36-119 P 'II,TRONS MUTUAL INSURANCE COMPANY OF CONNECTICUT 40
GLASTONBURY, CONNECTICUT -
A ITISAN CONTRACTORS POLICY DECLARATIONSr
P ':icy Number: CTR0000234 RENEWAL Effective date: 07/20/11
i MED INSURED AGENT 7040
OHN JOSEPH ALUEGENA R.G. NEYLON INSURANCE AGENCY, INC.
01 PALMER ROAD 2 AMHERST ST.
I/ARE, MA 01082 PO BOX 1220
GRANBY, MA 01033 -1220
(413)487 -9133
1icy Period: from 07/20/11 to 07/20/12 12:01 a.m. Standard Time at your mailing address shown above.
isured is: INDIVIDUAL
usiness Classification: CHIMNEY CLEANING (RESIDENTIAL ONLY) Code: 10042
LIABILITY _COVERAGE
OVERAGES LIMITS OF INSURANCE
Bodily Injury and Property Damage Liability $1,000,000 Per Occurrence $2,000,000 Aggregate
1. Medical Payments $5,000 Per Person
Products /Completed Work $1,000,000 Per Occurrence $2,000,000 Aggregate
. Fire Legal Liability $50,000 Per Occurrence
Personal and Advertising Injury Liability $1,000,000 Per Occurrence
PROPERTY COVERAGE
DESCRIPTION AND LOCATION OF PROPERTY
,Dc. 1: 401 PALMER ROAD WARE, MA 01082
OVERAGES LIMITS OF INSURANCE
_ Loc. # Building # Limit ACV
. Building
. Business Personal Property 1 1 $2,500
. Loss of Income ACTUAL LOSS SUSTAINED, NOT TO EXCEED 12 MONTHS. WAITING PERIOD: 72 HOURS
! Property Off Premises: Automatic Increase - Coverages A & B: 0% ANNUALLY
-operty Deductible: $500
SUBJECT TO THE FOLLOWING FORMS AND ENDORSEMENTS
P -100 Ed. 2.0 AP 0611 01 99 AP 0643 12 99 AP 043212 03 AP -222 Ed. 2.0 GL -895 Ed. 2.0
P 0700 01 08 AP 0688 06 02 AP 0690 06 02 AP 0692 06 02 AP 036510 06 AP 0233 01 08
PREMIUM AND BILLING INFORMATION
.NNUAL POLICY PREMIUM: $1,246 $500 Minimum Earned Premium Regardless of Term
NDORSEMENT PREMIUM: BILL TO: Direct Bill To The Insured
ERRORISM PREMIUM: $27
MORTGAGEES
I LINTED: 06/06/11 INSURED COPY THIS IS NOT A BILL
0
ZURICH WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6ZZUB- 0578N48 -7 -11 )
RENEWAL OF (6ZZUB- 0578N48 -7 -10)
INSURER: AFRICAN ZURICH INSURANCE COMPANY
1 NCCI CO CODE: 80012
INSURED: PRODUCER:
ALIENGENA, JOHN DBA ST GERMAIN INS INC
ABSOLUTE CHIMNEY SERVICE PO BOX 630
401 PALMER RD WARE MA 01082
WARE MA 01082
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period Is from 03 -21 -11 t0 03 - 21 - 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: $ 100000 Each Accident
Qom Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: 100000 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
D. This policy includes these endorsements and schedules:
o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
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: 03 - 14 - 11 WC ST ASSIGN: MA
OFFICE: ZURICH -ORLAN 809
PRODUCER: ST GERMAIN INS INC 76W3R
011040
r
411 Massachusetts - Department of Public Safet}
Board of Building Regulations and Standards
Construction Supervisor Specialty License
License: CS SL 101365
Restricted to: SF
JOHN ALIENGENA
401 PALMER ROAD
WARE, MA 01082 itrib
- -e-- — y-- Expiration: 7/20/2012
f u Mill i..i'Me Tr#: 1
,.. ijfte - Vr anv nonlueah7 oi✓K 4 iac%€lde a
` ,_ Office of Consumer Affairs & Business Regulation
-_ `F HOME IMPROVEMENT CONTRACTOR
4, ' 161245 Type:
r t Expiration: 10/7/2012 DBA
ABSOLUTE CHIMNEY SERVICE
JOHN ALIENGENA
401 PALMER RD 4"...e----„t9..5___
WARE, MA 01082 Undersecretary
City of Northampton
KH le f .k 4:,;,, S s � � $n .
Massachusetts - ,'e
DEPARTMENT OF BUILDING INSPECTIONS ' r te :
M
" `✓ 212 Main Street • Municipal Building ');
�� N orthampton, MA 01060 Ct WO
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
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made r
xi g 1
' I understand the above.
( Home owner /reside t' signature requesting exemption)
I will call to schedule all requi ed building inspections necessary for the building permit issued to me.
Date //// I/ //
Address of work location dti 1) 6c-6k,</d0
) mu [f a 61062.
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
_ mamm _ Office of Investigations
= 4, # ! l Washington Street .
0, wool: �:. I Bos i n MA 02111
' i , .mass.gov /dia
Workers' I , , I • , - - ' • • ance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business / Organization /Individual): 4b5 (e (l2 C/W
6 7 ✓ "/ it L e
Address: /ot f[ij M Kt
City /State /Zip: G e rr ` ( friA/ � t (J1 �' Phone #: `11 3 Q0
Are you an employer? Check the appropriate box: Type of project (required):
1. Ltd 'I -am a employer with 1 4. ❑ I am a general contractor and I 6. 111 New construction
employees (full and/or part- time).* have hired the sub - contractors
listed on the attached sheet. 7. ❑ Remodeling
2. I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. El Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. ❑ Other C ( / ( (fre(
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: A e r i c e v t - / Z t 1 C ` 1 i 11 ' G' d'0 ille —
•
Policy # or Self -ins. Lic. #: Ip 2. Z 03 G 5 7 N y 7 -/Q Expiration Date: 3 - d-f I
Job Site Address: ( 4 yo t3rr&k5 Cf rC (e City/State /Zip: FIU -C I1/ , vf c)
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.
./
ature / Da ti
Phone #: V( i'° 7' 6
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 #:
J
J
r SECTION 8 - CONSTRUCTION SERVICES
1 8.1 Licensed Construction Supervisor: . No • Appl ❑
Name of License Holder : Tnh 1I/ 3 A e � coo-'A - ( 5 SL 10/ 3
License Number
dal 0'No r f v J1/ - o(d $9- 7 - (4-C -1) -
Address Expiration Date
4.411, 1 107_ �- � d=-
Si. ' !ur: Telephone
` ,Re • is ereiL- Hortre m : rovemerit.Con .'ctor, "°°° Not Applicable ❑
: o6 (ea p /V.q- i t,/' c ---
Company /6 r Name // Registration Number
"4 1/ (A »i / lerci c e , . ` o f eit
Address Ex Date
3 J/( PialmL *fl 1(t7- T elephone b
0 WORKERS' COMPENSATION INSURANCE AFFIDAVIT {M G L c 152, §
z SECTION 1 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 ermit.
Signed Affidavit Attached Yes No ❑
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.
_ i
Homeowner Signature
( l iV r°-e.-C1
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) ,,
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks E0 Siding [0] Other [0]
nef Description o P ..ose. f ► .. Work: 4 0 " / .' 40 r i 1 1.4 1 !, .1 /) 1/0 01 f
Alteration of existing bedroom Yes No Adding new •edroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sal ew ouseiri r3 addition a ici iTa aliinzi aamplete.tiiefollowing:
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 B C WHEN
OWNERS AGENT OR APPLIES FORBUILDING PERMIT x:
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, , 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 penaltie cif p rju' ,
Print Name
� I 1 r, _� 1 / 7q l
Si of Owner /A•
, n Date
t ,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by'Loning m$t
This column to be filled in b
Building Department
Lot Size I I I !1 ' .
i
Frontage
Setbacks Front I I a-
Side L:_____ R:' L:' . i R:1 ......___J I I
Rear I
Building Height s l --'
Bldg. Square Footage { 8
'Open Space Footage % ;
(Lot area minus bldg & paved - { I I i
parking)
1 3 n j 1
# of Parking Spaces
Fill: ._..._ ..... _.._..._.__ _. _..___. e
(volume & Location) !
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT 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 i 1 Page and /or Document #1 s
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 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: ,, 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:
1
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.
t
Depart • e m t u :
se only *� 0
City of Northam Status of P e r ms
•
Bu ilding Department C • L rluew - :rm -
" 212 Main Street Se er /Sep is a labih � ti
Room 100 W . `..e vWel Av ,. . - :�
DEPT oFSU% RroH o °NS o rthampton, MA 01060 Ta e s o t at e la - � ., , �_
E
NO S phone 413- 587 - 1240 Fax 413-5 87 -1272 P a S l e P an f
Other Spec ify � ,.?
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO F A MILY DWELLING
SE CTIO N 1 - SI IN FORMATION
//� , Th i s section to be completed by o „ , , k
1.1 Property Address : . . n q, - * , tt
� � ^+ Jac,... ` I..QQ "!Map Lot r'-,, _- T Un �A
PO i ` �.. O 0 ''a" Cl § k ' '. 1 + r a a +, g ;e , k. +,,� ,„. -",'� *
f '+ On . � ' r n ,,°:,, '` OVeI' r :.:, r. ` z, s::, i l t'' -' .`.c "s�,
District ` - -.. CB District -
SECTI '2' - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Recor :
t - Io �1 �� � ( C� �` D�i'ICe
Name (Print) C :::: 1h1 Address �J `.—
, one 1
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
S 3 - E CON STRUCTION.COSTS
Estimated Co st (Dollars) to be Official Use Only
completed by permit app licant
1. Building 1" COL' �— ( a ) ` B ui lding Permit Fee
Item
2. Electrical (b 'E Tuta! Cos o f
Constru fr ( 6 )
3. Plumbing Building- Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section Fo r C 9ci Ilse Onl
v
Date
Building Permit Number, ,
Issued. �� � ; .
Si
Buildi Comm is s ioner /Irispector •o B Date
240 BROOKSIDE CIR BP- 2012 -0494
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 119 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: chimney rebuild BUILDING PERMIT
Permit # BP- 2012 -0494
Project # JS- 2012 - 000828
Est. Cost: $1325.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN ALIENGENA 101365
Lot Size(sq. ft.): 18469.44 Owner: HOECKH RICHARD E
Zoning: URA(100) //WSP II Applicant: HOECKH RICHARD E
AT: 240 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
240 BROOKSIDE CIR WC
NORTHAMPTONMA01060 ISSUED ON:11/17/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL CHIMNEY LINER
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 11/17/20110:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner