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38B-294
SINCE 1940 miLEs BUILDING MATERIALS SUPPLIER 'stall d:pro'ect Subco tragic o rs Project: PO/3 / r . fS Foq Xi /tI 7R A) 0/‘'Y1A /1 127 3 BA O /OrsO Subcontractors: If you have employees you must provide your Workers' Compensation Insurance Policy Number Subcontractor Name: R-7- 7 ag5,6,0 / i fi [ • Address: /04 » gtiv A30 Jo is, 1 1 P 3 -20z1- �� ' Ph � �1 ... Policy # rk ers' /2i742,3,? i 1' Insurance Company: Nn' �r l/-�jQ (This form must be attached to Project Workers' Comp. Affidavit) j. Installed Project Subcontractors 2/12/2010 l ACCRp CERTIFICATE OF LIABILITY INSURANCE oi�osjzoii i PRODUCER (802)362 -1311 FAX (802)362 -3316 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION W. H. Shaw Insurance Agency ONLY AND CONFERS NC) RIGHTS UPON THE CERTIFICATE 135 Bonnet Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 1067 Manchester Center, VT 05255 -1067 INSURERS AFFORDING COVERAGE NAIC # ' INSURED rk Miles, Inc. INSURER A: Firemen's Ins Co of Washington PD Box 1125 INSURER B: Manchester Center, VT 05255 -1125 INSURER C: INSURER D: INSURER E: COVERAGES 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 TO 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS R ADD'L POLCY EFFE P EXPIRATION INS NSRC TYPE OF INSURANCE POLICY NUMBER D /DD g - - - - -- - - LIMITS - -- - GENERAL LIABILITY CPP__0012473 - -26- 01/01/ 2011 01 /01 /2012;- -EACH OCCURRENCE _ __$__ __ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED , 000 PRFMISFS IFa nrr„ranre) r I CLAIMS MADE I X I OCCUR 4 MED EXP (Any one person) $ 5,000 A PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: } PRODUCTS - COMP /OP AGG $ 2,000,000 71 POLICY n JE n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS , BODILY INJURY NON - OWNED AUTOS (Per accident) $ PROPERTY DAMAGE • (Per accident) GARAGE LIABILITY ,. AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN — I AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABIUTY EACH OCCURRENCE $ OCCUR I J CLAIMS MADE AGGREGATE $ DEDUCTIBLE — S RETENTION $ 5 WORKERS COMPENSATION AND WCA0240314 -13 01/01/2011 01/01/2012 II l TnRY I Mlrs I 1OT EMPLOYERS' LIABILITY ! _ E.L. EACH ACCIDENT $ 500,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE s OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 500,000 SPIf y es, descri under NS bebw E.L. DISEASE • POLICY LIMIT $ 500,000 ECIAL PROVISIO OTHER D ESCRIPTION OF OPERATION / LOCATIONS I VEHICLES I EXCLU IONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS' istallation of W Doors etc. in Massachusetts. .ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE - - - - - - - -- - - EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO,THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. To Whom It May Concern AUTHORIZED REPRESENTATIVE arlonr?owno+-i _Marianne Connor /MCONNO CORD 25 (2001/08) ©ACORD CORPORATION 1988 - The Commonwealth of Massachusetts Department of Industrial Accidents " Office of Investigations '"":: 1 " _ 000 Washington Street =" f `�._ Boston, M4 02111 4x www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly R. /� ! C Name ( Business /Organization/Individual): !� . K /f " 01 r1�1 C, Address: 21 4)E S ----7 City/ State /Zip:_. __ . / FI C1D i/� Off Phone #: 1 7 � p (72/r _ ` Are you an employer? Check the app b ,x: Type of project (required): 1. I am a employer with 4. am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. [] New construction 2. E1 I am a sole proprietor or partner- listed on the attached sheet. 7. Ej Remodeling ship and have no employees These sub - contractors have 8. El Demolition workin for me in an ca aci employees and have workers' g Y P tY• 9. 0 Building addition [No workers' comp. insurance comp. insurance.. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance re uired. t c. 152, §1(4), and we have no q ] employees. [No workers' 13. they /0.A libi M D , comp. insurance required.] R G/-4li �T *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subm *t a new affidavit indicating such. tContractors 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. / am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / � Insurance Company Name: AA 1)7/1 1)7/1 _.LAV< /.,k 4 iU CC ' Policy # or Self -ins. Lic. / J ✓ #: �rA 0240 ,3/4 —' 73 Expiration Date: 0 A •da l� l7' O/ j Job Site Address : FYiR/ / �E L L ?i$4 C& City /State /Zip:_J v d ' /9MI O� 1' / 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 a pai and penalties of perju that the inform tion provided above is true and correc> Signature: /: L m4/ww:r1 "R Date: / J I) Phone #: 4/3 _2¢7- 673M //Z 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): ' I Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Confa Person: Phone #: SECTION.8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supeervissoo • Not Applicable ❑ Name of License Holder : /�./ 1 1 ^6 ,k R'vs /03 IT s r License Number fi L/1 62 (T gg / J / Z 20i- Address Expiration Da e ar Signature Telephone 9. Registered Home Improvement Contractor J Not Applicable El Company Name } Registration Number Addresss f�/� y' /� /� Expiration ate C/ v / / r7 / (�f tf,D , t L/14TT Telephone 1/3-c?--9 (�W" 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 b it 'ng 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 res onsible for all such work ierformed under the buildin' ' ermit. 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 ❑ Replacemen ndows Alteration(s) , I Roofing n Or Doors � Accessory Bldg. LI Demolition I 1 New Signs [D] Decks [El Siding [D] Other [D] Brief Description of Proposed A7 _,, R , 4 %_ � J'Zj) , /0s - ) Work: (�/ / � J-' ,�/ Alteration of existing bedroom Yes No Adding new bedroom Yes // No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New 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, R C It A/ l J/ /9 j rE / 7 , as Owner of the subject _property hereby authorize M V! )) DRAJJ * , ,/ f /7LGS C-- to act on my behalf, in all matters relative to work authorized by this building permit application. / Signature of Owner - Date I, R °BERT 0.,z /R67-7 U/� = -� 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 e pains and penalties of perjury. /� �` Fie ZT CSR /7R rr ref V Print Name Signature of Owner /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 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 C 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: 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. It 1 I , Department use only- ECEI ED City of Northampton Status of Permit: : uilh ing Department Curb Cut/Driveway Permit JUL I i 2011 2 Main Street Sewer /Septic Availability W Room 100 Water/Well Availability . • ha pton, MA 01060 Two Sets of Structural Plans °F " ' -'4 .1, r : Ii , ` -58 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 ( F/5/4 (( Map Lot Unit Cr Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: gret---fr 41472)77 S Name (Print) BR - V E p l -t Current Mailing Address: .4e/ 3 5741 3347 � op , / 4 ' Telephone Signature ' 2.2 Authorized Agent: ' f / / Id it - 5 - A 1-/A7F) Li l l Cifi Name (Print) Current Mailing Address: ,)/,-),4; 'l 3- .Z42- Y3f� 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- < 4. Mechanical (HVAC) 5. Fire Protection - 6. Total= (1 +2 +3 +4 +5)073 ` G Check Number ) This Section For Official Use Only Building Perm Date Number: Issued: C.. f Signature: - _ l 7/i 3/ l i Building Commissioner /Inspector of Buildings Date 15 FORT HILL TER BP- 2012 -0047 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 294 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2012 -0047 Project # JS- 2012- 000070 Est. Cost: $5100.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R K MILES INC 10388 Lot Size(sq. ft.): 3223.44 Owner: AVERITT BRETT T Zoning: URC(100)/ Applicant: R K MILES INC AT: 15 FORT HILL TER Applicant Address: Phone: Insurance: 24 WEST ST (413) 447 -8300 WEST HATFIELDMA01088 ISSUED ON: 7/13/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: Replacement windows (6) 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 7/13/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner V