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24D-186 ACORD. CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD /YYYY) 4/1/2009 PRODUCER (413) 586 -7373 FAX: (413) 584 -0859 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Aquadro & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 355 Bridge St., P. 0. Box 357 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northampton MA 01061 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Preferred Mutual 15024 William Conz INSURER B: 30 Quinn Dr INSURER C: INSURER D: Holyoke MA 01040 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. I POLICY EXPIRATION R TYPE OF INSURANCE POLICY NUMBER DATE (MM DD/YY) DATE (MM/ D/YY) LT INSRD T R INSRD LIMITS LT GENERAL LIABILITY EACH OCCURRENCE $ 300,000 AMAGE TO X COMMERCIAL GENERAL LIABILITY PREM SES (Ea occurrence) $ 100,000 A CLAIMS MADE X OCCUR CPP0100595753 9/17/2008 9/17/2009 MEDEXP(Anyoneperson) $ 10 PERSONAL &ADVINJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 600,000 J POLICY n JECT I PI 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 OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- IOTH- EMPLOYERS' LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER /EXECUTIVE 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 DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE FOR FILE ONLY EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 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 O PRESENTATIVES. AUTHORIZED : ' • • ACORD 25 (2001/08) © ACORD CORPORATION 1988 INS025 (0108).08a Page 1 of 2 • % 6 .. .: - .. .. ' . The Commonwealth of Massachusetts ... z.-a.=2,----- • , Department of Induitrial ACcidents ,.. ....... g Office ofbriIestigadonS , • 600 Washington Street - • -, =:41,-,..---. .1 : %EV I f- Boston, M4 02111 . . - ---- - . ,..,„, ......... .,.., • www.znass.gov/dia . . . -b ' • , e,.. , :' 'Workers' Compensation Insurance Affidavit: tuilders/ContraciorsfElectricians/Plumhers ..: • Applicant Information • . Please Print Ligiblv - l: Name (Businesi/Organiiationandividual): . v )4 yn % Co 14) t 1 1 1 7 • . . , , i . • ' Address: 'SO 62 I) i ,,,, Df\N a i<e_. / /0 i cityistateizipv-Alpie AA t ; .01 0 (Po Phone.#: 4,1/ 3- - - it 6 tc 4 0 - . . Are you an einployer?.Cheek the appropriatebox: .. 4, 0 I arda general contractor and I . . TYPe of proj (re ir 1.0 I am a employer with 6. 0 New construction • employees (full and/or part-time)•* have hired the sub-contractors 2..D I ath a aole proprietor or partner- . listed on theattachrA sheet. 7. 0 P.emodeling These sub-contractors have • ship and have no employees .8. 0 Demolition • . . " working forme in capacity 611449---CP-•*1-61v.e w ' 9;7 Er litinthk-iliditudii. • ti4er wOrkere comp. *Oran= - _ camp ioertreTic e. 4.. .. • required.] •• . 5. 0 We are a corPpinidan and its 10-0 repairs or additions • • 3. 0 I am a homeowner doing all work officers have ' -eisecl their • 11.E1 PIM:thing repairs or additions . . myself [No worlMrs' comp. . right of exemption per MGL 12.0.knof repairs • . - qinsurince reuir' e ctj t • . : c. 152, § 1(4), a nd have no • , r _ i , • . • . • .. . eircloyees, [No workers'. . 134:1 Other ' c comp insurance requizedj • ' • *Any applicant that checks box al must also fill out the section belMvshowing theirVforio7e•compessation pokey informatiee; • • 1 . • ' . , t 0 V.to subinit thii afridaVit.inckeatiig they are doing all work and then lire outside contactors must submit armatiffidavit indicating such. :Contractors that check this boimnst attached an adt&tional'sheet showing the name of the stib and stilt e-whetlier or notthose mititim have employees. If the sub have employees, they mustpravidit4eir workers' comp pokey somber. , ' • , ' . --: ;, .-• : - . -T . , ' .. , I an: an employer that &Providing workers' compensation insurance for my employees Below is the polieyand job site information. : `1 . . rj- . _,, , insurance Company NaMc: (Pc\c , l' ' M 0 t ila . . . -.. - . .. .- Policy # or Self-ins .. Lic. #: c p to 6, S 5'13 . Expiration Date: - c//..,.>,‘t 0' I "I . 41 ,e s5- '.• • • • 2 A4' • z• .lo Site Address: 6 )rm • .... . - . City/Stafe/Zip: -.• a"),-: .• • '4.. 01 0-..., Attach a Cap, of the workers' compensation Po#UY.dec4F0.9a..P.....;te.(s.#°744 the PPP9'.. *10.07. a nd . . : _c•Vir.00 1 ..daie)- Failure . to secure CoverikeiSie4iega Seetibli ea.164 the fniiiiOiiiiiiii ii raiii:iiiiiil iienali‘ of a fine up to S1,500.00 and/or one-year . iniprisonm*,. as well as civil penalties in the form of STOP WORK-ORDER and a fine • of up to $25000 a-day against die B e advitedthai a copy of this statement may be forwarded the C A InVettAiratiaili ati/ - ' - T.' --•„ : 7-7 7. --- - - ' ......... _:•.,1 .:1 Ti=7"*.:2771 l = :, de , , ,, , , , , pea ... - .0.(perjarylhaidu infOrmationprOvid;ittilat*IrLtine_antLeOrrocj ..,- i , ... ...: e-_-_.. -.....e.■:-... -,,nr.. • . . : i te- ' Ar . • . . • , . _ .....- . ' i • • . , • • . • • : , - - . - , , • . . • • Phone 4: . • Offieitil use only. Do' not write in this area, to be completed by ca - .it town affial4 . . .• ...City or Town: : ". . Permit/License # — ,....., Issuing Authority (circle one): • • .1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Insp actor 5. Plumbing Inspector 6. Other , . Contact Person: Phone #: • . • •.. 1 SECTION 8 • CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder : 01 1 Q V"; C [ 3r) g3 (✓ License Number ,3o Guinn �� yt oKe. ,4a. OIOLv 5/ J /ao Address Expi Lion Date -4(7) *‘7 '99;7/ (2 ignature Telephone s r6 s .�; x '. "' rr ��, �1 ... w.., � �,��� ,� , .. Not Applicable ❑ Company Name Registration Number Sc 01 / / o J� Address Expi tion Da Telephone Sa ni r SECTION 10- WORKERS' COMPENSATION INSURANCE* AFFIDAVIT (# 0.152, 25G(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 ❑ C �tv� l r > R ..... c ‘ .°.Y��'� ° �z. 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 May. 20. 2011 7:46AM Realty USA Vestal No. 3005 P. 4 3 E�?ti 1 1 , �� r,, ^ , j ,l .. a , 1rt a� 1 is L1� ii�� 1 1 ;; r i : IJ:iw i i 7 .: New House 0 Addition ❑ Repptaoemon Windows Atteratton(a) [J Roofing CD or Doors - Accessory Bldg. tJ Demolition New srgna (CJ) Decks tta biding tall Other (0 Brief Des Qf Proposed) WOW' 'OA r • • • /, • - w • . •0•• • Alteration of o deffng bedroom Yes No Adding now bedroom Yes No Attached Nanoue Renovating unfinished basement _ — VW - No Plans Attached Poi: . 8heet `-.0 1 e�Jl� .''-; J 11} a Use of building : One Family Two Family Other __- b. Number of moms In each family unit: . .. Number of 8athroome _ c• is there a garage attached? —,- - d. Proposed Square footage of new construction. Dimensions a Number of stories? f, Method of heating? - _ Firepteooe or Woodstoves Number of each g. Energy Cgneeivati0n Compliance. . Masscheck Energy Compliance form attached? __ - h. Type of construction i. !s eenstrciction 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 lc tMl 3buAding conform to the Building and Zoning regulations? Yea _ No I, SeptioTank.. - City Sewer_ Private well City water Supply _______ I +, ( 11 - , 1 •L >� ,7i ' - 777 -:•-• r 7+I�� yE�l� r i fj L ' ,,y u f� fi * t'� l ��� i� r t S iT R I I� ��' -'1 y � ' �`- s 1G�� } �r l fl 1� ��� � YYY- " J.. n ��• 4., +i%C 1 IVs `t: tr�577�' �i'��•._ as owner of the subject property hereby au oriz9 to cot o y behalf, In a I matters t el a to work authorized by t is bulkftn 1. permit - pplicetton. or 10 gi 7-0 24 I $ atute of • . Dale as Ownar /Autf►arized Agars a • y declare that the statamen = en. n • rrnatlun on the forego ng app ce on are true and ecourate, • the hest of my knowledge and belief. Signed under the pains and penalties of perjury, Print Name a . aturm ofOwnar/A:ant Data 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 i � Lot Size _ � _. w � i _ ff Frontage l.__ I i __ _ , [ ..__..,..._..._w_ Setbacks Front = �] 1=3 Side L:t i R:, . L:17 R:i i """""`"( . .. , f Rear I 1 1= I Building Height = _J €1 Bldg. Square Footage 1 , I J % [] 1_- L. .- -_.. Open Space Footage % --- (Lot area minus bldg &paved E= iml i _.. d,„. parking) , imi # 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: I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I Page! and /or Document #' i B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: i S 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 (;) 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. r, .. ,a ,r .; WI L IWA ,. s ,,* May, 20. 2011 7:45AM Realty USA Vestal No. 3005 P. 2 1 ttla 7 0 0 a Cty of Northam ton t3uitdi Department � � t _ � 212•AMain Street 1, , III '1 Room 100 nf eup ' • , . rthampton, MA 01 060 phone 413-581-1240 Fax 413-687-1272 , a ' 1 %1 APFLICAI1ON TO CONSTRUCT, ALTER, IMPAIR, R E N O V A T E OR DEMOLISH A ONE OR 1WO RAI Y oweLum e P`��19l . .ryTq yo. y . b r e� Add++as An ,4 � �� �� till tp t ', .. ,, • .s — s'J !' !�n 1 , � � hhr , ( hhP t fSi�l�tS s't � . PIA j ,.{ f / k �i.F ) } 4 k S 1c- icr ie � d J u s - , ,` T ar _ t t7 PIA G1v1A/� QA ,/1 A G ! / q ' , e t a ,_,A ` s i 1' r �r 'ti .a J t 1 e 4 ,t,'7, t� "1Y� j l J � i r 4 &'' I' z r " �.I�NYk { t t., � h ' � j "• 'f�. ° ^ k �i ; i P� +I �l '�' � 's' � � ' I a � • •, 4' �q r; ` I , � � 7 f il j z � r"+�" T, "�, .' �r.' . .. - :i° - .a `'' 'I 4 ' -a t-: .'. . ZiOwner of Recant: - • _5Usan 1Crar1s-- K 1 / °tom lit " o n d .' 3 ' 0 . 7 : st a". i Tale phena _,..... . i ,m2 Authorized Aa Name (Prim) Current Mailing Address:: aIgnruurn Telephone y MIIIIIIIIIIIII Cost (Dollars) to rie 7i im -' ~ . ` , `' •. " - :- .:, -; . 1. Building " t '` r .,,"p F ti 00 Z NlaaMcal ,. ,r� .�.� 3. Plumbing .. • ,}• l4 ^', `ti`':' �. ,_ 4_ Mechanical (HVAO) .' ' : -_>• '' 1. ,., . . - . - . • 6. Piro Protection ,V 11 '' ►�0 �• ' i.. • `iii 1.r1.1 ' ". , ' �' ,r , y am . F.. Total n q.4..?..-k 3 *4 -t � ? -- ... , a ► ► u,: 4bfldltrg trj�fc, b ' slwaee :. • '. . • • '' • gp �, / �, ,yy r - 1 , :t..! l ` 7 „[ - ; - - - - - , _ ;,. , ., .,...--b7 , . ' a'a. _.. - - /6/43 - 1 '. - 3re .. - -V. • ... +. ,-. -_ -.. 1 54 FINN ST BP- 2011 -0961 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 186 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofmg BUILDING PERMIT Permit # BP-2011-0961 Project # JS- 2011- 001570 Est. Cost: $5000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WILLIAM CONZ 13783 Lot Size(sq. ft.): 5183.64 Owner: KRAUSE SUZANNE L & CELIA KLIN Z.onp g; i;Rf'(19011 Applicant: WILLIAM CONZ AT: 54 FINN ST Applicant Address: Phone: Insurance: 30 QUINN DR (413) 265 -4920 HOLYOKEMA01040 ISSUED ON:5/20/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE MAIN ROOF,SHINGLE OVER STEEP SECTION 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: iisuiatk'ii: Final: Smoke: Final: .4-70t1 OZ� THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 1 4444 : 0 /4 r./.- Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 5/20/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck -- Building Commissioner