06-017 GUARD Workers' Compensation and Employer's Liability Policy
NorGUARD Insurance Company - A Stock Company
INSURANCE Policy Number JAWC332017
GROUP Renewal of JAWC224435
NCCI No.[25844]
Policy Information Page
____
[1] Named Insured and Mailing Address Agency
James D Ross FINCK & PERRAS INS AGENCY
PO Box 66 6 CAMPUS LANE
Whately, MA 01093 Easthampton, MA 01027
Agency Code: MAFINC10
Federal Employer's ID 061 - 55 - 9981 Insured is Individual I
Risk ID Number 0147592
Additional Names of Insured
(N2) JDR Builders
Locations on Policy
(L2) 177 State Road , South Deerfield, MA 01373
(01/29/2012 - 01/29/2013)
� [2] Policy Period
From January 29, 2012 to January 29, 2013, 12:01 AM, standard time at the insured's mailing address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $100,000
Bodily Injury by Disease - each employee $100,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in ,
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
_.] See Extension of Information Page - Schedule of Forms
[4] Premium -- _.____.m__. � �._._� .
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page) _...]
_
Total Estima Policy Premium $ 3,126 126
a.... .___
Total Surcharges /Assessments $ 164
Total Estimated Cost $ 3,290
INTERNAL USE XX Page - 1 - Information Page
MGA : JAWC332017 WC 000001A
Date :01/30/2012
MANOTE
16 South River Street • P.O. Box A -H • Wilkes- Barre, PA 18703 -0020 • www.guard.com
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : � � 1� — ' S n 1-[ % ` 0
License Num . - r
?LA Y it /Va. ttirrF l (,-'`cD l''► r9 . / o 6 4, / zc
Addres � 3 � Expiration Date
11- Sign t Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Th — ED) E (LS / 3a L.3 99
Company Name Registration Number
� �
i� t LP/ ,1 ,4 3 J � �)� 3 2--/
Address ' f Da te
Telephone S 7S ' ?
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 ❑ Replacement jndows Alteration(s) [] Roofing
Or Doors 1,�
Accessory Bldg. ❑ Demolition ❑ New Signs [E] Decks [E] Siding [0] Other [0]
Description o Pr�Rgpo d Ate'` , �-
Work: Brief ' cr 4 i l IC�J� O5 19N //U SA LC. k ip �/n wi eo try3
Alteration of existing bedroom Yes ){ No Adding new bedroom Yes << No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
Oa. 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?
y
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces er,Woodstoves Number of each
g. Energy Conservation Compliance/ Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 1 : ft. of wetlands? Yes No. Is construction within 100 yc Yes No
j. Depth of baseme • or cellar floor below finished grade
k. Will buildin• «.nform to the Building and Zoning regulations? Yes No .
I. Septic • nk City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
► ` `
I, (t v C(' ✓ a C, + R q IA , as Owner of the subject
property J '"��
hereby authorize -.J 1�'� T,) s S
to act on my behalf, in all matters relative to work authorized by this building permit application.
M 2- a1 ` i ! a.
Signature of Date
1, — `' V . 2.s -s , 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 rjury.
Print Name
2 r-2 7--2x/
Signature of Owner /Ag 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 Parkin paces
Fill:
(volume & Location)
A. Has a S eclat Permit /Variance /Finding ever been issued for /on the site?
NO 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 Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained t Obtained l , Date Issued:
C. Do any signs exist on the property? YES i NO et
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 (3
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
RECEIVED
Department use only
MAR •' la City of Northampton
Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
D r G arr ILDING INSPECTIONS Room 100 Water/Well Availability
' Northampton, MA 01060 Two Sets of Structural Plans
phone 413 -587 -1240 Fax 413 -587 -1272 Piot/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
25 i dit , % E Co 5 Map Lot Unit
\ /�' l � Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: p d
Name (RA Cur ; Mailing Address:
. ly 1 Telephone
Signature
2.2 Authorized Agent: g gay 2/ A/0,/-1,97-r--715-4.).,41/9_e,ez:,‘
' 1 ;I - " P ' e5 Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (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) Check Number
This Section For Official Use Only
Building Permit Num er: Date
Issued:
3 --2 ---/,2
Building Commissioner /Inspector of Buildings Date
357 HAYDENVILLE RD BP- 2012 -0758
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06 - 017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2012 -0758
Project # JS- 2012 - 001337
Est. Cost:
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JDR BUILDERS 074105
Lot Size(sq. ft.): 51705.72 Owner: RYAN WILLIAM J & LORRIANE M & T J RYAN & M M RYAN & E A RYAN
Zoning: SR(100)/ Applicant: JDR BUILDERS
AT: 357 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
P O BOX 4 (413) 665 -7587 WC
NORTH HATFIELDMA01066 ISSUED ON:3/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF & 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 3/5/2012 0:00:00 $70.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner