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15B-029 ACORIp CERTIFICATE OF LIABILITY 09 /26/201 PRODUCER 413 536.0804 FAX 413.534.7874 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Martin ] . Clayton Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1649 Northampton Street ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. P. 0. Box 989 Holyoke, MA 01041 -0989 INSURERS AFFORDING COVERAGE NAIC # INSURED Fireside Designs INSURER A: Harleysville/Worcester DIM: P & P Marketing, Inc. • INSURER B: Safety Insurance Company 0014 1769 Riverdale Street INSURER C. Amtrust Insurance West Springfield, MA 01089 INSURER D. INSURER E: COVERAGES THE POLICES 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. IN$R IJ TYPE OF INSURANCE POLICY NUMBER ( FECTIV g aWppry LIMITS rn AN GENERAL LJABILITY MPA 19961F .06/07 /2011 06/07/2012 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILRY DAMAGE TO RENTED $ 300,000 PRFMICFR (Fa nrn.rnnra I CLAIMS MADE n OCCUR - MED EXP (Any one person) $ 5 , 000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE ! 2,000,000 GEN't AGGREGATE LIMIT APPLES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 in POLICY fl PE . El LOC - — AUTOMOBILE LIABLUTY 6210727 07/17/2011 07/17/2012 COMBINED SINGLE LIMB . ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY B X SCHEDULED AUTOS (Per person} 100,000 X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per accident) 300,000 PROPERTY DAMAGE $ . (Per accident) 100 , 000 GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR n CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND NWCC46351745 08/31/2011 08/31/2012 I WCSTATTU -- I I eR EMPLOYERS' UABIUTY E.L. EACH ACCIDENT $ 100,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E L. DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Fireside Designs BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 1769 Riverdale Street OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. West Springfield, MA 01089 AUTHORIZED REPRESENTATIVE kpt0oar Harold Clayton ]r. /SANDY V � 111 ACORD 25 (2001/08) © ACORD CORPORATION 1988 ockenstonfoorza of, licalachwedeti Office of (4asetner Affairs &. Business Regulation 4,(tilif ; HOME IMPROVEMENT CONTRACTOR Registration: 158891 l' -r- Expiratlop: 3/1312012 Tr# 293213 Type: PrIvtite Corporation P&P MARKETING dba FIRESIDE DESIGNS . JEAN PELOQUIN 1769 RIVERDALF ST . WESTSPRINGFIELD, MA 01089 Undersecretary ................................. -...............--------rr7---r.---., i . 1 Viii $ lkii in cn 1 . I It1W4iVil 40 titilttlin" iitsi4t11.1.111fill ,,, ,tild Si 3144141111 ConstructIon Superv4or Spetsalty Ocense Lic.i.rtse CS it., 99194 R ti.ti tv..,-, SF JEAN PELOQUIN SR FIRESIDE DESIGNS . . . ... ,,,,:..... ___,,,,,,...., E ,i.vo,..it.:0( 412612012 99194 City of Northampton M assac h use tts d ° ` � ` iii ' � . e DEPARTMENT OF BUILDING INSPECTIONS � �' 212 Main Street • Municipal Building Ob ' V. ,n !�, Northampton, MA 01060 ^-- e) INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he /she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction 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 backfill), 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 permits in conjunction to the building f p rmit issued, and that they get their required inspections. Failure of the individual trades to secure t e permits and inspections as required can DELAY the project until such time as the proper permits nd inspections are made I, -4 cs) S S L , k.g understand the above. (Home own P � r /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date l< < R .co • lk Address of work location 3( 9.. Q A Rctoll V,Iur ASS ` k`t.1N ooss • The Commonwealth of Massachusetts Department of Industrial Accidents Ml = Office of Investigations W:.. a .= 600 Washington Street Boston � MA 02111 '�,. *._•tom v www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): l t1'�9 f � Q$ �.0.1us (S *5 a c Address: City /State /Zip: Phone #: 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 6. [I] New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [1] Remodeling These sub - contractors have ship and have no employees 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance. required.] 5. n We are a corporation and its 10.111 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their MO Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. fl 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. t Homeowners 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: 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 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): I. Board of H 2. B Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES a . 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date 'gnature Telephone II Ze ``is'tered lew m e rovement �'ont q'�°�' ,, C ro , s`:' " °' Applicable �> C �� � �` � ` "�` Not A licable ❑ t.CgC. @3 I�tiS Company Name Registration Number Address Expiration Date ctic $k Sky`∎ 1/41+F't . \ *\ a lciet TelephoneV`3'l3 * a SECTION 1 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 ❑ :, 1 � , ' one wnevmxerption 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 1083.5.1. 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 orthampton Ordinances, State and Local Zoni ws and StTfe of Massachusetts General Laws Annotated. omeowner Signature , • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) _ New House [l Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [[] Siding [0] Other [O] / f efDesc*nofPd ork: ��c�'a�l elk- \ t t•� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet .. -- -`°°" '�;r ., m ' cap" °^= W R °�,. sa lLNew house anddor4 addition.to existing housing4'complete then ollowiniq: 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, o li� . '� , as Owner /Authorized Agent hereby d tare 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. p 7 P'tName ture of ... t , er /Agent i Date . Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information c Existing Proposed Required by 'Zoning This column to be filled in by Building D arnnent Lot Size I ' 1 . ,Lv Frontage Setbacks Front I i 1 Side L: R: L :. ' R:� F i t Rear I Building Height i / Bldg. Square Footage i l I i% z i 1 Open Space Footage % (Lot area minus bldg & paved __ _� I parking) t I 1 # of Parking Spaces ' Fill: t (volume & Location) I 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 DONT KNOW 0 YES 0 IF YES: enter Book Page; i and /or Document #1 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 0 F IF YES, describe size, type and location: 1 I 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: s 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 ® IF YES, then a Northampton Storm Water Management Permit from the DPW is required. RECEIVED Departure Us2 drl rs ` ;° :,it of Northam Stat , of ee*, � Building Department fit! ® ii'' evu y erin ,. d�� 2 6 201 212 Main Street Se erl ep Ic v,,liwil , Room 100 W t � el Ia : Y. Nc rthampton, MA 01060 T ®Se s ® tr�ctu� INSPECTIC" E N O n+ � 4 ,3.587 -1240 Fax 413- 587 -1272 i e I W I � � APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING CTION 1-- SITE INFORMATI 1.1 Property Address: x Th is se ction to be completed by office . a^,i -. x�u "'' � 5 s +� a .E �.- ,c � �-. �""xY wt � c '� wu� a !.'� k Zone r t e a ,- .Overlay District k "� Elm St Distgct " CB District •` SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: \1OSE Y� , t �- ��� 3 l� �o� Name (Print) L Current Mailing Addre '�l \3. 586• © �3 � /tip �ttiL.r„ Telephone ture .2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - "ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Off cial Use Only . completed by permit applicant . 1. Building L/ (a) Building Permit Fee 2. Electrical (b) Estima Total Cost of Construction fro (6) 3. Plumbing B u ilding Permi Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 1 + 2 + 3 + 4 + 5 Check Number ' ff ( ) 0 0 ... .This Se ction For Official Use O Building Permit Number. Issued. Signature: - Building Commissionerllnspector of Buildings , Date • ■ • 312 CHESTERFIELD 1W BP- 2012 -0430 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 15B - 029 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit # BP- 2012 -0430 Project # JS- 2012- 000688 Est. Cost: $4300.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: FIRESIDE DESIGNS 99194 Lot Size(sq. ft.): 40597.92 Owner: MISTERKA JOSEPH P & JUDITH ANN Zoning: RR(100)/ Applicant: MISTERKA JOSEPH P & JUDITH ANN AT: 312 CHESTERFIELD RD Applicant Address: Phone: Insurance: 312 CHESTERFIELD RD WC LEEDSMA01053 ISSUED ON:10/26/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL PELLET INSERT IN FIREPLACE 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 10/26/2011 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner