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31B-061 k _ -, _ • . _ _ _ _ _ _ I4CCLURE I RARNICE Fax 4137318548 Jan 6 2010 01 :31ne P001/001 AGORD,„ CERTIFICATE OF LIABILITY INSURANCE . . • Tow memo THIS CERTIFICATE IS ISSUED AS A NATTER OF INF McClure Insurance Agency. Inc- ONLY AND CONFERS NO R1GHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES warmers), > E OR 103 Van Deere Avenue P. Q Box 339 ALTER THE COVERAGE AFFORDED BY T G HE POLCI BELOW. West Springfield, MA 01090 INSURERS AFFORDS COVERAGE - > W+IC 1 ENURED >F al= k Acadia kISurancs '� . URBAN sons DiISULATION co., INC. g: A.I.M. . Mutual Insurance Co . r - 383 LIBERTY STREET c: The Travelers Cos. ` - . SPI1t3F>ELD, MA 01404 M1ER D MUNN E COVERAGES THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 0 DILATED. NOTWITHfraraNG ANY RIEQu$ 8AENY; YERu OR CO 10inON OF ANY courRACT OR OTHER DOCUM ATT WITH RE$P6CT TO WHV H 11- S C,ER1F'.CATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCR ED HEREIN MS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS Of POLICIES. AGGREQATE mere SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ . L= TYPE of NSORANDE POLICY RUNNER :._ 1114F-43--"T/7., i llit7A5 . -4 .. HON uwTS ,: • . . A r' A MINERAL umarrY CPA018807'913 0$IO1109 08/01110 EAGN OGGORRENGE 4:1x.000 X commRCALC. u.la8Lnr R, I .350;000' 1 CLANS MADE in occuR MED EXP W7 ow p_ 4s.bso . X BUPD Ded:1,000 PERSONAL a ADY Aw NwRY 1100 GFJERALAGGREGATE ! M0AA0 GENT. AGGREGATE Lear APPLIES PER PRODUCTS - COMP/OP AGO x'1, POLICY III M ■ Loc C A4n:meaMJe nr GAM 8OWT3809SEL 08/0110.9 08101110 c omemlEDSINT uWIT 1,000.00 — ANY ALTO (IN AMMO AU. OWNED AUTOS BODILY (Rimy $ • X SCHEDULED AUTOS leer person • X HREDAUTOS BODILY INJURY X NON OWNED AUTOS G'e+ eoddrW X Drive Other Car PROPERTY DAMAGE T (Pc auddet) . GARAGE UANJTY NUiO ort-r - EAACOIDENT { ' . R ANY AUTO i OTHER THAN EA ACC $ . . • AUTO ONLY: AGO i .. - . A v GEDNI LA i mmam- CUAO20840712 88101/09 , MOW 0 EACH ocCURRENCE F1 ;DQ11,000 X1 OCCUR ® CLAIMS MADE AGGREGATE $1;0,000 E - RETENTION $ i , • - B T+rQ IS ATM]IfAf WMZ800G556012009 07/01110 01107/11 I TORY 1 SST S :' TOT :.; . ORY I tldT1 EMPTOYERIP Lu►elLrrr EL EACH ACCIDENT 080:00-0 � R WrIVE E.L. DISEASE - EA EMPLOYEE, t8@0.000 v yes. dm*? under E L DISEASE - POLICY LrMIT I 0 1 000 SPECIAL �Hwtsrolls r - • - DESCRIPTION OF OPERATIONS l LOCATIONS I VEHICLES' EXCLUSIONS ADDED BY ENDORSEMHIT I SPECIAL PRQVt JOMS - _ • Proof of Coverage CERTIFICATE HOLDER CANCELLATION 1 - s All OF YIN ABOVE ®POLICIES BE r. Fn g F T1 EXPIRATION To Whom ItMay Concern DATE 7IB( 60F, THE lBftlNT ;p1IURB1 NU- ENDEAYORTOMIA- OATS WRITTEN *WPM to - nee c. N - nee r*Tra YLL oLDER MAYEO TO THE LEFT. BUTFA IQT> TO DO 90 SHALL IMPOSE NO OBLIGATION OR WORMY' OF ANY (DUD WON THE NCR WSAGEN S OR �.._ 1 REPRESENTATIVES. AUTNDReeO REPRESENT ATIYE , . S ' : L ACORD 25 (2001108) 1 of 2 #$45309(M44093 CAS o AC4RIP C ORATION 198$ • 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 buildingcodes - and regulations. The inspection process requires that the building department be called to inspect wo at various stages, w-u'c inch cle foundation /fvotines (before- baelif}ll), 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: Ifie work can fie insj ected 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 I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required bu inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents • t-4 1-. r Office Of Investigations F.. 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /EIectricians/Plumbers Applicant Information Please Print Legibly • Name (Business /Organization/Individual): Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 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' 9. ❑Building addition No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner-doing-all-work officers have exercised their 11.n Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box it 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. 1 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 employee's. 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 , 506:00 and /orone- yearimprisonment —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 ' 'Under the . . • i nd penalties of perjury that the information provided above is It and correct. � Da te: 0 Sienature: Phone #: �2' T.72--- J 'Z� 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. -Beard-of-Health-2. Building Department 3. City /Tuwu Cletk.__. Jltc_t ica In:� cctor 5. Plumbin Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: * Not Applicable ❑ Name of License Holder : Ai1/ - 7/1 di.14,4.j 1'4065 License Number Addriss Expiration Date " 7)z °7f2-2- Signature Telephone 9. Registered Home Improvement Contractor ', Not Applicable ❑ Company Name Registration Number :tr Gr +�Y �'r _ L v`. -moo /n - '7 / 2 Address Expiration Date Telephone 772°" SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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 i9— No ❑ 1�3 : June - emote,: 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 fthe- 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 El Or Doors D Accessory Bldg. ❑ Demolition El New Signs [0] Decks [D Siding [0] Other [It(j .. "Airy /47iOC) Brief De�y�,'iption of Pro osed /00 /41/10' /7/ Work: 19QGts11J d/- /'b <te-- l- t Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa if "Newrhouse and or addition •ta 'existine -ficusrnc>t; corii iete.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 . 1. 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 1, , as Owner of the subject property hereby authorize_ to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1 /622/1-- , as Owner /Authorized Agent hereby declare that t 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. /9 ziL ,14- e- /7/ - Print Name / 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:-- Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: 1 (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: 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 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: 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 0 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 4rtftpartment ixSe ohl,k City of Northampton ;atoms oFerrti# �� • _Building Department urrCu#3xmewa p *rrnt 212 Main Street ,oevieriSermutvvAirtRiuty _ - Room 100 rate ntue` 1 Avoilabthty Northampton, MA 01060 Two S of Structural P.ians 1 • L4 0 le 413 -5'87 -1240 Fax 413- 587 -1272 PI ©t/S to Hans {ithgr Spp"a y APPLICATION TO CQNSTRUC \ , 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 1/ 4, J r 72-e/ Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: — %v,�c_- r - __ /(' /Lc! �f/J Name (Print) Current Mailing Address: Telephone 2 ' 9 ()^ j '� Signature J ® `f 2.2 Authorized Agent: /9/(/AC /f / 1-it— /1 49� c,.� /2-a/: Name (Print) Current Mailing Addres Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS item Estimated -Cost( Dollars)-to be Official Use Only completed by permit applicant 1.� , (a) Building Permit Fee rr^_e0 �- / at / J J 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 ' -- TtiisSec'tion For OfficiaC'Use �n7y Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date ..._....... . File # BP -2011 -0139 APPLICANT /CONTACT PERSON URBAN & SONS INSULATION CO INC ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413) 732 -3922 PROPERTY LOCATION 11 LANGWORTHY RD MAP 31B PARCEL 061 001 ZONE URA(95)/URC(6)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 7V d7��� Fee Paid Typeof Construction: BLOWN INSULATION IN ATTIC & WALLS - NO KNOB & TUBE EXISTING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 101878 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF_ QJ MATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ 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 Permit DPW Storm Water Management - s lition Delay /C Signature of Building 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. t � 1 LANGWORTHY 1W t BP- 2011 -0139 GIS #: COMMONW TH OF MASSACHUSETTS ap :Block: 31B - 061 i t NORTHAMPTON Lot: -001 PERSONS CONTRACTING REGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO TH 'UARANTY FUND (MGL c.142A) Category: BU . -DING PERMIT Permit# BP- 2011 -0139 Project # JS- 2011- 000233 Est. Cost: $2724.00 Fee: $55.00 PERMISSION IS HI :RANTED TO: Const. Class: Contractor: License: Use Group: URBAN & SONS INSUL ) , CC INC 101878 Lot Size(sq. ft.): 4878.72 Owner: ALEXANDEh. IT , Zoning: URA(95)/URC(6)/ Applicant: URBAN & SG ;ULATION CO INC AT: 11 LANGWORTHY Applicant Address: 1 Insurance: 385 LIBERTY ST (4. 3922 WC SPRINGFIELDMA01104 ISSUED ON:8/20/2010 0:1 TO PERFORM THE FOLLOWING WORK 3L( 2ULATION IN ATTIC & WALLS - NO KNOB & TUBE EXISTING POST THIS CARD SO IT IS VISIBLE FROM THE STI Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: i' ootings: Rough: Rough: House # Foundation: Drivew ; Final: Final: Rough Frame: Gas: Fire Department "replace /Chimney: Rough: Oil: Insulation: Final: Smoke: Pi nal: THIS PERMIT MAY BE REVOKED BY THE CITY ", 'HAn3.' " "ON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy FeeType: Date Paid: Amount: Building 8/20/2010 0:00:00 $55.00 212 Main Street, Phone (413) 5S (413) 587 -1272 Louis Hasbrouck — Bi, ioner