LIABILITY N/A CACLI OCCURRENCE
7 OCCUR n CLAIMS MADE AGGREGATE
DEDUCTIBLE - 1
__ RETENTION S _
W” ^TATi
WORKERS COMPENSATION AND WC 8664947 05/03/10 05/03/11 X rory I iNIT3 =T " '
EMPLOYERS' LIABILITY Y a r_,L EACH ACclDCNT $ 100.000
A ANY PROPRIETOR(PARTNRRII;XECUTIVE _
OFFICER/MEMBER EXCLUDED?
(Mnrulntery In NISI E L. UtSEASE4E /1 P;pIPLOYFF 500,000
It yen. Contrite under
E' . LPP.!V)3IDN3SCrow -__�i - F „1. DISEASE- POLICYLINiT S 100,000
OTHER NrA
DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
CLASSIFICATION: CARPENTRY /SIDING INSTALLATION
WORKERS COMP POLICY INCLUDES COVERAGE FOR CORPORATE OFFICERS
CERTIFICATE HOLDER CANCELLATION ,
THE JUBB COMPANY, INC. SHOULD ANY 0 THE ABOVE., DESCRIBED POL,ICIFN ii, CANCELLED SE SRI T.-Ii-
EXPIRATION DATE THFRF 'EF THE ISJ1ANG INSURER WILL E'•,DLAvOR1C) MAlf. IT ;AVS
P.O. BOX 429 ;WRITTEN NoTCE Tp rHP CERTTrICATE HOLDER N /',VIED T,. • TI 4:. i.FI -'I NJ: AURIC T:;
GREENFIELD MA 01302 ID,: so SHALL impose Nr, CIALIOATION OR LIARC_ITV OF ANY RING :,PON:' uaURE_'. T S
AGENTS OR REPRESENTATIVES
AUTHORIZED REPRESENTATIVE
Attention: r � /:�
0e. Qkl err
ACORD 25 (2009/01) CorI flcate / 22955 J 1988-2009 ACORD CORPORATION. All rights reserved.
Tl)c ACOR.!0 n3rno and I::90 ar.• Ir ;istPred markt, of ACORD
p.
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AFFIDAVIT • . • . .
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• . As a result of the provisions of MGL c 40, S54, I acknowledge that as a condition of Building Permit
• . Number 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 I50A_ . •
. I certify that I will notify the Building Official by •
. (Two months maximum) of the location of the solid waste disposal facility where the debris resulting from ,
• the said construction activity shall be disposed of, and I slot] submit the appropriate form. for attachment
to the Building Permit. • • . .
• - • 6 I Y") /0 • -
Date • Signature of Permit Applicant
(Print or type the following information) • .
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w if i Q I 4- - � 00 J
Name of Permit Applicant
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. Finn Name, if any •
d ..
:. C/ .
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• • . • • , . • • Addi+ess .
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• ': 112 tri'lI •be'' dis of': `'• . . ... .
U \Th 0, ,t (
Location of Facility
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: _ Not Applicable ❑
Name of License Holder : --,,Cr L " l r J I S - T‘
5 ) D . ,
(- , , , License Number
C - y(�� o Li � � , l Ic ��� .c5 .2-1
Address ^ Expiration Date
Signature Telephone ' — 7� � , /)
9. Registered Home Improvement Contractor., Not Applicable ❑ I
Company Name Registration Num r
— - hc u� h I ( � --I --t h / S' / /C
Address Expiration Date
Y�
I-� 1 D lL 1 C i ( f f 0 ) )6 1 Telephone -7-) - (e ( J
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SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) I
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 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
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacemedows Alteration(s) ❑ Rooting ❑
Or Doors
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [p Siding [0] Other [o]
Brief Description of Propose I _ / �l.r
Work: c .14.1)19' C J n S4 Gj II 1 e fr, 4� 'G:� C C.. l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. 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
I, , 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
I, hC� k--C.: v "r'l( ( I - ) --- J L.-- () 6 . J r te_ , 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.
Signed under the pains and penalties of perjury.
Print Na
._ ,° ( /s //6
Signature of Owner /Agerl Date
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i"` , Department use only
City of Northampton Status of Permit
7 6 ) Bui lding Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
-, \ Room 100 Water/Well Availability
• Northipton, MA 01060 Two Sets of Structural Plans
" phone .49-587-1240 Fax 413 - 587 -1272 Plot/Site Plans
. /---- Other Specify
f APPLICATION. TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIONI -SITE INFORMATION
1.1 Property Address: 7 This section to be completed by office
'3 1 C---r n d v , c , -t' Map Lot Unit
Zone Overlay District
fC i C , f, , i ( _
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Punt) Current Mailing Address: _ S i _66
JEMMZI■41110....71•11110.! . 1 MOW
Telephone
Signature
2.2 Authorized Auent: 0 6 r
,,,_,,--,,,,,,_ (-21--17_4_, -Y
Name (Print) Current Mailing Address:
sue=.
aaa¢!7
"---'-r--' 7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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 , � I
6. Total = (1 +2 + 3+ 4+ 5) 4 (4(i , C c _ Check Number 107
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
s
ff
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„ # ` t BP- 2010 -1134
GIS #: COMMONWEALTH OF MASSACHUSETTS
t e k: 17A - 097 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -1134
Project # JS- 2010- 001662
Est. Cost: $4626.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THE JUBB CO INC
Lot Size(sq. ft.): 9365.40 Owner: DREYER BARBARA J & SHIRLEY I SICURELLO
Zoning: URA(100) //RI/WSP Applicant: THE JUBB CO INC
AT: 37 GRANDVIEW ST
Applicant Address: Phone: Insurance:
P O Box 429 (413) 772 -6217 Workers
Compensation
GREENFIELDMA01302 ISSUED ON:6/11/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 2 REPLACEMENT DOORS
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 6/11/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo