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11-004 ice o onsumer Affairs an Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 164072 Type: Private Corporation Expiration: 8/14/2011 Tr# 287999 TAYLOR & BRYAN ASSOCIATES LLC. KELLY NEALE 60 SCHOOL STREET HATFIELD, MA 01038 Update Address and return card. Mark reason for change. El Address ❑ Renewal [] Employment El Lost Card 'S-CA1 0 50M- 04/04- G101216 eammaou a ✓l�aerac/tuseka Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation - skia C Registration: 164072 10 Park Plaza - Suite 5170 1 { Expiration: - 811412 Tr# 287999 -'� Type: Private Boston, MA 02116 Type: Corporation TAYLOR & BRYAN ASSOCIATES LLC. KELLY NEALE 768 SOUTH STREET SUFFIELD, CT 06078 Undersecretary NR I without signature . - _ • = = Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston Massachusetts 02108 Construction Supervisor License Update Address and return card. Mark reason for change DPS•CAI C, 50M- O5f0a- PC8490 Address Renewal Lost Card :Massachusetts - Department of Public Safetti Board of Building Regulations and Standards Construction Supervisor License License: CS 101410 Restricted to: 00 KELLY NEALE 768 SOUTH ST SUFFIELD, CT 06078 Expiration: 5/3/2012 ('•n llll ,,ucr Tr#: 101410 00 - Unrestricted _ 1G -1 2 Fatally Homes Failure to possess a current edition of the . Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS • 1 r _ r r cs ) . F) /L\ 1 I .' DESIGN - BUILD - REMODEL 768 SOUTH STREET, SUFFIELD, CT 06078 * TEL (860) 752 -6357 * FAX (860) 752-6358 * WWW.TAYLOR- BRYAN.COM Job Location: 80 Country Way, Florence, MA 01060 Subcontractor Name: Employees: Yes /No 1CM Home Improvement 'r P.O. Box 329 Workers' Comp Policy #: lv A. Leeds, MA 01053 �. f The Commonwealth of Massachusetts Vii*= Department of Industrial Accidents k Bost Office of Investigations 600 Washington Street � on, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly , I ` Name ( Business /Organization/Individual): I Li' 12- 6'(4, jy 3 ik`'` c-' Address: 7(s^ 5 i City /State /Zip: j%3Ef 1 (i. 6 Phone #: g,O -75 & 357 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. PE I am a general contractor and I 6. El New construction employees (full and/or part- time).* Cs have hired the sub - contractors 2.W I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling ship and have no employees A1,7 These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.gRoof repairs insurance required.] t c. 152, §I (4), and we have no �7c • employees. [No workers' 13. ig Other SOW ( t E.M1 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 da against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of th IA for insurance coverage verification. I do hereby c fy der jam y g , - %ms and penalties of perjury that the information provided is trr e and correct. Signature: Date: 1 l t (" Phone #: 00 . 1 )- - 6 3 '1 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 #: • • • ACORD_ CERTIFI OF LIABILITY INSURANCE OF bat °'""""' 3 03105/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Charles G. Marcus Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 842 Silas Deane Highway HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 290756 ALTENTHECOVERAGEAFFOROEOBYTHEpOUCIEGBELOW Wethersfield CT 06129 -0756 Phone: 860- 563 -9353 Fax: 860- 257 -8404 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURE 2 A National Orange Mutual 14788 INSURER Et DB& TAXLOR > COWAN* INSURER c 760 SOUTH SWAN= *CURER 0: SUFFIELD CT 06078 INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEBI ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD RIDICATED. NOTINTIHSTANDING ANY REQUIREMENT. TERM OR COMMON 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 70 ALL THE TERMS, D(CUJS1ONSAND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIN CLAYS LTR MARL TYPE OF INSURANCE PON x Y NIMBI DATE (1MLODITY) DATE YY] LIMB INSTOO I. LMBLITT EA01 OCCURFE NCE $ 1, 000 , 0000 a X COLDIERCIAL GENERAL LIABLITY 06271000 03/05/09 03/05/10 r oea�ience) $ 500,000 ( CLAIMS MADE n OCCUR N®ow(Ar► one person) _ S 5,000 PERSONAL 4ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,090 GERI AGGREGATE UMITAPPLESPER PROouCrs -OCAS OPA6G $ 2 Pam n . CTCT n LOC AUfOMOBLe LMBa.flY COWIPED SINGLE UNIT $ ANY AUTO (Ea accident) _ ALL OWNED AUTOS BODILY INJURY • _ SCHEDULED AUTOS (PerPesen) $ HIRED AUTOS GODLY INJURY NON-OYNH»AUTOS (Per accident) $ PROPERTY DAMAGE (Per a Mut) $ GARAGE Y AUTO ONLY - EA ACCD6Ur $ _ ANY AUTO EA ACC $ AUTO MY: AGG $ EXCESSAANIREUA LIABLITY EACH OCa>R $ OCCUR I I CLANS MODE ASE DEDUCIBLE $ RETENTION S s WOftKERS COMPENSATION AND 1T0R"r wt..a rAns " E1FLOYERW LIABILITY ANY PROPRERIRIPARINER/DIBZUTIVE EL EACHAOCW1T $ OFFICERIM62 EXCLUDED? EL DISEASE - EA ERirLOY$ If Al. PRO IS1C T LDISEASE- POUCTUPIT $ SPECW. PROVISIONS below OTHER oescernos OF OPETtADONS J LOCATIONS rve.Ix.ES N scansions ADDED BY eaKmmasaff J SPECMI. PIIOnIB1OIis CERTIFICATE HOL CANCELLATION SHOIRD NW OF THEABOVE Orate POLICES BE cmaiLLED BEFoSE THE EXPIRATION DATE 1FERE0F, THE 1BEWIG INSURER LL BDICFAYDR aw. 10 DAYS WRITTEN NOME TO THE CERTIFICKIE HOLDER HAYED TO DV LEFT, BUT 'AWOKE TO DO SO SHALL SIPOSE NO OBLIGATION ORLMIM.SYOF ANY NIB) UPON THE INSURER. ITS AGENTS OR NTATNEE 41 77/ 11 Z EN Z ACORD 25 (2001108) ® ACORD CORPORATION 1988 . SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 1� qq Not Applicable ❑ Name of License Holder : - I-L l"( . i- j G5 (E i 4 ( o License Number 72, ScorA ST. 5: 7 1 ct 66076 5131 :Zdl - Address Expiration Date f34 7'52 -(F 3`5 Signa ; -- ■ Telephone ed P' 9. R - • iste IT ome Im • rovement Contra tor: Not Applicable ❑ " (G- - P --y ' 4 1( Company Name Registration Number , 0 C xl -. Sr I I f iftAirk 010 '55 b i l4 1.2,01 Addr. s � 1.13" Expiration Date ie Telephone 361 - i 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 building permit. Signed Affidavit Attached Yes y 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 to. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing El Or Doors t] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding [0] Other [iXll] Brief Description of Proposed - f Work: AZ- NEPfh1�- �7 n11rt* FPw∎M r - l it- ( T-ur>Fi ll 1f.1w- jt (AJ(t( -fLIt. (u)Pii Alteration of existing bedroom Yes X No Adding new bedroom Yes )( No Attached Narrative Renovating unfinished basement Yes X 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, 00( l'APOOSIZ, , as Owner of the subject property hereby authorize 11 tA/k5 7 0W bv■Lhj ef. 1 i- A1 t q . NO Cc fil - p. ) ( to act on my behalf, in all matt relative to work authorized by this building permit application. O 1 e of Owner Date I, , ` V y W , 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 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 F- it,j6 140 This column to be filled in by C, tr Building Department Lot Size ,ZO �) 6 F I ,4 l 5 F; Frontage Setbacks Front 52. 1 Side 3e L: 25 R: 35 L: R: Rear 40 6 • Building Height 35 Z h_ p '''' 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 0 DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO tg DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO 1/jf IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO ti, 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 © NO (14 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. kla x Department use only City of Northampton Status of Permit: ;� Building Department Curb Cut/Driveway Permit , 212 Main Street Sewer /Septic Availability � \ Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 -587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office ., ,,,, j v i,�a�. i Map Lot Unit r'�. -C7 �`ic.t3t. - m t r4 i f 0 4 a jtk , Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ' -k7 I N V/Pc ` / 0 C o.iate iJrr -1, 1tr i M r olC Name int) Current Mailing Address: it)j-/A444— J ?).././6"-- Telephone { '1 , C� Signature ✓ �� ✓ \ / 2.2 Authorized Agent: -r w\ ? M (0 6G z . t ., kill fc, m 1 oto30 Name (Prin) 9,3 a Current Mailing Address: �. c-— '3 ii7 - - 1 3 6 l Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building tk I ° I UU � '7 � ''o (a) Building Permit Fee 2. Electrical b o (b) Estimated Total Cost of Construction from (6) 3. Plumbing e ,, Building Permit Fee U. 4. Mechanical (HVAC) r,; 5. Fire Protection b • / 6. Total = (1 + 2 + 3 + 4 + 5) ' l* I D i Vt5 , °' Check Number //9,g f t 6 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0307 APPLICANT /CONTACT PERSON KELLY NEALE ADDRESS /PHONE 768 SOUTH ST SUFFIELD (860) 752 -6357 PROPERTY LOCATION 80 COUNTRY WAY MAP 11 PARCEL 004 001 ZONE SR(100) / /WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �j Fee Paid d9- i/& Typeof Construction: REPAIR TREE DAMAGE (ROOFING,SIDING,TRIM & INT DRYWALL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 101410 3 sets of Plans / Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: A pproved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER: § Intermediate Project: Site Plan AND /OR Special Permit With 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 ' , ,..c.- 7 ' .2 Z Z r Signature of Building Official Da e 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. , . , 80:000NTitY WAY ' BP - 2010 - 0307 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 11- 004 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 -0307 Project # JS- 2010- 000408 Est. Cost: $10895.00 Fee: $66.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KELLY NEALE 101410 Lot Size(sq. ft.): 20211.84 Owner: MAHAR RICHARD S & BRENDA F Zoning: SR(100) / /WSP Applicant: KELLY NEALE AT: 80 COUNTRY WAY Applicant Address: Phone: Insurance: 768 SOUTH ST (860) 752 -6357 SUFFIELDCT06078 ISSUED ON:9/22/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR TREE DAMAGE (ROOFING,SIDING,TRIM & INT DRYWALL 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 9/22/2009 0:00:00 $66.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo