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GEORGE S GARVVOQD
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ACORD /} to atlLLft. UtP 111.:^ 0 %.1 I IGr
ACO(OGt/T. CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY)
11/29/2011
'ODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
'illiam Gallagher Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
surance Brokers, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
r0 Atlantic Avenue
oston, MA 02210 INSURERS AFFORDING COVERAGE NAIC #
>URED INSURER A: One Beacon Insurance Company • 21970
Next Step Living, Inc. INSURER B: A.I.M. Mutual Insurance Co. 33758
25 Drydock Avenue INSURER c: Riverport Insurance Company 36684
5th Floor INSURER 0: Hartford Fire Insurance Co. 19682
Boston, MA 02210 -2600
INSURER E:
DVERAGES
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.
R �100 T YPE O INSURANCE P OLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
NS RC DATE IMM/DD/YYYY) DATE (MM/DDIYYYYI
GENERAL LIABILITY 792000560 11/11/2011 11/11/2012 EACH OCCURRENCE $1,000,000
AMAGE X COMMERCIAL GENERAL LIABILITY P REM PREMISES ( occurrence) 51,000,000
CLAIMS MADE X I OCCUR MED EXP (Any one person) 510,000
PERSONAL 8 ADV INJURY $1,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $1,000,000
POLICY 78: LOC
AUTOMOBILE LIABILITY 390001209 11/11/2011 11/11/2012 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $1,000,000
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS
BODILY INJURY
X 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 I UMBRELLA LIABILITY 792000561 11/11/2011 11/11/2012 EACH OCCURRENCE $3,000,000
X 1 OCCUR 1 1 CLAIMS MADE AGGREGATE s3,000,000
DEDUCTIBLE $
RETENTION $ j $
i
WORKERS COMPENSATION AND 71733288 11/11/2011 11/11/2012 X I TORY ITS ! W ER
EMPLOYERS' LIABILITY
ANY PROPRIETOR /PARTNER /EXECUTIVE TBD106787 11/11/2011 11/11/2012 E.L. EACH ACCIDENT s500,000
OFFICER/MvMBEER EXCLUDED? I N
(Manddatary n ) E.L. DISEASE - EA EMPLOYEE s500,000
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT s500,000
OTHER
Property 08UUMHX5485 11/11/2011 11/11/2012 $212,594
ESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS
; ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Evidence of Insurance DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 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
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
',CORD 25 (2009/01) 1 of 2 #S239491/M239489 @ 1' 8 -2009 , CORD CORPORATION. All rights reserved.
11/16/06 TRU 17:04 FAX 617 393 2915 _.`_:,y ` - • rT: 0005
i
t The Contnronweallh of Massachusetts
.Ma.,-a
- Department of lndustriel Accidents
, "k 1: ::r • ,r Office of lntvestigations
3 t ;1 :. :r 606 Washington Street
t � fi ' Boston, MA 02111
_ _ -- www.massgov /die
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant )(valorisation Please Print UAW
Name ( Business /Organization/individual): k) Q 4 1 c , p k Iv; ,--) 1 h f
Address: c3. '0 ry (X;o c, k A -,,..
City /State /Zip: P3c 0 n V c, Mil 1 0 Phone #: (.4c at ) '( -) ' 4 s n-1
Are you are employer? Check the apP nice box: Type of project (required): 1. in I am a employer with ,_ _ J / 0 4. ❑ 1 am a general contractor and i 6. ❑ New construction (bill and/or part-time).* have hired the sub-contractors 7. ❑ Remodeling
2. ❑ I am a 9010 proprietor or partner- listed on the attached sheet
ship and have no employees These sub barn 8. ❑Demolition
working for me m any capacity. workers' P insurance. 9. ❑Building addition
No wokers' comp. insurance 5_ ❑ We are a corporation and its
cnqu r , ) officers have exercised their
10.0 Electrtr�l repairs or additions
3 ❑ I am a homeowner doing all work right of exemption per MGL 11.[] Plumbing repairs or additions
myself. (No workers' comp. c. 152, § 1(4), and we have o0 12.0 Roof repairs
insurance required.) t employees. (No workers' 13.1X1 Other Tr i w,
comp. Iaswinoe required.)
Any applicant dot checks box tt I must also hill out the section below showing theirwoekate' compensation policy information.
I Homoowoeas who submit this affidavit indicating they are doia<Yl work and then him outside onennaors must submit a mew afildavh Winning such.
aeomuadon that d:k niis box mutt amaebe4 so additional sheet showing ems name of the sub•eomtootors and their workers' camp• policy intonation-
f am an employer tray is providing workers' compensation insurance for my eagvloyu . Below is the poky mul job site
rnfontsaton.
Insurance Company Name: F e f vx \ 1 v, — cyle • e.
Policy tk or Self-ins. Lic. #: ) 1 ) 3 \ Z' OS - Expiration Date : t l i y l zo, Z
Job Site Address: City/State/ltp:
Attach a copy Odic workers' compensation policy declaradoa page (showing the policy number and expiration dale).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal ptaraldes of a
fine up to S1,500.00 and /or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the viol .. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance -'v - _ etlfic etion.
I do hereby oratiA, under the , . - ir of perjury that the hsformadonn provided above is Brace sad connect
r J• / _
/ +
Phone k: `/
Official use only. Do not write in this area, to be complied by city or town offideL
City or Town: Perusit/L.iccase #
issuing Authority (circle one):
__11 — Board of Health 2. Building Department 3. City/foram 16 kirk 4. Electrical Inspector- 5. Plumbing Inspector
f,. Other
Contact reason- Phone- k
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 01 Name of License Holder : (� 2: ��C 7t - r t _! ( a_0-
A �]�/ License Number z)
Address Expiration Date
C .. & /C -170 70 00
Signa Telephone
y, :a s _ .d__ it ,s "L°ibair; : .,i z V11 . Not Applicable El
c (-7 �S • cco 4360 5,
Company Name Registration Number
29 /1411A7 / , Z5rW /c /C✓ (J ) /-a.
���Cj v Ex
Address ira on Date
Expira
— Telephone5CP` ?' 7fC °7/X3
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 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.
Homeowner Signature
0
SECTION 5- DESCRIPTION OF PROPOSED WORK (heck all malleable)
New House Addition ❑ Replacement Windows Alteration(s) r Roofing n
Or Doors Cl
Accessory Bldg. El Demolition ❑ New Signs [0] Decks [( Siding [0] Other [DJ
Brief Description of Proposed
Work: ` Sc t7 e-- 14__7C�7 e / V G c vj
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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
1D 1070 - WHEN � . . " ` N Atou rottstftemo PERMIT
I, ro(27 6 . z Cy , as Owner of the subject
property / /�
hereby authorize ( O / -C � c 1 T e f
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1 , , 4i! (mil 1 , 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.
c-76.01cr - (7 ) / 4— 4.
Print N
� !1 IZ • 7 Lo
. ! - • gent 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 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 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 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
fi "� y, t - �,T ,, . . a F" �,
ty of Northampton �` I d f °'` ? Y
Fir-k-0 B ilding Department ,��1
' 12 Main Street . n .
DEC 2 (2Q ( Room 100 ;r �� } '
t
o a ampton, MA 01060 x ,3
- _,•� 3 -5 7 -1240 Fax 413- 587 -1272 „, A i mow
5 ^ 1 E d sg :I'M- 9'{'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
,e
(Lori I f - lJ T I
FLO cc M A d1C�(� ''
itnAtiletrktt
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
E ( J C--, Elf L= 2.��L LL 7 �-v f i s T t -�F"�' S r R rEMc�
Current Mailing
Name (Print) ng Address:
NExr _. a. , 9 ., C
,,c e
Telephone 1 . V
Signature (V .
2.2 Authorized Anent: L.k t l � i 0 5 1 N Cl'
Name Current Mailing AddresscjI5 & 5 rz
�O ______,,,./c _ �{� � — `7 / 0 0
Signature Telephone
$ T S - EST1M 'E c T I C9IVk TS
Item Estimated Cost (Dollars) to be _ Official Use Onty
completed by permit applicant
1. Building (a) Bu&Ing Petmit Fee
2. Electrical (b) i ' Total cost of
` , r a Eir
3. PlumbingiI�NttIIRI"
4. Mechanical (HVAC)
5. Fire Protection f �
6. Total= (1 +2 +3 +4 +5) �� • ' �9
I
Tlris$sctl+�n,F� � Date
Bu ildir Permit Number: Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File # BP- 2012 -0604
APPLICANT /CONTACT PERSON NEXT STEP LIVING INC
ADDRESS/PHONE 25 DRYDOCK AVE BOSTON (508) 410 -7100
PROPERTY LOCATION 67 WHITTIER ST
MAP 43 PARCEL 094 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out y ---
Fee Paid k(Y�
Tvpeof Construction: INSTALL INSULATION & AIR SEALING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 81022
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
I. 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 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
De :i • la
Signature of Building Official Date
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.
67 WHITTIER ST BP- 2012 -0604
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 43 - 094 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0604
Project # JS- 2012- 001049
Est. Cost: $1201.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NEXT STEP LIVING INC 81022
Lot Size(sq. ft.): 102801.60 Owner: REILLY EUGENE P
Zoning: SR(100) / /WSP II Applicant: NEXT STEP LIVING INC
AT: 67 WHITTIER ST
Applicant Address: Phone: Insurance:
25 DRYDOCK AVE (508) 410 -7100 WC
BOSTONMA02210 ISSUED ON:1/3/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL INSULATION & AIR SEALING
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 1/3/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner