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38B-040 r Lase or registration valid for individul use only before the expiration date. If found returu_to: Beard of Building Regulations and Standards . I One Ashburton Place Am 1301 Boston, Ma. 0210$ Not 41;(4k. without signature o a A Restricted to: 00 00 - Unrestricted 1G -1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS r c Bu alia:1ofis and YStandards Board e oatdseeekh s 1 1 -' - 6 HOME IMPROVEMENT CONTACTOR I ''' j �.� R.ilistr t; 153246 n s /13/2010 Ti* 284644 FOX BUILDERS ' MARK GIBSON a f — a. ti " 44 O V E R H A N D R � ! � GREENFIELD, MA 01' ''*.'00 Massachusetts - Department of Public Safe Board of Building Regulations and Standards Construction Supervisor License License: CS 102478 Restricted to: CIO MARK GIBSON 44 OVERLAND RD GREENFIELD MA 01301 � — G — — Expiration: 12/3/2012 ■ Commissioner Tr#: 102478 i ® DATE (MMIDD /YYYY) / 'A� ° CERTIFICATE OF LIABILITY INSURANCE 7/14/2010 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(ies) 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 Christine Sullivan NAME: ,quadro & Associates (aHC °,NNo,Ext): (413)586 - 7373 F4X (413) 584 -0 85 9 (A /C, N E-MAIL - _ - -- 1- - - —- 355 Bridge St., P. 0. Box 357 ADDRESS_ PRODUCER 00006980 CUSTOMER ID #: tiOrthampton MA 010 61 INSURER(S) AFFORDING COVERAGE NAIL # INSURED INSURER A :Preferred Mutual Insurance Co 15024 INSURER B : Mark Gibson, DBA: Fox Builders & Remodeling INSURER C: j 11 Summer St INSURERD: INSURER F : Greenfield MA 01301 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1071402263 REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD r- 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, XCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !NSA. j ADDL SUBR POLICY EFF POLICY EXP LTR [ TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM /DD/YYYY) (MM /DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000 , — DAMAGE TO RENTED 100 000 ' X COMMERCIAL GENERAL LIABILITY PREMISESfEa occurrence) $ s 7/14/2010 17/14/2011 �1 CLAIMS -MADE X OCCUR QPAC0100113629 MED EXP (Any one person) $ 5 , 0 0 00 • PERSONAL & ADV INJURY $ 500,000 . _ - -. GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 1,000,000 i • POLICY 1 ECT I LOC $ • I „ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ j ANY AUTO - (Per r - ' 1 BODILY INJURY (Per person) $ ALL OWNED AUTOS - — — BODILY INJURY (Per accident) $ HIRED AUTOS j PROPERTY DAMAGE $ SCHEDULED AUTOS (Per accident) C ,_ _I NON -OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ (I RETENTION $ I $ WORKERS COMPENSATION l I WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N —_ - TORY LIMITS ER ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT _ $__ OFFICER/MEMBER EXCLUDED? N / A - - -- - '" (Mandatory In NH) E.L. DISEASE - EA EM PLOYEE $ • If yes, describe under DESCRIPTION OF OPERATIONS below I E.L. DISEASE - POLICY LIMIT $ bESCRIPTION OF OPERATIONS / LOCATIONS / 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 MARK & BRENDA POIRIER ACCORDANCE WITH THE POLICY PROVISIONS. 20 BLANCHARD ST CHICOPEE, MA 01020 AUTHORIZED REPRESENTATIVE C Sullivan /CMS t %rea_ + ( - crutic ' ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. 1 INS025 (200909) The ACORD name and logo are registered marks of ACORD G '1e/ 4:o a ndz r Acceptance Signed By: )40,21C-- dete4;>4 Date: A s /°? 0/0 Print name: When both parties sign this proposal, this instrument constitutes a legal and binding contract between the parties. This proposal may be withdrawn if not accepted within fifteen (15) days from date of submission. Fox Builders Proposal submitted by: hSn.v Date of submission: Proposal submitted to: Job information: Ai S•••+le �--1 vN .L Scope of work: Se Sc,o•. ,F cad+-k Plans and Specifications: N /,4 Nora,: &ct.. >''taT.a. t. filic wac t'P Ids $ eta..e7t [Proposal is based on the submitted plans, with revisions as indicated.] Fox Builders proposes to furnish the aforementioned material and/or labor in accordance with the above conditions for the sum of 6 6.3s oo Dollars ($ ). Proposed price shall remain in effect for a period of months from the date of acceptance. Any work required under this proposal after this date is not covered within the scope of this proposal. Payment Schedule: a /� 02.• 3.5- f>e-yac)4-- ce,o.ap — o�..�ei' •t i cr - >o. ' -.e lc: P y , ..,. ! /ta. m+cak. T 'Mao Al< Gib SoAr Payments to be made as listed above. Payments not received by invoice due date shall be considered past due. Past due accounts will be charged an interest charge at the rate of 1.5% per month until the balance is paid in full. No release of lien shall be signed unless all payments are paid in full. Fox Builders Signed By: t2" J Date: This is your authorization to complete the work as outlined above according to conditions on the front and reverse sides of this proposal. 9•7EC1 urarnsiSas,m ICE 10 VPYPfa?RSaauO 3.i ZOt ISO Pac!*u:mn saa.u$ a:c:cn; I I srorq:J Y ASSN gunaPm.W , apt! ±o; 0 sxg P $[0.11 I � sa=ns W.S W . LIT FOX BUILDERS & REMODELING 11 Summer Street Greenfield, MA. 01301 Phone 413- 475 -3725 Mrg3@comcast.net September 3, 2010 Scope of work We here by agree to supply the following: The installation of dust control on 2nd floor (poly) The removal of existing medicine cabinet, vanity, vanity top, faucets, toilet & tub The demo of existing tile in tub area, floor, & above vanity The demo of existing wall material in tub area Clean up of bath area and removal of Debris from site The prep of wall area and floor including the installation of drywall as needed (finished ready for primer and paint) The installation of cement board in tub area & on floor The installation of seam tape and the installation of waterproof sealer on walls in tub area and floor prior to tile installation The installation of tile in tub area (approx 50sq') and the grouting of same The installation of tile on floor (approx 35 sq') and grouting of same The clean up of area The installation of sealer of grout joints in tub area and floor The plumbing labor to remove existing drain & waste of vanity and toilet The removal of water supply connections to vanity & toilet The removal of existing tub waste and drain The removal of existing shower valve The removal of fixtures (3) The installation of vanity top, faucets, toilet, shower valve and tub including waste and drain The labor to remove and replace toilet in 11 /2 bath The installation of a GFI circuit for jetted tub as per code The installation of new vanity, top, medicine cabinet and mirror over vanity The final clean up and removal of all demo from site We will pull all permits and pay for same All work is being performed by licensed and insured trades people For the sum of 6,635.00 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building, department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper iermits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location r The Commonwealth of Massachusetts Department of Industrial Accidents _T4i� � 1 Office of Investigations �f._ � 600 Washington Street . ! Boston, MA 02111 www mass gov /dia • - Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lez;ibly Name ( Business /Organiiation/Individual): FOX. .13n; I.P�.:s 5' k Address: // ��.y.... r► S City /State/Zip: K; n ,,..,,, F; n�a. - a , i t Phone. #: ej ► 3— 4 — 2->.a s" Are you an employer? Check the appropriate box: Type of project (required): 1 ' 1. El I am a Y Io.er with 4._ l I am a general contractor and I . 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2. p:Qprietor or partner- b �d on the attached sheet 7. Remodeling These sub-contractors have. ,- ship and have no loyees 8. ❑ Demo�xtion working for me in any capacity. employees and have workers' _. comp. in ranee.# 9' Q B tldmg addition [No workers- comp: insurance — 5. We are a corporation and its 10.0 Electrical repairs or add'iti'ons r equir ] ffi i officers have their 11. Plumbing 3.0 I am a homeowner doing all work ❑ g repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs . insurance required] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance requited. }. *Any applicant that checla box #1 must also fill out the section below showing their compensation policy information: . t Homeowners who submit this of idavit:iadicating 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: . Policy # or Self- -ins. Lic. #: Expiration Date: - 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 ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Of'ce of Investieadons of the CIA for insurance coverage verifi Ido hereby certi undr • arras and pen • • - - �. fy e � p er�ury that the information provuiedsrbave rtirrce_andcorraer Si40• ture: s Pate• Q /° Phone #: 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 ❑ Name of License Holder : /qu J? So,u ind, T �6 License Number s F: eat Mk. 0I ? 0 I 1.2- 3 - A C ) Q- Address l Expiration Date oi- L9r �_ - Li/ 3 � s - 3?-75 Signatur Telephone 9.r Registered Ratile4ttittra'vetnetittirti recfat y a , '. , .... i , a, eg a i f . ` . _. Not Applicable ❑ ,''k , / k . R H, '. -i /3 Company Name Registration Number /1 Si�4,... 6>` Nom4 o f ao it / / — - A0 Address ' / Expiration Date Telephone 4/i3 - 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 ❑ //It ILA >ii a gip& 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 Windows Alteration(s) Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding [0] Other [O] Brief Description of Proposed Work: 6 3 /Zn /Ze a l_ Alteration of existing bedroom Yes - No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes l�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 SECTION Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I , as Owner of the subject property 5,e e � 4 hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date .wL� g , as Owner /Authorized Agent hereby decl 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 Own /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 I L _ •J L , _ Setbacks Front I Side L; R La __ R:` , Rear 1 1 } Building Height j r ! Bldg. Square Footage 1-----1 l j% F - 1 I 1 I Open Space Footage % (Lot area minus bldg & paved q ! -� f �m parking) # of Parking Spaces 1 Fill: 1 (volume & Location) ---- A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Regist f Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO eDONT 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 , Date Issued C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0-- IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavati , r filling) over 1 acre or is it part of a common plan J that will disturb over 1 acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. s ` ' City of Northampton m AY Building Department I$ 212 Main Street a $ Room 100 Northampton, MA 01060 phone 413 - 587 -1240 Fax 413 - 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A 0 E OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by, office . Unit Zone, Overlay District A7 sow Elm St bistrct CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 9 s,/ g Z 8 > :.a t _ . Name (Print) Current �M �KQ Z=1-- Mailing Address: e e Telephone Signature 2.2 Authorized Anent: / ?ua IZ (v),1 S on! /I y .yC 5.1 <n 144., o / Ic Name (Print) Current Mailing Address: — — 35A-5 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 6G ,?b" �o 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) (S 3 Check Number /6/.V7 oL3 9-S I This Section For Official Use Only Date Building Permit Number: Issued: Signature: !� > ��1 .—/-4/6 Building Commissioner /Inspector of Buildings Date 467 SOUTH ST UNIT #1 BP- 2011 -0300 GIS #: COMMONWEALTH OF MASSACHUSETTS ititomock:k3Alat CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -0300 Project # JS- 2011- 000497 Est. Cost: $6635.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Mark Gibson 102478 Lot Size(sq. ft.): Owner: HOLLINS SUSAN D & MAURA HOLLINS- AMBUTER Zoning: Applicant: Mark Gibson AT: 167 SOUTH ST UNIT #1 Applicant Address: Phone: Insurance: 11 SUMMER ST (413) 475 -3725 GREENFIELDMA01301 ISSUED ON :10/4/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK :2nd Fl Bath Remodel 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 10/4/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner