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38B-137 (2) s , SINCE 1940 MILES BUILDING MATERIALS SUPPLIER Installed Subcontractors Project: RA?Kkpe c 0.rk,/1 Opo A Subcontractors: If you have employees you must provide your Workers' Compensation Insurance Policy Number Subcontractor Name: 4-7-pe givA5 Address: 5/ A f/A ( Sr 1/41-110fDP ,/ Phone: 1) Policy #t 1 e Insurance Company: (This form must be attached to Project Workers' Comp. Affidavit) Installed Project Subcontractors 2/12/2010 Acadia Insurance WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY ADDITIONAL LOCATIONS b .icy No. WCA 0240314 -12 Issued By Firemen's Ins. Co. of Washington D.C. Policy Period 01/01/2010 to 01/01/2011 NAMED INSURED AND ADDRESS AGENCY NAME AND ADDRESS 05111 (802) 362 -1311 R. K. Miles, Inc. 618 Depot Street W.H. Shaw Insurance Agency, Inc. P.O. Box 1125 135 Bonnet Street Manchester Center, VT 05255 -1125 PO Box 1067 Manchester Center, VT 05255 Location U.I.A.N. Name and Address Loc 1. 618 Depot Street Manchester Center, VT 05255 Loc 2. 691A Depot Street Manchester Center, VT 05255 Loc 3. 88 Exchange Street Middlebury, VT 05753 Loc 4. 385 Cole Avenue Williamstown, MA 01267 Loc 5. 24 West Street Hatfield, MA 01038 Loc 6. No Specified Location, NH Loc 7. No Specified Location, NY WC 00 00 01A 01/01/10 DAL 12/29/09 Original Acadia Insurance ?X 4. fhe premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. SEE SCHEDULE OF OPERATIONS EST ANNUAL Minimum Premium $ 1,000 Subject Premium $ 129,790 Premium Discount $ 13,098 - Expense Constant $ 338 Estimated Annual Premium $ 117,030 Terrorism Risk Insurance Act of 2002 (Code 9740) $ 515 Terrorism (9740) $ 552 Catastrophe $ 552 (other than Certified Acts of Terrorism) (9741) Vermont Assessment Fee $ 764 MA D.I.A. Assessment $ 2,908 Total Estimated Annual Premium $ 122,321 T Authorized Signature WC 00 00 01A Page 2 Original Acadia Insurance WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI Carrier Code #27723 P,_icy No. WCA 0240314 -12 Issued By Firemen's Ins. Co. of Washington D.C. Previous Policy WRA 0240314 - 11 One Acadia Commons Westbrook, Maine 04098 1. NAMED INSURED AND ADDRESS AGENCY NAME AND ADDRESS 05111 (802)362 -1311 R. K. Miles, Inc. 618 Depot Street W.H. Shaw Insurance Agency, Inc. P.O. Box 1125 135 Bonnet Street Manchester Center, VT 05255 -1125 PO Box 1067 Manchester Center, VT 05255 F.E.I.N. 030141661 U.I.A.N. Bureau File No. 911735261 State: VT Entity of Insured: Corporation I LOCATIONS I See Attached Schedule of Locations POLICY XERIOD 2. The Policy Period is from 01/01/2010 to 01/01/2011 12:01 .AM Standard Time at the insured's mailing address. L COt RAGES 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA, NH, NY, VT 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 $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND, OH, WA, WY AND STATES DESIGNATED IN ITEM 3A OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedules: SEE SCHEDULE OF ENDORSEMENTS This policy is: X Direct Bill 12 Pay Plan Agent Billed WC 00 00 01A Page 1 Original /i Acadia Insurance WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY SCHEDULE OF OPERATIONS MASSACHUSETTS Policy No. WCA 0240314 -12 Issued By Firemen's Ins. Co. of Washington D.C. Policy Period 01/01/2010 to 01/01/2011 NAMED INSURED AND ADDRESS AGENCY NAME AND ADDRESS 05111 (802)362 -1311 R. K. Miles, Inc. 618 Depot Street W.H. Shaw Insurance Agency, Inc. P.O. Box 1125 135 Bonnet Street Manchester Center, VT 05255 -1125 PO Box 1067 Manchester Center, VT 05255 Premium Basis Total Estimated Rate Per Estimated Code Annual $100 of Annual Loc No. Classification Remuneration Remuneration Premium 4 8058 Building Material Dealer - new 169,000 3.45 5,831 materials only: Store Employees 4 8232c Lumber Yard - new materials only: 188,000 4.87 9,156 All Other Employees & yard, warehouse, Drivers 4 8742 Salespersons, Collectors . or 44,000 .20 88 Messengers - Outside 4 8810 Clerical Office Employees NOC 71,000 .12 85 5 8058 Building Material Dealer - new 200,000 3.45 6,900 materials only: Store Employees 5 8232 Building Material Dealer - new 408,000 4.87 19,870 materials only: All Other Employees & yard, warehouse, Drivers - 5 8742 Salespersons, Collectors or 309,000 .20 618 Messengers - Outside 5 8810 Clerical Office Employees NOC 269,000 .12 323 5 5437 Carpentry - Installation of Cabinet 60,000 5.93 3,558 Work or Interior Trim Subtotal: Premium Subject to Modification 46,429 9807 Increased E. L. Limits 1.00% 464 9898 Experience Mod Fctr 0.87 6,096- 0277 ARAP 1.00 0 Subtotal: Subject Premium 40,797 WC 00 00 01A Page 1 Original \ The Commonwealth of Massachusetts Department of Industrial Accidents _= ° Office of Investigations '^tci!►l M 600 Washington Street Y .' = zr Boston, MA 02111 .'t, . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): R. k /1 /I5 C, l Address: 21 / S1 ' / City /State /Zip: /14 / F1 tCCD /IA O Phone 4: ^), - ,el7 �3a )( // s Are you an employer? Check the app b x: 4, Type of project (required): 1. ❑ I am a employer with am a g eneral contractor and I 6. ❑ 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. ❑ Demolition working ca employees and have workers' g for me in any capacity. �' 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.] f c. 152, §1(4), and we have no n employees. [No workers' 13.P.2 tither GUJJV, pAl nk ,D6e comp. insurance required.] Rt"Ri4 CEA ffiV7 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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: ACA b/A — /, , — �V &RA /i CE Policy # or Self -ins. Lic. #: W rA 024o3/4,--/z, Expiration Date: / - r�/ f Job Site Address: 7/ (. COL- 631' S A vT - City/State /Zip: L7 f c7// i) 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 kz a pal s and penalties of perju info provided above is true and correct. ./ T2 Signature: •, NAnfR(rfk Date: / Phone #: 4/3 -217 J f3 7l fig Official use only. Do not write in this area, to be completed by city or town official • City 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 __ — alt et erson. _. " - _ Phone #: g -� , , - / _=,____ t Sir= 1 7:.=_ _ Office of Consumer Affairs and Business Regulation 10 Park Plaza -Suite 5170 °y Boston, Massachusetts 02116 • Home Improvement Cjantr actor Registration - _ Registration: 165435 `~, Type: Private. Corporation . ' Expiration: 2/17/2012 Tr# 293477 R.K. MILES, INC. DAVID NORRIS `"' - -' , 24 WEST ST ROUTE 5j NORTH �- ,0£ WESDT HATFIELD, MA 01088 - y am. Update Address and return card. Mark reason for change. ❑ Address 0 Renewal El Employment 0 Lost Card DPS -CA1 0 50M- 04/04- G101216 Ow -690.0 a ea1Ct o/ aaac/iuee -- 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 - . -- Aingi Registration = 165435 1 10 Park Plaza - Suite 5170 Expiration 17f2012 Tr# 293477 Boston, MA 02116 Type ' Prnates Corporation R.K. MILES, INC 1 z = ° — � � /�� Board of Building an - - DAVID NORRIS -, ` g Department of Public Safet3 24 WEST ST ROUTE 5 lE RTH ' � -,� i U l f Regulations and Standard WESDT HATFIELD, MAN-01088 Undersecretary Not valid witho t signature Construction Supervisor Specialty License License: CS SL 103888 Restricted to WS # 111 0 1111 k DAVID NORRIS 195 CHESTNUT ST ; BRATTLEBORO, VT 05301 1 --� ----- Expiration: 11/2/2013 (' o mmissi one r Tr#: 103888 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: D i l i U /. � O R)$ /0 3 ill License Number / ` 7t6 N nT Sr � 3 � L�,��R a, ll % // 7 70)3 Address J Expiration Da / /42X11/1'; '11,3 Si/a, Signature Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration tuber 24 1,Dfs - r 4.7 ) b r � � JJ ) 2 ) 7 2n)2 Address ,,. Expiration ate Telephone Z� 0.P d 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 ❑ 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 . SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition [] ReplacementOndows Alteration(s) n Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D] Brief Description of Proposed / �/ / , l .r Work: T'G =� /� ��1.*l.(��1"�;L� '' ,,:��'-' ✓J"C %� • Alteration of existing bedroom Yes >4 No Adding new bedroom Yes x No ,/ Attached Narrative Renovating unfinished basement Yes AC_ 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, , as Owner of the subject property hereby authorize A `7 101 J� VT /WAS D- J. /`�� /)) C-f C- to act o my ehal , ' all matter lafive to work authorized by this building permit a plicatig�i. ,--1..-4._,/--g._, 11 l2c. fl G, Signature of Owner Date I, , as Owner uthorized j en he by declare that the statements and information on the foregoing application are true and accurate, to the best of knowledge and belief. Signed under t pains and p- nalties of perjury. 1 , Print Name c , Signature of Own -r /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 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW 0 YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO >; 3 DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Ift IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO Qf 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. I Department use only City of Northampton Status of Permit: Building Department Curti cut/Driveway Pe 212 Main Street Sewer /S Availabi Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 41'3- 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 Map Lot Unit . 7, < 1 coz W,,`J Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: > i /P ). � , � (01.;4 l �5 iV ; A4/ Name (Prir j Current Mailing Address: 4'13 ! • 4 - 3 f ` Telephone Signature 2.2 Authorized Agent: tiA ftp‹- A)T-Lr it). 4A7Fict4 Name (Print) ✓ Current Mailing Address: I -1/3- 42 °13od 747 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building M 2117419- (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) // g Z'1 ? Check Number / / q 035 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date � T 27X °'` BP- 2011 -0481 GIS #: COMMONWEALTH OF MASSACHUSETTS 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- 2011 -0481 Project # JS- 2011- 000787 Est. Cost: $10987.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R K MILES INC 10388 Lot Size(sq. ft.): 17206.20 Owner: BRICKER PHILIP & MARGI CAPLAN Zoning: URB(100)/ Applicant: R K MILES INC AT: 72 COLUMBUS AVE Applicant Address: Phone: Insurance: 24 WEST ST (413) 447 - 8300 WC WEST HATFIELDMA01088 ISSUED ON:11/23/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 11/23/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner