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24D-181 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID FCC DATE(MMIDD/YYYY) MAHAN -1 05/27/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PHILLIPS INSURANCE AGENCY INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 97 CENTER STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. CHICOPEE MA 01013 Phone: 413- 594 -5984 Fax: 413- 592 -8499 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Selective Insurance 12572 _ INSURER B: Hermitage Insurance C ®pany Mahan Slate Roofing Co, Inc. INSURER C: Hanover Insurance Company 22292 PO BOX 2860 INSURER D: Springfield MA 01101 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. 1NSR AOD L POLICY EFFECTIVE POUCY EXPIRATION LTR INSRC TYPE OF INSURANCE POUCY NUMBER DATE (MMIDDIYY) DATE (MM/DDMf) LIMITS GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 B X COMMERCIAL GENERAL LIABILITY HGL56537309 12/30/09 12/30/10 PREMISES (Ea $ 500,000 CLAIMS MADE L. XJ OCCUR MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY PRO- LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 C ANY AUTO AWN6853629 12/30/09 12/30/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE UABIUTY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABIUTY EACH OCCURRENCE $ 5,000,000 B X ] OCCUR CLAIMS MADE HUP56537409 12/30/09 12/30/10 AGGREGATE $ DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPENSATION AND I ER O I H- TORY TORY LIMMITS EMPLOYERS' UABIUTY ANY PROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER A Property Section S1917303 01 /01 /10 12/30/10 Equipment $160,000 A Equipment Floate S1917303 01 /01 /10 12/30/10 Deductibl $1,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Job: 947 Main St Springfield, MA Louis C. Allegrone, Inc. is additional insured with regards to General Liability as their interests appears with regards to work performed by the insured on the holders behalf. CERTIFICATE HOLDER CANCELLATION LOUI SCA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR LIABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTH ZED REPRESS TATIVE p i p lA g i40.6 ACORD 25 (2001/08) © ACORD CORPORATION 1988 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) TM 05/14/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Applied Risk Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO Box 3646 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Omaha, NE 68103 -0646 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (877) 234 -4420 INSURERS AFFORDING COVERAGE NAIC # INSURED INsuRERA:Continental Indemnity Co. 28258 Mahan Slate Roofing Co., Inc. INSURER B: PO Box 2860 INSURER C: Springfield, MA 01101 -2860 INSURER D: CTL 1273 505226 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 CONTRACTOR 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. INSR ADD'L POUCY EFFECTIVE POUCY EXPIRATION LTR INSRD TYPE OF INSURANCE POUCY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURANCE $ _ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurence) $ CLAIMS MADE r JOCCUR MED EXP (any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ - 1 POLICY PRO- I LOC JECT AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABIUTY EACH OCCURENCE $ _ OCCUR [_ CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND • WC T- EMPLOYERS' LIABILITY X TORY L LIMIMITS E ER R A ANY PROPRIETOR/PARTNER/EXECUTIVE 46- 822206 -01 -01 12/30/09 12/30/10 E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1, 000,000 If yes, describe under SPECIALPROVISIONSbelow E.L. DISEASE - POLICY LIMIT $1, 000,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES AUTHORIZED REPRESENTATI 1783118 ACORD 25 (2001108) © ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information kA ` ' f Please Print Legibly Name (Business/Organization /Individual): AI A►J SL�TL R ( I CCU, ' O t`-- Address: rD j OK 2-6 6 O b 110 City /State /Zip: FR-IVs Ft Phone #: 788 9'521 Are you an employer? Check the appropriate box: Type of project (required): 1.14 I am a employer with I Q 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. ❑ New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9. Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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 12Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.0 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. pp Insurance Company Name: 1PPti� i P/Si_ /iV 5u, 2.4(JC (TEA C4J Policy # or Self -ins. Lic. #: 9 - 9O2v9a 6 6/ 0/ Expiration Date: 12'3c Job Site Address: ,2 L /CN ST- City/State /Zip: A/Oi i7/AMP7 X44 2 /0t C3 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 ce u er the pains nd penalties of perjury that the information provided above is true and correct Signature: fdki Date: -�3 Phone #: � �J / � � / 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 #: I SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: , tt II Not Applicable s ❑l Name of License Holder : tAK3 (- M AI N Ci - 6) License Number G/3 L-�e 4q/zt) AA i C LO,AI6' /,4 O/o 2--8 - 12 Address Expiration Date /'. ,'. -.4E-- 5 -- 33o ._ 8 Z 2-._ nature Telephone 9. Reaistered Home Improvement Contractor: Not Applicable ❑ 6'N 14N r MAk4 /Tar lb &W Company Name Registration Number MA A SL.A re_o or 80� Co, ( ,0<< 9 - /a Addres-s2 O) / ` n �/ 785 U Expiration Date - Th l�' 2- (2& 1° F i � VIA 0 (lO� Telephone I li ?32 SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) I 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 )d{ 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 1083.5.1. 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 El Or Doors 0 Accessory Bldg. ❑ Demolition El New Signs [DI Decks [I=] Siding [p] Other [II Brief Description of Proposed Work: , cMt?VE . x (S7j SLATE Ar16 I fJ 5071 - 1L M6_1+0 COMBO 3, T t E ot,J Alteration of existing bedroom Yes X No Adding new bedroom Yes 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 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, � A © P/(.1�� -- , as Owner of the subject property / r / hereby authorize C7 / MA/IA/kJ ` /k / to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date ' j —. 01 - } t■J F HA f- -0t .- , 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 m� G - /� l Sign re 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 Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT 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 Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q 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 Q 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only r�0 City of Northampton Status of Permit: Bulkjing Department Curb Cut/Driveway Permit r • • 7 , - 2'12 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 I 1.1 Property Address: This section to be completed by office 0 f) ,4 Cl// r Map Lot Unit_ A/ O K' ' �-' 21 7 - / ,4M� Z I /(,.4 Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Ji'9 Q.// , 2 2 A1-6 /J (/7 S rE'6t Name (Print) .. Current Mailing Address: �-- Telephone _ 3052 Signature '4 // 3 2.2 Authorized Ascent: : T o m J F M AHA\ To box ZS SpFL1 i44 no Name (Print) Current Mailing Address: L "713 788 95 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. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) _ Check Number ‘d 9r r This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 22 ALDRICH ST BP- 2011 -0146 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 181 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 -0146 Project # JS- 2011- 000241 Est. Cost: Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MAHAN BUILDING & SLATE ROOFING CO 006760 Lot Size(sq. ft.): 4530.24 Owner: PAAR CHRISTOF & SARAH A FOWLER Zoning: URC(100)/ Applicant: MAHAN BUILDING & SLATE ROOFING CO AT: 22 ALDRICH ST Applicant Address: Phone: Insurance: P O BOX 2860 (413) 330 -8622 WC SPRINGFIELDMA01101-2860 ISSUED ON:8/20/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & INSTALL 1/2 SLATE 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 8/20/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner