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24A-198
AR WCIP ' 1 V,Q' Liberty ISSUING OFFICE 181 /i *� Mutual.. Workers Compensation and INFORMATION PAGE Employers Liability Policy ACCOUNT NO. SUB ACCT NO. Liberty Mutual Insurance Gmup /Boston 1 - 371520 0000 LIBERTY MUTUAL FIRE INSURANCE CO 16586 POLICY NO. TD /CD SALES OFFICE CODE SALES CODE N/R 1ST WC2 -31S- 371520 -019 XX X WESTON 102 REPRESENTATIVE 3000 1 YEAR ASSIGNED 2009 Item 1. Name of JAMES D ROSS DBA JDR BUILDERS Insured FEIN 06- 1559981 Address PO BOX 66 RISK ID 147592 WHATELY, MA 01093 Status 01 - INDIVIDUAL Other workplaces not shown above: SEE ITEM 4 Mo. Day Year Mo. Day Year Item 2. Policy Period: From 01 -29 -2009 to 01 -29 -2010 12:01 AM standard time at the address of the insured as stated herein. Item 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident 100,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily Injury by Disease 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rates LINE 110 Per $100 Estimated Code Estimated of RE- Annual Classifications No. Total Annual Premiums muneration Premiums SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 500 (MA ) Total Estimated Annual Premium $ 3,462 Interim adjustment of premium shall be made: ANNUAL This policy, including all endorsements issued therewith, is hereby countersigned by Authorized Representative Date 02 -26 -09 Loc. Code Term. Oper. Audit Basis Periodic Payment Rating Basis Pol. H.G. Horne State Dividend 02 -26 -09 NR MA NEW 10 R1 Copyright 1987 National Council on Compensation Insurance we o0 00 01 A Insured Copy • _ r The Commonwealth of Massachusetts ...� Department of Industrial Accidents Office of Investigations g4 ti IA r 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): s) . 13 LAU:h.:173 Address: 90 O' -G 6 City /State /Zip: ( A-1 L` Al ii-- 0 ►6 Phone #: 6 a) S " ")S E7 7 Are you an employer? Check the appropriate box: Type of project (required): 1. [X,I I am a employer with ' 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10. ❑ 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 12.21 repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *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 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: L..\`C3so'c. m - rum.- Policy # or Self -ins. Lic. #: C..A— 3 1 S °3 J 3 10 0 j Expiration Date: 1 "' as S - 26 i 0 Job Site Address: 36 mu2ph - 1 - 6 c- City / State /Zip: all i - i. ril - r i AM- C) 0 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 of the DIA for insurance coverage verification. I do hereby cer y �� u , nndeer pains and penalties of perjury that the information provided above is true and correc J" t. Signature: V" Date: 1,` / ?- 0 Phone #: lt/l ° e5 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 #: r I SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : .A'1Y14- -S1 License Number P v `3a.)( ( e. LOA 47(3 d`7PfI Address Expiration Date i. f Ce (os- •? Signatd - Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 0\ 13 ©3 / 7 Address i ff ` , ,s- ,. i /� Expiration Date f C) b U �Q W 1�G�'te il1IO? Telephone 1/45 E 7 / f 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 14 Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O] Other [0] Brief Description of Proposed }- Work: 1eMCGV C 3 GA'-(G{�Li GA' 5\.vA S'`� -NSt614 PI�(w0004 8S R (� 711 1 t .5`Ttc, 3ov 5)}I g Ce Alteration of existing bedroom Yes 1f No Adding new bedroom Yes A No Attached Narrative Renovating unfinished basement Yes 1( 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 , e l)k +RIV A c C c.c c Zu l 0 , as Owner of the subject property hereby authorize 1-7AVY'r---3 3S i '31)(-J 1L) r' to act on m ehalf, in all matters r ive to work authorized by this building permit application. , / �6 CZ.. _$ . it -. Signature of Owner Date 1, J �� 5 , 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 penalties of perjury. Print Name SWF Lit i_U Signature of Owrce 1n 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 X 1 fk' SSE Frontage 1 Setbacks Front _ Side L: 15_ R: 1S L:, R: Rear Height 1 ST Spn Bldg. Square Footage ' %, Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces 3 3 Fill: YV Gam` 1,CY•E (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW YES 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 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 O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO 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 O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • Department use .only City of Northampton Status of Permit: Building Department Curl) Cut/Driveway _Permit, 212 Main Street Sewer~ /SepticAvaitabUity Room 100 Water/Well Availability Northampton, MA 01060 Two Sots< f5, ` c` t aTP1an ; phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site -O n r . , 1. 13 OtherSpicify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ON DR Tq'V9 F4M$Y DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This sectiorl' be completed by_office 3 0 rno'2p 1"L, C°C Map Lot Unit M,m }CYV Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ' DI RN C o c.c,,oLu b 30 rnurtPII4'j Name (Ply? Current Mailing Address: Telephone Signature 2.2 Authorized Agent: T = s?--CXs 1z'33O L0&fZ Pa d x CD 6 cum 7 1 V144 Gt 04 Name (Pri it Current Mailing Address: (otosc ` X _ l�� Signat e Telephone SECTIO 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ^ (a) Building Permit Fee Lt 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 3 ( 7.6 This Section For Official Use Only Building Permit Number: I sssuu ed: Signature: Building Commissioner /Inspector of Buildings Date , File # BP- 2010 -0076 APPLICANT /CONTACT PERSON JDR BUILDERS ADDRESS /PHONE P 0 BOX 66 WHATELY (413) 665 -7587 PROPERTY LOCATION 30 MURPHY TERR MAP 24A PARCEL 198 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT F Paid Permit Filled out ee Paid Typeof Construction: Strip and Reroof New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ ti Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission iL4-1/4.--) o 7/z 09 Signature of Bu ding Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 30 MURPHY TERR BP- 2010 -0076 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A -198 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit # BP- 2010 -0076 Project # JS- 2010- 000082 Est. Cost: $6200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JDR BUILDERS LotSize(sq. f): 9365.40 Owner: COCCOLUTO DIANA DAY Zoning: URB(100)/ Applicant: JDR BUILDERS AT: 30 MURPHY TERR Appiic.:srtt Andress: Phone: Insurance: P O BOX 66 (413) 665 -7587 W HATELYMA01093 - 0066 ISSUED ON: 7 /22/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: Strip and Reroof 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: Smoke: Final: 66-C 8 4 203 THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON VIOLATION ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: ----" r—es,...›e " *Agee FeeType: Date Paid: Amount: Building 7/22/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo