24D-246 ISSUING COMIIANY Workers' Compnensation
ACEPROPERTY & CASUALTY INSURANCE M
NCCI CARRIER
12254 and Employers Liability
12254
Insurance Policy
Information Page
POLICY NUMBER 17 New 71 I Renewal C Rewrite
Symbol: NWC Number:C4 63 88 21 5
PREVIOUS POLICY NO. C Individual I I Partnership
Symbol: NWC Number: C45823337 E Corporation I
Item 1. I V�LLIAM J MITCHELL Inter /Intrastate ID No.:
Named 72 TEAWADDLE HILL ROAD
Insured LEVERETT MA 01054 Federal Employer ID No.:042809179
Mailing
Address
(_ Employer's ID No.:
PIIC CODE:89999
For other named insured see Extension of Information Page - Schedule of Named Insured, WC 99 99 99 A
For other workplaces see Extension of Information Page - Schedule of Other Workplaces, WC 99 99 99 B
Item 2. Policy period: From 11 -11 -2010 To 11 -11 -2011 12:01 A.M., standard time at the named insured's mailing address.
Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here:
MA
Item 3B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A.
•
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
Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT
ND,OH,WA,WY,
AND STATES DESIGNATED IN ITEM 3.A
Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information
required below is subject to verification and change by audit.
SEE EXTENSION OF INFORMATION PAGE CLASSIFICATIONS
If indicated here, interim adjustments of premium will be made: Minimum Premium collected in MA $ 500.
❑ Semi - Annually [ � ] Quarterly ❑ Monthly Total Estimated Premium $ 8056.
Deposit Premium $
This policy includes these endorsements and schedules:
SEE SCHEDULE OF FORMS AND ENDORSEMENTS WC999999D
PRODUCER NAME AND MAILING ADDRESS
TPA INSURANCE AGENCY INC
10 NEW ENGLAND BUSINESS CENTER
SUITE 303
A ein MA 01810
tiia ����
.cachu.ett% - Department of Public Salop ��, ,Pr B �
Board of Buildin!„ Regulation. anti Standar :its Office o s ii r ► ' t ries
Construction Supervisor License ; ,HOME IMPROVEMENT CONTRACTOR Type:
License: CS 6457
4 e Registration: 103775
Restricted to: 00 Expiration: 7/9/2012 Individual
1N1tLtAM J. MITCHELL
WILLIAM J MITCHELL
72 TEEWADDLE RD William Mitchell
LEVERETT, MA 01054 72 TEAWADDLE HILL RD. G4.., --
LEVERETT, MA 01054 Undersecretary
• Expiration: 8/14/2011
( mmi, iomer• Tr#: 916 1I Counci —
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed). insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
Permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
1 , understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date
Address of work
location
-,
. .
i
The Commonwealth opfassachusetts
Department of Industrial Aacidents
Office of Investigations •
600 Washington Street
trl: :mew= Iff Boston, MA 02111
'• -
www.mass crov/dia • :--,
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiblv
, , 1
Name (BusinesS/Organiiaticm/Indiviehin1): 0 a u k ■1 1/1,, I - cl- V\C- 1 I
Address: '79 - recki,occd(r It) ( PL . . - •
City/State/Zip: L€ . vc.4 c -A--1- MI4 of0S4— Phone.#: 11 3 t 1 -- f -
,-,
Are you an employer? Check the appropriate box: Type of project (required): 7
1 I am a employer with '9---. • 0 I am a general contractor and I
6. 0 New coistruction
4
employees (full and/or part-tune).* have hired the sub-contractors
hsted on the attached sheet. 7. 0 Remodeling • 2. 0 I aril a sole proprietor or partner-
ship and have no. i)loyees These sub-contractors have 8. 0 Denrolidon
working for me in any capacity. employee sand have workers'
. 9: 0Building additiOn
conip..insymnei. I
[No workers' comp-. insurance -
10.0 repairs or additions
requirecL] - . 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers havexercised their
11.o Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL ro•r .:. .
12461.Koofreparrs
insurance required.] t :. nce
, and we we have no , 1. e 1 ,...., , i., )i .5 • ,,,,, Other at r C,, .1) . al
t
vt 1-l/ CIA4V
employees. [No workers' 13-LN
, .
*Any applicant-that checks box #1 must also fill out the section Mot showing their workers' conipeUsation policy information.
t Homeownere who submit this affidavit inciting they are doing all work and then hire outside contrtors must submit a new affidavit indicating Sulrh
:Contract= that check this box must attached an additional sheet showing the name of the subcontmators and state whether or notthose entities have
employees. If the sub-contraCtors have employees , they must provide their works comp. policy number.
1 am an employer that is providing workers' compensation insurance for my einplOyees. Below is the policyand job site
information.
Insurance Company Name: A t- 1
Policy # or Self-ins. Lic. #: C- A Q7 3 , r 2- 5 Expiration Date: - t t •
1 1 ( 1 L E:2
-, , ' v\, .0 lo 0
Job Site Address: `..) 3 59 : (- .`(...- c r. ,;er T. III:0J MAC4.11
• Attach a copy of the workers' compensation policy declaration page (showing the policy number andexpiration date).
Failure to secure coverage as requited tinder Seetibit 25K'ofMGL 152 can lead to the imposition of dining, penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties is the form of a STOP WORIC-ORDE:R. and a fine
of up to $250 00 a day against the violator. Be advised that a copy alias statement may be forwarded to the Offce of
Effe ofthe faiiiiiiiiidi , iqii - fi6ciii — - - . -- ' " ' . — TT: — -- :' - .' — '... -- .7. - .77 ------- ,-: 7 , - .,,, - 7:17. _ :: -'-''-'_-•—•,.. _,
_ .! de here/7w)* under thepa .i , enalties of perjury that the information pray& e d above_isince_andioriect.______ _
., . . 1 i
Signature: U.) 6 Path: / 11 , I
Phone 4:
. . .
. official use only Do not write ix: this area to be completed by cay or town ojrzczaL
• City or Town: % Permit/License # •
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricalinspector 5. Plumbing Inspector
6. Other , ri-
Contact Person: Phone #:
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Constructi Supervisor: Not Applicable ❑
Name of License Holder : W i �(l lit -) IN I is T L C, \e( f' D 7
License Number
7 . T L mil(! 14,1 ( L- v4- i— itl P 01054— 4s' I 1 —19,0 I(
Address Expiration Date
`
Signature Telephone
41. " � - > �`�.samilm : Not Applicable ❑
w M '�- � I' C 0 c '� t� x.::'1-1 O V i s - 7 7S
Company Name Registration Number
7.
w ti) At e " ( ( P,_�. 7 I q Lie 9 - -
Address Expiration Date
�C: V C 41 W 0 10 Telephone _ '� ` � 1
—
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 r No ❑
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) ❑ Roofing n
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [17] Other [p]
Brief Description of Proposed f I is �� + T ^ e p f d r_ �� r 002_5'
Work: (0-,M �a V mo w- p i a l NC f _ ' 4 ' 0 !Pt t Al A " 0 t r C k — \A O to I t r� � / c- W u v 4 , xctom e it
Alteration of existing bedroom Yes /\. No Adding new bedroom Yes 1 No
Attached Narrative Renovating unfinished basement Yes k No
Plans Attached Roll - Sheet
ba Whew hn anti:or a on xi tins wcruslc� Qlnt # h+r . tf+ ' p:.
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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
y r
I, O'&C) 1 , as Owner of the subject
property V (I i l'
hereby authorize �V \,Ir z l
to a on my behalf, in all matters relative to work authorized by this building permit application.
Signature f Owner Date
I, iN i t ( ti f✓V\ "� ifl ( +� vi {_ 1 ( , 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 and the pains and penaltie § •pefjpry.
VIA \WU/
Print Name
‘(ck 1. M f
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 1 1
Frontage I
Setbacks Front = 1
Side L: ; R: L:1 1 R:?
Rear 1
Building Height j i 1
I t
Bldg. Square Footage 1 - [- % 1 = i
Open Space Footage %
(Lot area minus bldg & paved I j 3 _ _ E
parking)
# of Parking Spaces i M-~-
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW ® YES 0
f
IF YES, date issued:1 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i i P and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO OD DONT KNOW 0 YES Q
W 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 •
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location: 3
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
4,
4 •
City of Northampton ,a I a,
Building Department - z '/
212 Main Street
. , 1 2��� Room 100
Northampton, MA 01060 ¢
I phone 41387 -1240 Fax 413 - 587 -1272 - ,,tkt4ir ; ,, , ,,_:
a � ., A4 N'���M
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 <
,� . ..- " I • Map „ , Lot
Unit
Zone W. Overlay District
Eim St District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: . 1...f__
1 (1' `�, IN MO
r 4 I (� ��' 1 r? i 1 ` ,J � - - , L ' S C L ' v 1 i' v � v �/� r•% `7
Name Fint) n
Current Mailing Address:
t � i IT+ J 3 9' in -/` 7
1 ,\ \L'a `- '∎--'` Telep
Signatur 4)
2.2 Authorized Agent: 0 V C `q
\iU ,1� . w w�4 , �� \ ( c. \ � 7 .): T e it i,+,'cZRr� ■ e ("� � (( jj L,c_i,tt i- M
Name (Print) Current Mailing Address:
w
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION: COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
000 (a) Building' Permit Fee
1. Building '
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection 1h
6. Total = (1 + 2 + 3 + 4 + 5) Check Number �/ V ∎ ��
Section For Official Use Only
This Sect y
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
55 BP- 2011 -0631
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0631
Project # JS- 2011- 001019
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM MITCHELL 000457
Lot Size(sq. ft.): 17511.12 Owner: WOOLF PHYLLIS J
Zoning: URC(100)/ Applicant: WILLIAM MITCHELL
AT: 55 CRESCENT ST
Applicant Address: Phone: Insurance:
72 Teewaddle Hill Rd (413) 548 -9526 Workers
Compensation
AM H E RSTMA01002 - 9805 ISSUED ON:1 /11/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE ROOFING,SIDING, TRIM 2
WINDOWS & REPAIR WATER DAMAGE
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 1/11/2011 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner