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38B-203 (3) JUL -26 -2010 12:18 FROM; CATHY CROSS TO:5871289 P.1 JUL -26 -2010 11:09 From Xfo:914135873028 P.3'3 Peerless Workers Compensadon And Employers Lam/ Polity r• Insurance. lY*VerY1MMMMyGny RENEWAL l won ElledWe: 08/102010 INFORMATION MOE DIRECT BILL a. AmenwilM■or r► Policy Number: WC 8301812 IPifor Policy: 8301812 ' Date leased: 04/222010 Coverage Is Provided ht PEERLESS INSURANCE COMPANY - A STOCK COMPANY NCCI Nurr her: 11355 1. Named Insured and Wiling Address: Agent: OPEN AND SHUT LLC WEBBER a GRtNNELL INS AGCY INC RAYNOR DOORS DBA 8 NORTH MC STREET SUITE 1 30 REAR LYMAN ST NORTHAMPTON MA 01060 EASSTHAMPTON MA 01027 Agent Code: 6200843 Agent Phone: (413) 68b-0111 Federal Employer iD Number 051698963 H6ng Number. 000459174 SIC Code: 1751 Other Workplaces not shown above: RBBER TO ADDITIONAL WORKPLACES SCHEDULE Entity of Insured - LIMITED LIABLJTY COMPANY 1 2. Polity Period: The Policy Period Is tram o611W )i 0 to 0S11012011 , 12:01 AM Standard Time at the insured % m ding address. 3. A. Worker's Compensation Insurance: Pad One of the policy apples to Walter's Compensation Law of the states aged here: MA B. Employers Liab8itjr bhswm►oe: Part Two of the policy applies to work in each state !fisted in 3.A. The Imaa of Saba/under Part Two are Body injury I Accident $ 500 , 000 each accident Bodily injury by Disease $ S 00 , 000 polity Ittnit Boclly injury by Disease $ 500 , 000 each employee C. Other States Insurance: Pert Three of the policy applies to slates, if any, listed here: All states incept North Dakota, Ohio, Washington, Wyoming and states designated in !Kern 3A. on she Information Page; D. Endorsements and Schedules: This policy k>cludes these endorsements Slid Schedules: See Esctenslon of Information Page 4. Premium: The premium for this palsy will be determined by our Manuals of Rides. Cons, Raba and Rating Plans. All Information required below is subject to MerMcalion and change by aud'd. Premium Basis Rate Per Estimated Code Total Estimated $160 ef Annual Number Classifications Annual Remuneration Remuneration Premium See Extension of information Page POLICY PREMIUM TOTALS Tote) Estimated Mandan! Pranium $ 8,062.00 0900 Expense Constant tT 338.00 T otal Esti naled Premium S 8,400.0o Total A rhsntoiFunda1Sureharges S 570. 00 Total wed Coat $ 8, 970. Minimum Premium $ 500 . DO Deposit Premium $ .11,070 . 0 0 Adjurmment Period: ANNUAL Date:.. Countersigned bin: suebodzsd templed 1U7 Nallonal Council oa Componsatios In.urane. r„ _. .... ..- .... au..u+rn "AM., MONO= J06107 PCAFPPN 00013906 Pep. 11 JUL -26 -2010 12:18 FROM:CRTHY CROSS TO:5871289 P.3 TIL -25 -2010 11:08 From: XTo:914135873028 P.1 /3 JM1 LB 1U l U. "T TO I 1 TV 103 . YVI , • - • HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 7SOCMR 1 083.4 to act as his/her construction supervisor. The state defines "Homeowner" as.," Pe rson(s) - who owns a par4 on which he/she resides or intends to bc, a one or tWo foully dwelling, attached' or detached structures actessory to such use aaa/or farm structures. A person who constructs more than one home in a two period shall not be considered a �me owner." . 1ho boitding farthe City of Noxthaii n wants perspa(s) Who seek to use the btu oimmi aaeiptiim, o'acr as their o sir©onstrai Snper"vuvr, *A* aware that by doing so you become responsible for compliance with state banding codes sod regulations.' The inspects process requires that the.building department be called to inspect work at various std which include fougdatioalfeetlluts (before baek1l), segatat >h.a tbctmr+e �o :cob bum ' ' n tbelbreworkc is col cea1a� la iucp boa ( fte and a fi>Mal di irr � The building depattneat requires these inspections beforethe work is emended, Wore to secure these lashketieus can aesn6 so failure to obtain a ei r to Of ecenpaoe9 be insociin:d. until If the bo h ares unbar trades to perform. work (electrical, plumbing & gas)'the hoineawner will be.responsible to make sure that the trades hired seam their proper itcnnits in coajanctiotn to the building permit issued, and tint get their required inspections. Failm+e of the individual trades to secure the pits and inspections as required can DZI. A.X the project until such time as the proper permits and inspections are made • • , I. LPL understand the above. . one weer /resident's signature requesting exemptiow) . I .r call to schedule all required bonding inspsetions necessary for the building permit issued tome. D am 7���riio • Address of work location / /1)'m C7 ,4';77 /Wig 4 /e-/.N'/ --_______- . - :ill IwOlid - :1701.13a pcja03 - ...--....—. " • IMP *9 "pachwir irp•fatfula 's Aopadiatimn.spagg 1,. Imo amok/AD - 1 - poion.stdoci Aiming t Wiggle p4:00 'V - . . • :aue pip KlizeklinV 2 uPksil ___________,----:L,---- . 9 asamtripa.t9,1 . . . . • I ' . . , .trI4Crel Oil - • Olt Arr • ' ' Ng • 1,. / • . . . . " • • Vt?ii:.67-4 t.-:e45 - - 1 - ih#7 • 4.Guara — • . . _...... - _ • . . f /IP • v.c A ig .""' .r!v . • --- - - -Fiziccepormia-zx • - - ..p aiRfilag:sylastifsdk .. . 4 : • , , ... •---..,.,.... — '„-.■....r.,........' •'" '''' - .- .-' :- • : ' :- - -. - - • - . -.. - . T .•-''. • . • ..devet ' - M: " Zig° •1: t . . • — l Toga Alakfryilig &Ks 41 scli ! — PROW! sa 2 °Filt•i ora dr 4vry iiIdu.1 . . 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' 04 *Mid • twypreiuoliq 1.IIT3Iftlay ...-.:: gn q tar thrfgaNPILIMINOPC4u 0 3/snPL ni a :WicuParV xhar-Qatfl noPlmrcratkI00 cs•lallioAto • . stawitaiirearrataku ... -- ..., . . ruto rm 'woof - . i= ---• - A t - - - A4.4is ocoswrismi 009 • , • . . • • ximpu210 r4fo /;-__- ■ . • .-----,---..=.• -:-. . • Mal II: P V 0 1.4ilniie PizraUrciaa . . . - mosirvvsspArfo iginasatomtyrp3 ?vi N5;* - • . . . - • v..1 ..... 71.0714 LIT WICS.JOC ...I IRR T OM !Li eue,!..nT Ill OF rne S'/R'A 132171ELIMEIbt6: :w 80:TT �t$2-92-1ff 2'd 68212_8S:0i SS0d3 AR1UDI'W0d3 81:2T OT02-92-111f m SECTION 8 - CONSTRUCTION SERVICES / 8.1 Licensed Construction Supervisor: Not Applicable 2 Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable V Company Name Registration Number Address Expiration Date Telephone 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 (I) 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 "homeown- - tifies and as m• . res, ,nsibility for compliance with the State Building Code, City of Northampton Ordinances, St; • . 1 Local Zo l . ,a - d State of Massachusetts General Laws Annotated. Homeowner Signature 44E,, _ A Of SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition El Replacemen in dows Alteration(s) El Roofing El Or Doors D�0 Accessory Bldg. ❑ Dem n � N ew Sig w+ - -- Decks [I] Siding [El] Other [O] Brief Description of Proposed Work: tal41 I X Alteration of existing bedroom Yes /� No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes K 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, Jac /I tC. G/ , as Owner of the subject property hereb authorize ' M1 a /g to a , n my behalf, i II mat -, s relative to work authorized by this building permit application. i Signetur of ca ner Date - — • I, EaNri • C/41'%*---- , as Owner /Authorized Agent '-by d_' are that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and b- f. Signed under the pains and penalties of perjury. 1 p1 // 6 Print Name / Signature of O , %ent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning V /1 6 X This column be filled in by Buuilding g Department Lot Size FfA Frontage 6gd Setbacks Front XO Side L: R: / L: R: Rear Building Height / Bldg. Square Footage /fob Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Sp -cial Permit /Variance /Finding ever been issued for /on the site? NO 4401 DON'T 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 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO t) DONT KNOW (3 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO qj IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, -x avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO YES, then a Northampton Storm Water Management Permit from the DPW is required. • Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans, phone 413 - 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 �s 37 ��,� /' -y / C Map .K.96 Lot/` ' / ? Unit Qv/ ,/ A1/9 � ` Apr /f1 Bey Zone v Overlay District a/v t d Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record 75a/ l'� ( e r idlil •Ail Q'(re -- Name rint) ,/ /t Current Mailing Address: Telepho Sig re 2.2 Authorized Agent: Name (r Current Mailing Address: : gnature Telephone SECTIO - - ESTIMATED CONSTRUCTION COSTS Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 3 57x" (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) r Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 1 -IAN sr . BP- 2011 -0066 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 -0066 Project # JS- 2011- 000119 Est. Cost: $3500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RAYNOR DOOR CO Lot Size(sq. ft.): 5009.40 Owner: CROSS JOSEPH G & CATHY G Zoning: URB(100)/ Applicant: CROSS JOSEPH G & CATHY G AT: 37 MANHAN ST Applicant Address: Phone: Insurance: 37 MANHAN ST () 586 -8045 () NORTHAMPTONMA01060 ISSUED ON: 7/26/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL GARAGE DOOR REPLACEMENT 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 7/26/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner /37 NANHAN BP- 2011 -0066 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B .. 203 r 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 -0066 Project # JS-2011-000119 Est. Cost: $3500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RAYNOR DOOR CO Lot Size(sq. ft.): 5009.40 Owner: CROSS JOSEPH G & CATHY G Zoning: URB(100)/ Applicant: CROSS JOSEPH G & CATHY G AT :: 37 MANHAN ST Applicant Address: Phone: Insurance: 37 MANHAN ST 0 586 -8045 0 NO RTHAM PTO N MA01060 ISSUED ON: 7/26/2010 0:00:00 TO PERFORM THE FOLLOWING WORK :INSTALL GARAGE DOOR REPLACEMENT 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: O k 9 _ I v c. THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE U � • S / Ave tya1r� ; of Occupanc " / signature: FeeTvpe: Date Paid: Amount: Building 7/26/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner