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24A-059 FROM (SUM,MAV S 2010 2� 216/ST. 23: 12/Mo. 7619560467 P 1 4R CERTIFICATE OF LIABILITY INSURANCE OP ID LX DATE (MMAiDD/YYYY) 05/10/10 PRODUCER THIS CERTIFICATE I8 ISSUED AS A MATTER OF IN ORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Haberman Insurance Group Inc HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 95? Ashley Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Springfield SSA 01089 Phone: 413 -781 -7000 Pax:413- 733 -9545 INSURERS AFFORDING COVERAGE NAIC INSURED INSURER A: Ts."ler. xa.oremse orimmATY 40282 INSURER 9: American International Co R r AACCZ Z ice %lateeld tt estoration INSURER C: American Safety Insurance West S Syri MA 01089 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MR 1 N SRE TYPE OF INSURANCE POLICY NUMBER OA DA LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 C X COMMERCIAL GENERAL LIABILITY 1NV023710 -09 -01 09/21/09 09/21/10 P`R�I"isES(E %"o2wTmc.i s50000 CLAIMS MADE u OCCUR MED EXP (Any ono pors°n) s 5 000 PERSONAL aAtN mum , s 1000000 — GENERAL AGGREGATE : 2000000 _ GEML AGGREGATE p U MT APPLIES PER PRODUCTS - COMP/OP AGO s 2000000 (l poucY I JECT l l LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 IE. ° A __.. ANY AUTO BA4168N336 07/01/09 07/01/10 4°4) _ ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) Z HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Peer a°ddent) $ .— PROPERTY DAMAGE (Per occident) GARAGE LIABIRY AUTO ONLY - EA ACCIDENT $ — R AMY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ 3000000 C E ocaa El cLIMSMADE ZLu023712 -09 -01 09/21/09 09/21/10 AGGREGATE :3000000 s DEDUCTIBLE s _ X RETENTION : 10000 s — ' WORaER* COMPENSATION (WC S1A 1. f AND EMPLOYERS' LIABILRY Y/ N S TORY LMMTS 1 X 1 ER $ ANY PROPRIETORIPARTNEFUEXE WC9768130 • 07/01/09 07/01/10 E.I. EACH ACCIDENT :1000000 OFFICERIMEIBER EXCLUDED? l _ u ovy I o I)) E.L. DISEASE - EA EMPLOYEE s 1000000 SPECIAL PIi01/191ONS Wow E.L. DISEASE - POLICY LIMIT _ $ 1000000 OTHER DESCRIPTION OF mammas 1 LOCAToes J VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL mimosa CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES SE CANCELLED BEFORE THE EXPIRATION 'AO DATE THEREOF, THE OWING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIRCATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OSLJGATION OR LIIIBBJTY OF ANY KIND UPON TIME INSURER, ITS AGENTS OR Town of Northampton REPRESENTATIVES. 212 fain street AUTHORIZED REPRESENT ME Northampton N► 01060141-4i41984.-2009 ACORD 25 (2009101) ORPORATION, 47 The ACORD name and logo an registered marks of ACORD • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Ci API w 2 L,t. G 5 r1 -14)(49 License Number 1Z5 CreS r Z-1 4-v--) 6 th'ti4, Ct 0 q i I zo t Address Expiration Date 913 -- 6 z 6 Z.c) Signatur Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ ACE 'F��w - w -TAN- g-� ro - i / Z t/ Company Name Registration Number fv Z te- rH 57 tv f(f-2 -19 /1,m, c /DS 5 5/2 3/06/ Z Addr :4 - z/ / -. p 31 e.0 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 (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) n Roofing X1 Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [0] Brief Description of Proposed IN I {� _ Pe / 5 • I ` �n le 0 P Work: U" Oa 1J �'`^ fit �r E 'Tz He.t,L ,X� 1� Alteration of existing bedroom Yes X No Adding new bedroom Yes >e No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family 74. Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? iI J d. Proposed Square footage of new construction. Dimensions e. Number of stories? 2 1 /2 f. Method of heating? kW g PJ Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction X01 Q 61.44 i. Is construction within 100 ft. of wetlands? Yes )4 No. Is construction within 100 yr. floodplain Yes x No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? ,C 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 �� 0011) - 45 , as Owner of the subject property hereby authori - A f.L..-t + », tr • act on my j f, in all matters rel�y to work authorized by this building permit application. •ia■.r _a le) lv Signature. i r Date GC4/ 1 k' It li1l /1 / Ac. 1-T /�'i��f2 Fired- I C - ATT_OI� -? las Owner /Authorized Agent hereby declare that the statements a d 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 a 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 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW iv 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 g YES Q 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 ® NO (56 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO 0 :4 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, gradin cavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES, then a Northampton Storm Water Management Permit PPermit 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 c , G'' , 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: p This section to be completed by office g3 p id e. VV OOct 7-e r r c-C. Map Lot Unit 4/0,1 pia rn7 d 0 1 40 I a Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: '' rr - i - /�, & LLIWS 23 leiCC hood /tea // . 414, e (Print) r 1 Current Mailing Address: ' / /� ,—(J C rc ' Telephone i ` 2.2 Authorized Agent: At i rt.+ Wm a- ti - r►--) t- /5 a4V, Aer $- v i- *0 Nil Name (Pri Current Mailing , A / ddress: �� 7 /3 730 - SzD d 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 IZ 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 03 5 - - 5. Fire Protection //_ 6. Total =(1 +2 +3 +4 +5) # / 2. int)° Check Number 411(0 ,:- This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 23 PiDOEWOOD "TER 4 BP - 2010 - 1006 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 059 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- 2010 -1006 Project # JS- 2010- 001478 Est. Cost: $12000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ACE FIRE & WATER RESTORATION INC 074416 Lot Size(sq. ft.): 8232.84 Owner: COLLINS PAUL L & SALLY L Zoning: URB(100)/ Applicant: ACE FIRE & WATER RESTORATION INC AT: 23 RIDGEWOOD TER Applicant Address: Phone: Insurance: 18 ELIZABETH ST (413) 750 -5200 Workers Compensation WEST SPRINGFIELDMA01089 ISSUED ON:5 /11/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR WATER DAMGE TO ROOF 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 5/11/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo