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17A-162
AtcoR CERTIFICATE OF LIABILITY INSURANCE OPID SH l DATE(MM/DD/YYYY) ARSSE -1 I 09/28/10 PRODUCER I MIS GtK I IM(A I t IS ISSUtU AS A MA I I t Ul- INP-UKMA I KM ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rodman Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 145 Rosemary St., Bldg. A ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Needham MA 02494 -3238 Phone: 781 -247 -7800 Fax: 781- 444 -0090 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A. Star Insurance INSURER B ARS Services Inc INSURER C 38 Crafts St INSURERD Newton MA 02456 INSURER E COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INJK 4JU L POLICY NUMBER POLICY EFFECTIVE POLICY tXPIRATION LIMBS LTR NSRC TYPE OF INSURANCE DATE (MM /DDNYYY) DATE (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ vv M,vOE TO HtNitu COMMERCIAL GENERAL L IABILITY PREMISES (Ea occurence) $ CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ - 7 POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY .AU OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS ! UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X TORY LIMITS OI H AND EMPLOYERS' LIABILITY A ANY PROPRIETOR/PARTNER /EXECUTIVE YfN WC0428702 10/15/09 10/15/10 EL EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E . DISEASE - EA EMPLOYEE $ 1000000 If yes, describe under SPECIAL PROVISIONS below E . DISEASE- POLICY LIMIT $ 1000000 OTHER DESCRIPTION OF OPERATIONS ! LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT ! SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION NORTHAM DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR City of Northampton 2 REPRESENTATIVES. 12 Main Street AUT�REP SENTAT E Northampton MA 01060 ACORD 25 (2009101) © 1988- 009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD . . • Client #: 235036 ARSSERVICE ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(o1o"YYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HUB International New England ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 600 Lon water Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR g ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Norwell, MA 02061 781 792 -3200 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Steadfast Insurance Company A.R.S. Services, Inc. INSURER B: Twin City Fire Insurance Co dba A.R.S. Restoration Specialists INSURER C: Hartford Fire Insurance Co 38 Crafts Street INSURER D: Zurich American Insurance Compa Newton, MA 02458 INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRC DATE (MM /DDIYYYY) DATE (MM/DD /YYYY) A GENERAL LIABILITY GPL5860576 09/24/2010 09/24/2011 EACH OCCURRENCE $2,000, X COMMERCIAL GENERAL LIABILITY DAMAGE ( RENTED a DAMAGE T R occurrence) $100,000 CLAIMS MADE X OCCUR MED EXP (Any one person) $5, X CPL Included PERSONAL & ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $2,000,000 7 POLICY n JERCOT n LOC D AUTOMOBILE LIABILITY BAP6725249 09/24/2010 09/2412011 COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per accident) X Drive Other Car PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY A U T O OTHER THAN EA ACC • $ AUTO ONLY: AGG $ B EXCESS / UMBRELLA LIABILITY 00KB0236511 09/24/2010 09/24/2011 EACH OCCURRENCE $$5,000,000 X I OCCUR CLAIMS MADE AGGREGATE $$5,000,000 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND I AV I MITS I I O FR EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE V/N E.L. EACH ACCIDENT $ (Mandatory in NIiEc EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ C OTHER property 08UUMR06539 09/24/2010 09/24/2011 Bailees: $350,000 $1,000 Deductible DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 10 Days for Non - Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Northampton DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL %fl DAYS WRITTEN 212 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Northampton, MA 01060 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZE TATIV� ACORD 25 (2009/01) 1 of 2 #S435077/M434190 © 1988 -2009 ACORD CORPORATION. All rights reserved. P0002 The ACORD name and logo are registered marks of ACORD . ' SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 't Not Applicable ❑ Name of License Holder : 4. 04/t' C.j / 0 15' License Number d GCox t' ?,'`'' (A)i -. rte, '& z17€A, q I(0' 2.0I3 Addre s Expiration Date f 3•7:7Z °0 c0I Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Nes Seue)1 1 v (043 6 Company Name Registra 'on Number ' b e t-s e t' INe e, . M Q 4 �� ` � 1 z) 2 fa Address Expiration Date Telephone 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 buildin permit. Signed Affidavit Attached Yes l� 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 4 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition Er New Signs [D] Decks [C] Siding Or Other [D] Brief Descriptiggn of Proposed - L �� 1 R �� Work: K ►oVc 5VI I-47A 4 " ♦� �` 4. � } C: a iQ � Osaliq + Alteration of existing bedroom Yes 1 No Adding new bedroom Yes f✓ No Attached Narrative Renovating unfinished basement Yes V---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, a e ok4.., V •‘Ct$c1" , as Owner of the subject property hereby authorize 0J et U () 'tS)C1 t .) C9 W�5 5-csievrzA to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, `J , 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. Flu I b f.&0CL-4 ) Print Narr`1 n j Signature of Owner /Agent 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 parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT 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 'f� DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, cavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 111, Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit OCT _ 1 I 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 41 3 - 587 1240 Fax 413 -587 -1272 Plot/Site Plans i _ __._._. Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Prooertv Address: This section to be completed by office q °7 Map Lot Unit / Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Nicole Vaget 19 Fox Farm Road, Florence, MA 01062 Name (Print) Current Mailing Address: ., arelf,_ 413 - 320 -2091 Telephone Signature 2.2 Authorized Agent: eS 'Ci? . 9 - � Cto1 Sabo & tPo aox 11 Wi t- fit�ltJ 0fO€ Name (Print) Current Mailing Address: C 4--,02-; qi3 ' 2 7L - 010 1 S ignature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 15,000 (a) Building Permit Fee to / / 2. Electrical 1,000 (b) Estimated Total Cost of Construction from (6) I (DC M ) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 910 e) 5. Fire Protection 6. Total = (1 + 2 +3 + 4 +5) 16,000 Check Number / 35 7 9 0 96 This Section For Official Use Only Building Permit Number: Date Issued: Signature: _ —....0- ,0„007" I /0 _1 — 7` 1 ,-1 Building Commissioner /Inspector of Buildings Date f . P • 19 FOX FARMS RD BP-2011-0316 GIS #: COMMONWEALTH OF MASSACHUSETTS Map :Block: 17A -162 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- 2011 -0316 Project # JS- 2011- 000514 Est. Cost: $16000.00 Fee: $96.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: David Sabourin 103157 Lot Size(sq. ft.): 19906.92 Owner: VAGET - GRANGEAT NICOLE C Zoning: URA(100)/ Applicant: David Sabourin AT: 19 FOX FARMS RD Applicant Address: Phone: Insurance: P 0 BOX 1737 (413) 272 -0101 0 WESTFIELDMA01086 ISSUED ON:10 /5/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP,SHINGLE,PLY & REPLACE RAFTERS 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 10/5/2010 0:00:00 $96.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner