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18C-136 SINCE 1940 MILES BUILDING MATERIALS SUPPLIER • Installed Project Subcontractors Project: J ( � U iJi tirv1,iblie j L,q)Q Subcontractors: If you have employees you must provide your Workers' Compensation Insurance Policy Number Subcontractor Name: Ri ` 9 Ut5/6/ • Address: 10 4 J f th .S i 0"-P/if f • Phone: 4r;-, / 1— 9 Y Policy #: C. �.C Insurance Company: t.� 61d &7"& (This form must be attached to Project Workers' Comp. Affidavit) Installed Project Subcontractors 2/12/2010 r. , ' - A'CORO CERTIFICATE OF LIABILITY INSURANCE 1 01/05/2011 PRODUCER (802)362 -1311 FAX (802)362 -3316 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 'W. H. Shaw Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 135 Bonnet Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 1067 Manchester Center, VT 05255 -1067 INSURERS AFFORDING COVERAGE NAIC # INSURED rk Miles, Inc. INSURER /V. Firemen's Ins Co of Washington PO Box 1125 INSURER B: Manchester Center, VT 05255 -1125 INSURER C: INSURER D: 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 I TR INSRI; DATE IMM/DIWY1 DATF IMM/IIt1/YY■ GENERAL LIABILITY CPP 0012473 26 01/01/2011 01/01/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 250,000 PRFMI.SFC vanrol CLAIMS MADE n OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 X I POLICY n jEC n LOC AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ^r 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 AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA UABILITY EACH OCCURRENCE $ _ - n OCCUR n CLAIMS MADE AGGREGATE _ $ DEDUCTIBLE $ - RETENTION $ S WORKERS COMPENSATION AND WCA0240314 -13 01/01/2011 01/01 /2012 I TORY I IMITS I O FR EMPLOYERS' LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 500,000 Ii yes, describe under SPECIAL PROVISIONS below E L DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS Installation of Windows, Doors etc. in Massachusetts. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. To Whom It May Concern AUTHORIZED REPRESENTATIVE � J Marianne Connor /MCONNO ACORD 25 (2001108) © ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents -_' ` . Office of Investigations €...•,..- . --"� 600 Washington Street t ,� = ° � Boston, MA 02111 ^x iii www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /Individual): R. , . Al /Ics ___J1/C1 Address: ,21 /,<) '7 S/ ^ City /State /Zip: /7 /FIN) i-/A Ogff Phone #: ^ J, / e1 g3N )(//8 Are you an employer? Check the appropriate b x: Type of project (required): 1. ❑ I am a employer with 4. am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction 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. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ 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 12.0 oof repairs insurance required.] t c. 152, §1(4), and we have no l3 ther WZMONs) "€ 2) , employees. [No workers' comp. insurance required.] R ' ?/) C- *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: ( ?1 t//3 — /VS-7 A Ai c _ Policy # or Self -ins. Lic. #: wry( OZ o /5 -• / , j _ Expiration Date: 07 07 2 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 o the DIA for insurance coverage verification. I do hereby ce ti under a pal s and penalties of perju that the inform ? lion provided above is t we and orrect Signature: - i /i ' �' - MA/VR6� is Date: J Phone #: 4/ 5 -2 ,673,e) ,673,e) fi p 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 #: _ _ SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable � ❑ 2 �`�/ Name of License Holder : .DA V it J V (// �J `/./ �/ Y !I License Number /7.5- ESr II I 4gA--ter 335, , Y ` // 2 zca Address l Expiration D to " XtinL Signature Telephone 9. Registered Home Improvement Contractor "' Not Applicable ❑ /e�5 - �3Y Company Name I Registration Numbe ,4 /Js i 57- ,e�/l7 A90/2, Address f � Expiration ate f ! /iT �° iWJ / i /� / �j Telephone // 4 — 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 )4_ No ❑ 11. — : Home .Owner Exempt 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) n Roofing I 1 Or Doors El Accessory Bldg. El Demolition ❑ New Signs [D] Decks [[] Siding [D] Other ] Brief Wo k Description of Proposed teigcf rx/ . fUg Po/Er,/ c ptivi s Alteration of existing bedroom Yes �-- No Adding new bedroom Yes `' X- No ,,,,r 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 A NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i C .1 I, ' _ -./ AI; _ , as Owner of the subject property hereby authorize j) 1/F AbeRa 6 F Eie, //i(,� ) /i) C to act on my alf, in all matters relative to work authorized by this building permit application. o be . C i-v , ,t7 J J. 2 V 2 11 Signature of Owner Date I 42/3t c/ / f7: (1L1 as Owner /Authorized Agent hereby declare that the st ements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed er the pains and penalties of perjury. i 1 ) r Lt .,1 - f' Q /L_ Print Name 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 0 DONT KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW (3 YES 0 IF YES: enter Book Page and /or Document # 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 0 , Date Issued: C. Do any signs exist on the property? YES (3 NO 0 IF YES, describe size, type and location: 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: 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 V IF YES, then a Northampton Storm Water Management Permit from the DPW is required. \ Department use only ckiCj ity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit 2 2Z ° 12 Main Street Sewer /Septic Availability A Room 100 Water/Well Availability • ampton, MA 01060 Two Sets of Structural Plans :- + • -+i'': ✓ : ne 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 Pro pert Addres I /7 This section to be completed by office • 8vz //fLi. Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ��� 7,5 8cRT LRl)E gitioba ) ,, Current Mailing Address: /f / „_ 6 -1 ,[ d 6 i L % ?( e_ ic Telephone s t / �1 Signature 2.2 Aut rized Agent: o/ 'liOR / , .l'liit's 24 /,t)Esr ST 1.Ali77ir ✓4 Name (Print) Current Mailing Address: !24:y j i3 - �2 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only co leted by permit applicant 1. Building 63 � / t-�- (a) Building Permit Fee 2. Electrical / J (b) Estimated Total Cost of Construction from (6)__ 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) f ;co s 5. Fire Protection i63C 6. Total =(1 +2 +3 +4 +5) 7 Z5, 01 / / r Check Number /11f This Section For Official Use Only Building Permit Number: I Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0186 APPLICANT /CONTACT PERSON R K MILES INC ADDRESS/PHONE 24 WEST S WEST HATFIELD (413) 447 -8300 PROPERTY LOCATION ' • BLACKBERRY LN (. MAP 18C PARCEL 12 001 ZONE URB 100 / U THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out r 3 Fee Paid //4/ VV Typeof Construction: REPLACE PORCH COLUMNS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 10388 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN PRESENTED: Approved 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 Peiniit 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 ay, 1, 1 Date Signature of Building Official g g 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. 68 BLACKBERRY LN BP- 2012 -0186 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C - 136 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -0186 Project # JS- 2012 - 000291 Est. Cost: $3725.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R K MILES INC 10388 Lot Size(sq. ft.): 10846.44 Owner: CALLANDER ROBERT A Zoning: URB(100)/ Applicant: R K MILES INC AT: 68 BLACKBERRY LN Applicant Address: Phone: Insurance: 24 WEST ST (413) 447 -8300 WC WEST HATFIELDMA01088 ISSUED ON:8/25/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE PORCH COLUMNS 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 8/25/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner