Loading...
31A-166 A CERTIFICATE OF LIABILITY INSURANCE 5i E 1MWDD YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Chris Sullivan _ Aquadro & Associates AtO,11 (413)586 -7373 (419)584 - 0859 No y EMAIL 355 Bridge St., P. 0, Box 357 ADDRESS -. ODUCE B.IDe 00006154 Northam ton MA 010 61 - � �— _ INEURER(S) AFFORDING COVERAGE � I/ INSURED INSURER Travele Indemnity Co.. __ 5658 ._ INSURER a :Phoenix Insurance c o 25623 VLADIMIR AGAPOV DBA QUALITY CLEANING SERVICES mum __ C � _ INSURERC Mutual _ 0005 134 8 3HELBURNE RD INSURER D :... ..� ...� . INSURERS: GREENFIELD MA 01301 INSURER F : COVERAGES CERTIFICATE NUMBER:CL112202735 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 ro 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TNSR.! _.._...._ - ....__....._.AbbL$DSR.. .._ °-- ... ..__. . POLICY EFF POLICY - ,.._. —.... ._. —.... ..... _. . —..... I : TYPE OF INSURANCE • INSR VINO - POLICY NUMBER IMMIDD/YYYY) (MMIDD/YYYY) LIMITS GENERAL LIABIUTY EACH OCCURRENCE $ 1,000, 000 MAGETO RENTEG , A 1 COMMERCIAL GENERAL LIABILITY II . PREMISE,I gmtrepce) 3 -- -, 300, 000 A l CLAIMS MADE }(I OCCUR 6802381L9742ND10 /20/2011 14/20/20121 MED EXP (Any one person) $ 5, 000 PERSONAL &AOVINJURY $ 1,000,000 J GENERAL AGGREGATE I $ 2,000,000 GEN'LAGGREG_ATE LIMIT APPLIES PER: . I PRODUCTS - COMP /OP AGG $ 2,000,000 PRO � .. rX 1 POLICY 1 ( JECT • I 1 LOC $ I AUTOMOBILE LIABILITY l I COMBINED SINGLE LIMIT 8 - -_ - -, • (Ea ecctdent) ANY AUTO BODILY INJURY (Per person) $ 100 , 000 B ALL OWNED AUTOS SA- 9439C327- 10 -SEL 1/12/2011 1/12/2012 ----- I BODILY INJURY (Per accident) $ 300, 000 1 X SCHEDULED AUTOS PROPERTY DAMAGE X 1 HIRED AUTOS (Per accident) $ X Uninsured motorist 81 split limit $ 100 , 000 _NON -OWNED AUTOS Medical payments $ 25,000 UMBRELLA LIAB 1 _1 OCCUR EACH OCCURRENCE $ _ EXCESS LIAB AGGREGATE $ - -{ I CLAIMS -MADE - ^ 1 DEDUCTIBLE l $... RETENTION $ I $ WORKERS COMPENSATION 1 WC STATU- 0TH- AND EMPLOYERS' LIABILITY Y / N .._._I TORY_LIM1i$ I Fft . ANY PROPRIETOR/PARTNER /EXECUTIVE 1 E L. EACH ACCIDENT $ 100,000 OFFICERJMEMBER EXCLUDED? N/A 6 / 18/2010 .6/1 @/2011 (Mandatory In NH) CT31S3788@6010 : E.L. DISEASE • EA EMPLOYEE $ 100, 000 If yes, decribe under DESCRIP OF OPERATIONS below E.L DISEASE - POUCY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN FOR INFO ONLY ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Johanna Kostek/JLK h,o '• ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD SECTION 8 CONSTRUCTION SERVICES 81 Licensed Construction Supervisor: c��,r� LCD � Not Applicable ❑ Name of License Holder : P & C - �1�.: cr �l JtJ q 6 6O License Number 33 P .u. iP3 ST_ ���tcU frM n(3o( 12/2.7 2.6(2. Addr ss / Expiratio Date �vl.itl. � . gnature Telephone (3) 6? — 2 (22 "lie : T `" eredF ` dais, m• rovemerit ontracto i Not Applicable ❑ V t ?PI iR /—` 9 oV 1 69 69 5 Company Name Registration Number (U, Ct C nJ 1 JQ55Tne ANT ON) '7/.2- 7/2—e t Address E p ation ate 13 (4 S . kk(a1 -'?i 0 g t R Q- Teleph 1 /74- - 7 - )37 _ CeLc NIFi.t9 r—ik 0t30\ 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 • J SECTION 5 DESCRIPTIQN'OF =PROPOSED WORK.(check all applicable) _ ., _,„ ,, 3 x New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 17( Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [0] Brief Description of Proposed Work: 1Q.X - PDF tN 01-m REA', Ae . 2 SQ _ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 60 Ateiridia sewn • addifion§ foexisting 'hoesiiiq�corispl iouuing: 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 SECTIO417a OWNER.AUTt1ORIZAT TO BE COMPLETED W1iEN,� OWNE coNTRACTOR FOR $UiLDiN ER1 ; , t _ * '.. ..... ,. ,b w '�. S ltve. � ... a ..-r a� _, . ... f, " n?? AA.) I S LIZ , as Owner of the subject property / hereby authorize V CA-0 klicce3 v to act on my behalf, i matters relative to work authorized by this building permit application. Signature of Owner Date , 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 Name Signature of Owner /Agent Date Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information , `" ` e Existing Proposed Required by'Loning '7 / This columnr:to be . lled in by Building Dto •.. .t t Lot Size `„ Frontage i i Y Setbacks Front j Side L:` 1 R:= L :_ . ? R:` 1 77 Rear = = Building Height i I I I j , Bldg. Square Footage 77 1 % Open Space Footage (Lot area minus bldg & paved I I ` pazking) # of Parking Spaces i Fill: - . __ .__.. _ ____ _.__ _._ _ (volume & Location) 1 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:I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I I 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: 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 88 MAYNARD RD BP- 2012 -0617 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 166 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2012 -0617 Project # JS- 2012- 001067 Est. Cost: $12000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: QUALITY CLEANING SERVICES 96600 Lot Size(sq. ft.): 7492.32 Owner: SLATER PAUL & MIRIAM SLATER Zoning: URB(100)/ Applicant: QUALITY CLEANING SERVICES AT: 88 MAYNARD RD Applicant Address: Phone: Insurance: 134 SOUTH SHELBURNE RD (413) 774 -7737 WC GREENFI ELDMA01301 ISSUED ON:1/3/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REROOF 20 SQ 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 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner