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25A-082 (2) I CERTIFICATE OF LIABILITY INSURANCE DATE 19;10 ) PRODUCER 1- 404- 995 -3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Two Alliance Center, 3560 Lenox Road, Suite 2400 F axes ( 21, GA 30396 I I NSURERS AFFORDING COVERAGE _ !AMC # Fax (2121 943 -0702 _ INSURED I � CO I The Home Depot, Inc. L INSU, ER Ins C 26337 i , Home Depot U.S.A., Inc. I INsiiRER Br ZW: CLI AzneraCan Ins Co 16535 1 2455 Paces Ferry Road NW INSURER c New Hampshire Ina Co 23941 suilding C -20 'r Atlanta, GA 30339 I INSURER D: NATIONAL UNION FIRE INS CO O. PI TS 419445 ____ 1 1 INSURER E: Illinois Union The Co -' 127360 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. INSR D/�C''LT - � --- 1 -- -i- -- � POLICY EFFECTIVE iPLR_iCYEXPIP,A'rlOidT "_._.._.._._ LTR INSRDI TYPE OF INSURANCE I POLICY NUMBER I DATE (MM/DO/WO DATE IMM IW /DDYY1 LIMITS A I GENERAL LIABILITY I0L04897714 -00 03/01/10 I 03/01/11 L I EACH OCCURRENCE __ 4,0_00,00_0_ - j DAMAGE TO RENTED - X . COMMERCIAL GENERAL LJABILIT: i ( PREMISES (Pa occurrence) - 1 $ 1,000,000 _ ' _ 1 CLAIMS MADE [ X I OCCUR I I MED EXP (Ar y one pe esr) ti EXCLUDED V 1 L PERSONAL 3 ADV INJURY $ 4,000,000 --.-' -" 1 . G EN ERAL AGGREGATE � $ 4, 000,000 GENt AGGREGATE LIMIT APPLIES PER: I 1 PRODUCTS - COMP!OPAGG_ I$ 4,3D 0,000 i I X I POLICY I I ECT I 1 L OC I 1 I I I H LAUTOMOBILE LIABILITY (SAP 2939953 -07 03/01/10 ( 03/01/11 t COMBINED SINGLE LIMIT ' '$ 1,000,000 I X 1 (Ea accident) 1 ANY AUTO i I , F AUTOS 1 r-----' !BODILY INJURY • I $ , I ALL OWNED AUTO., 1 I (Per person} SCHEDULED ALTOS HIRED AUTOS � ._._._J HIRED I ! i BODILY INJURY $ I NON -OWNED AUTOS 1 ' Per accident ' I i I ( } 111 LX SELF INSURED AUTO 1 ` - - --_— INSURED I PROPERTY DAMAGE I (Per accident) $ ( PHYSICAL DAMAGE I GARAGE LIABILITY , I AUTO ONLY ACCIDENT i i 1 I I ANY AUTO ! i OTHER THAN - . - ' 4 ) - - - - - - _ _ . . . _ _ . _ . . . i 1 I -- --- AUTO ONLY: aGG $ A j EXCESS / UMBRELLA LIABILITY i 0L04097714 -00 03 /01j20 1 03/01/11 CE I a 5,000,000 - -- _. -- X 1 OCCUR E� CLAIMS MADE i I AGGREGATE , $ 5,000,000 • DEDUCTIBLE (...._.__ _ ...._.._. .. __..... _- _ 1 I RETENTION $ f i b C WORKERS COMPENSATION 03/01/10 1 WCSTATJ- ! ,--7 - 1 - I W I WCO20342355 (AOS) I 03/01/2]. 1 X 1 v AND EMPLOYERS' LIABILITY . l N ' 1 / �1Qh= 11M1T $1 E$�._ -- - --- - -- D ' ANY PROPRIETOR /P.ARTNERJEXECUTIVE� IIWCO20342356 (CA) ! 03/61/10 03/01/11 I E.L -EACH ACCIDENT - 1$ 1,000,000 OFFICER /MEMBEREXCLIJDED? 1 �- L I i 1 - t - -' - - -' - '" - 5 I (Mandatory in NH) I WCO20342357 (FL) ( 03/01/10 03,01/11 j _E,LDISEASE - EA EMPLOYEL 1,000,000 I It yes, describe under I SPECIAL PROVISIONS below I I i 1 E,L DISEASE - POLICY LIMIT i $1,000,000 J E f OTHER TX Employers Excess 1 TNSC46242373 (TX) ! 03/01/10 03/01/11 [ Occurrenc e /SIR 30M /2M D (Workers Compensation 1 WC0910566 (QSI) I 03/01110 03/01/11 I C 1Workers Compensation IWCO20342356(KY,8IO,NY,WI,+WV) 03/01/10 i 03/01/11 I_ --- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ' EXCLUSIONS ADDED BY ENDORSEMENT i SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE • -- - - _—___. _ - CERTF:CATE HOLDER CANCEL LAT =ON �� SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCEL LED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN HUMS DEPOT U. S . A. , INC.. NOTICE TO THE CER T IFlCATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 2455 PACES FERRY ROAD NW BUILDING C - REPRESENTATIVES � — -- ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE og gimatiguisse USA ACORD 25 (2009/01).....'.....' --- © 1988 2009 ACORD CORPOR.AT -ON A -- rights reserved The ACORD name and .ogo are registered marks of ACORD _ _ t , . . ._ .2 . . _ 2, _ , , 22:2,2.22„:.....2.2,22„2., 2_2 , 2_. . for rai.h P .., urt ..s n,.. �., i - .uum .. ...t.:.. ari.j tarn .s.. u� ?i ..,u�: > .,:� ..c_, u..uaz vu - {,i:laFraa ..i:x ° °.:`;ti a Laa .a anta sxu? rr•:a u as.. - n.r ,..3.:..as »...1 ..i bL :: - ,crr_ nair: -.. 55.1f. . ..:?5 :_t.b....: �s t.... ,. 1 .. __ 1r ?. x -s ,y(ci zmfi.?. e:f P..ifs. ,,r1.1 sea. 3._L...d u air E".....a a . ®.. i . 5 _011 �_ €.. - ' nrsV:L..,.. fr•of th:e, ..z.. t rt .i n rar:l n,., — .3aatt Tr; ti a't taUt -t 9sa a eitfOS}irSr3 '1311 is - ii: t - ? € +, .: t .A' i, 3?t,rai -.t 3d tilt tittle' Y ata *11.41. kks _§../_e.. a { [ ea f_tr ifiel ?c 4 .,=101r: :S. «cr �,, vl. s H f . _:,:x ±.,.. u • _t w r _ f?M_,. .__ hit tai ibrf >rr t'«rk» ti:ut>rtatital .tittt to ' r t prou,tirti by 1 aw Home [}era( r.tr .xat$)e_tel arty S rtiv ?ri"BSL.rthrt>t;Eh the 41 - itta :rf tt 1"ndlititiam. Oru.S Isn't 'Ai:Tr u (_!Ytti� "std 1.61t1t of t1"iss .=ngseeaaerai Inv 4131ct13etsei uulier aptaisystflt flaw. `P rzi+ is +.i vi OEPr }r MA 2 siNrr� '.e;Li ra <ti; "Gas 'x r'. 'r anti u: anx� Fax, u.`. :' Cra .sa .:s �a. .s.. - ..a - .,: - .rt.a ;. z. a° :s. ..z. xac - a.:-L s. t ..i .ktfitNG klir`.+ + - OA.1- fz_r',S3E e ;r43i(3E_"°, >. i.ca' pixftcF s3sae it thors ,xa. ' r. t ..., f•r �.:vf,r:, nti l this. ..iQ , . ,ru ,,..T' , 1 , , . ,t . c, . u ' - ), 'r , , , . s . i.u..f ._, ars.y ..�..-n Cr�-s ^:, , s..h. >:.xr. r, ..,., M:; " nr J „ - f• i'�r<,gf ..,arse r+. ... e,:: u. .._.�,:+: :1 ..:e.rs raa �'.x $. .sxic.n. -. . Y..f:�•. r.'33„:"3.,;413.33.,'.:-.1•''l ..,;»tr ...k, i...w>v .I,a.c..... r N.".: 'i _g terra'. ,.tot' i Fm ( =Rt sstAME 1' €ikI[} " S k' :y? 3S ? ! (1.O8UG.tnU()N 3 -4.it:: O:e t 'tAi..`:. ..tt It t, 3—.3;'5..., r.,:114 ,rve tti. "YF".: :'.T.: :i38�: T . 'a +':s S: "r ,. •'.` fhlS If-1E St.P'PLJtME11' Al`f_.sCIL§W ILL_t. .!'C f.:13'3SrilifliEit'S STATE. .bUt IL a.a ,t.UtatitU'LA3, I Pr.,UNIN ANC: H3.1)33.'C1■ 3N,ti A8tt V`f.R'11,1) efrt F Pit•. R.^stti at' 3".4339+'. Aiti @A ARNl VAR 1 (83 3 tfi?i i i3'L itAri ' T 1_3li_(3S1 f: ,Ct'; VJF +r era,..,,-*.:. V.,i{....• _.. ',.iMn,... Pant.. - 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 — ---------- pets-i-n- conjunction_ to _thebuilding.permitissued,_ 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 building inspections necessary for the building permit issued to me. -Date Address of work location T • The Commonwealth ofMassachusetts Department of Industrial Accidents aR. =,: ► _ E Office of Investigations ' k = t - 600 Washington Street 1tcfc_ Boston, MA 02111 www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 1 - ` I/ - III •.. OA Address: q C7 �l t w► d ' L�, y , • City /State/Zip: P-:— f,� �� j0 •j 3 Phone " #: ')('� F � 7 1.0--- Are u an employer? Check the appropriate box: Type of project (required): /' 1. I am a employer with 4. 0 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. 0 Remodeling ship and have no e loyees These sub - contractors have. . 8. ❑ Dembl on for me in any capacity. employees and have workers' working Y P ty 9. 0 Building addition [No workers' comp. insurance comp..mstnce required.] 5. p We are a corporation and its 10.0 Electrical repairs or additions 3.0 I ama- homeowner -doing l -work office�,s liave their I1. ❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 R insurance required.] t c. 152, § 1(4), and we have no� employees. [No workers' 13. Other o 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 worke ' compensation insurance for my employees. Below is the policy and job site information. i Insurance Company Name: i A.,) ...A , S 1 1 rm ( 0 Policy # or Self-ins. Lic. #: lr� -., r. w Expiration Date: Job Site Address: ._ JIM City /State/Zip: 111 :. #1 , Pt., Attach a copy of the workers' compensation po I declaration page (showing the policy number and expir tion 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. lie advised that a copy of this statement may be forwarded to the Office of Investisations of the b or insurance coverage verification. I do hereby certify un . �� ,,f d p0 nalties ofperjury :that the information provided above_i .true andcorrect. _ Amy Signature: ,i / Date; L / Phone #: Tj` c fficial use only. Do r write in this areizJab e comp -_ O ed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): f. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector __ 6. Other - - Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Superv' or: Not Applicable ❑ Name of License Holder : ` Li 1 byyni 1) I License Number rr � C/10 AddAr ��C /. �' Expiration Date • ignatu " Telephone 9. Re itteredHomelin rovement:Contr "" lcirt ,., . , , iz ue_ emu ... a .,... ! Not Applicable ❑ Company Name 1 1 Cr— Registration Number ' c & .3 A ") Address ^ ( ` e Expiration Date J 43 , � .e n ?Telephone _ SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit t be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi ermit. Signed Affidavit Attached Yes No ❑ - 0111CF: tat 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 — _ Nor•tl ampton r its d ` n a n c e s , S t a r e ' a n L at"" • : — . • ° r s- Gener-aILaws- Annotated. Homeowner Signature ' r SECTION 5- DESCRIPTION. OF PROPOSED WORK (check all applicable) New House [l Addition [l Replacement Wi ws Alteration(s) ❑ Roofing 0 Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [CI] Brief Description of Proposed +r I am l , Work: V : 4 --- IA m ' . i . .�f . IYI°P Alteration of existing bedroom Yes No Adding new bedroom Yes No 514 Attached Narrative .Renovating unfinished basement Yes No Plans Attached Roll - Sheet Ga 1 (e [ iViii r>!iAadittei lsiln6livusiiiiir6atn e e `ielotiwin : 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 p c 1 l4 as Owner of the subject property 1 hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application r Signature of Owner Date tI DWI-E' as Owner /Authorized Agent hereby declare h ` statements d information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed lip the pain alties of perjury. Pre f -ign. ureofOw'er /Agent Date w 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 I , i _ I . .. _ . ? Frontage _____ Setbacks Front j i ! i ! 3 Side L: R a L.., R: Rear L7. Building Height , --_ —,; Bldg. Square Footage I 1 I % ( i Open Space Footage % (Lot area minus bldg & paved parking) # of Parking Spaces Fill: i 4 (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 _I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O 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 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 tfie 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • w City of Northampton z N r Building Department �, se 212 Main Street r A� ')V Room 100 m Northampton, MA 01060 �; phone 413 - 587 -1240 Fax 413 - 587 -1272 5 M APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION This section to be completed by office 1.1 Property Address: C-onl IGp Map Lot Unit t7rakiveliel7litigulce4:4 , '`' ?one Overlay District EIm District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTH ZED AGE te 2.1 Ow .�Qil;i�i rd: 94 % (9, 5 (zit, t'+.• 4 P W 00 ►s. ILI, 14., WV 1.----4-.-. —_ - Name (Print) Current Mailing .. Z.: '"�C) L:11.7-1(.6 0a i C { Telephone Signature 2.2 Autho — Agent: f .� ■ _� 'U ' 10 :i •' _d / ii,...Li ! I i / 6 667 Current Mailing Address: Ai _ _ 1 9 3 0 -� 411 1W. ure Telephone SE a ION 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) 114(c.../1"— Chck Number This Section For Of se Only Date Building Permit Number: Issued: Signature: Building Commissioner/lnspector of Buildings c Date - 23 COMBM AVE BP- 2010 -0760 GIS #: COMMONWEALTH OF MASSACHUSETTS Map;Bf q 5A - (82 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- 2010 -0760 Project # JS- 2010- 001134 Est. Cost: $2461.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq ft.): 6621.12 Owner: PACKARD JOSEPH JR & GERALDINE Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 23 COOLIDGE AVE Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation WORCESTERMA01607 ISSUED ON:3/2/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL REPLACEMENT DOOR 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 3/2/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo