29-080 (5) ' JUL - 30 -2010 11 40 From:MCCLURE INS. To:5258116 Paae:1 /1
Clients: 40154 URBAN
ACORD CERTIFICATE OF LIABILITY INSURANCE 7, `" '"""'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS '
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE Coven/ GE AFFORDED BY THE POUCIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(5), AUTHORIZED
REPRESENTATIVE OR PRQDUCE1t, AND THE CERTIFICATE HOLDER.
IMP. • ANT: If the certificate harder Is an ADDITIONAL INSURED, the policy/les) must be endorsed. If SUBROGATION IS WAVED, subject to
the terms and oondillons of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CoNTAI:r Cara Sherman
McClure Insurance Agency, inc. t N. : 413 781 -8711 N 413 731 -3548
103 Van Deena Avenue E4WL -
P. O. Box 339 A te ~° -- "
West Springfield, MA 01090 CUSTOM= ID -
tNEUReO M�Sl1RJ S'AFFamalG COVERAGE , NAC
Urban & Sons Insulation Co., Inc. INBtIRER A Acadia Insurance
335 LIBERTY STREET IN$LREJ s ; AIM. Mutual Insurance Co.
INSURER
SPRINGFIELD, MA 01104
I+sUReR0:
INSURER E :
INSURER F I
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
This IS TO CERTIFY THAT THE POLICIES OF INSURANCE uSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUiRENIENT. 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 POUCIES DESCRIBED HEREIN IS EUUJBCT TO ALL YHE TERMS,
ear EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED PAIDF .
1 TYPE OF INSURANCE POLIC NtIN R �1MW WYYYYI E A UNITS
A 46NaaALLLABILnY CPA018807914 00101/2010 08/0112011 EAcH OCCURRENCE ti ,000,000
X COMitERCIAL GENERAL LIABILITY rpm= U *50,8
1 CtAJMS•LIA'3E E OCCUR MED ExP ATM/ one person) s6,000
X SUpo Ded:1 PERSONAL BADV WAY $1
_ OSNERAL Assneakra - : ;000
CIERL AGGREGATE LIMIT PER: PRODUCE$ -CORMS' A4a 52(000,000 ,
— 1 POLICY f 7,s4-- n
L.00 a
AUTOMOBILE TOMOBILE IJA8ILITY MAA035297110 08/01/2010 08/01/2011 ° SINOIE 11MIT f s
(a acclaim° 10000.000
_ ANY AUTO BODILY uutnry peeaoe:) i
~r
AA1.1. A1.1. a WNBO AU roe 13Q61LY INJURY (INF natiA/ut) E
X SCHEDULED AUTOS PROPERTY DAMAGE 5
X HIRED AUTOS (Peeaandrnt)
$
X NOR -OWNED AUTOS -
5
A X IAABRELLALIAa X OCCUR CUA020840714 08/01/2010 08/0112011 EACH OCCURRENCE $1 000 000
EXCESS LIAO CLAIMS -MADE AGGREGATEi,,;t 000
_ ceaucrIBLE - -• S
••
RETENTION 5 5
TYumurIs c meeasaTIoN WC STATLL 17TH
AND EMPLOYERS* t
e iA190.1YY W{NZ$p05556012010 01!0112010 01ro'1/�011 �7(�{v,etlirC ra
ANY PROPRETDR FART CUTIVE EL. EACH ACCIDENT 000,000 OFFI I XCLUDPD? I I WA E.I. ••ex..Ae. EAmetovEEJ500 1 000
(Manapay In NIO
DESCRIP N Of o5An0NS Maw _ E1.. DISEASE - peLltr iAdll' :000.000
DESCRIPTION Of OPERA r ORS U LOCATORS (VEHICLES (Attach ACORD 101, AEtuisnil Remarks Schndub, It 15416 space IS ream*
CERTIFICATE NQLDER CANCELLATION 30 Days for Non-Payment
SHOULD ANY OF THE ABOVE 8L
OVE DESCRIBED POLICIES BE GANCL€D BEFORE
LI
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Proof of Coverage IZEP ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHDR REPREEEIITATNE
I
019U-2009 ACORD CORPORA All rights reserved.
ACORD 25 (2009109) 1 of 1 The ACORD name and logo are registered marks of ACORD CAS
#8474001M47347
a g2e - alfft791001.1.11eald 61. W
' °b Cementer Office of Affairs & Business Regulation
_ } . • ,I - =MOVEMENT CONTRACTOR
r Registration: . gp Type:
i.
n 611 12 Supplement t
URBAN 8. SONS 1NSULATUOlCO :, INC
ALAN URBAN = _
385 Liberty St G2-- °--� --
Springfield, MA 01104 - Undersecretary
3- 1,1assachusttts- Der.r€trsz ti _:£ Public Sal et
Board of Building Regulations and Staiitizrds
Co is ti ItiOr S +u e s3 - Sec altyLicense'
License: CS SL 101878 .,
Restricted to IC
ALAN URBAN
117 PIDGEON DRIVE ; SPRINGFIELD, MA 01119 + ;
�i�- - -- Expiration: 811812012
t nntnti incur Tr-`: 101878
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, is includefoundatinn /footinggs- f-before-baekfi l),
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 worms can�Ge inspected�' Y'
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 buildin inspe necessary for the building permit
issued to me.
Date
Address of work
location
•
r 4 The Commonwealth of Massachusetts
Department of Industrial Accidents
^' Office bf Investigations
600 Washington Street
Boston, MA 02111
A > www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): 1 Cky\ > 0 t t3 .� �v l t� �' C� ✓�
Address:
City /State /Zip: / 6 Phone #: ? 3
Are you an employer? Check the a ppropriate box: Type of project (required):
1.0..I am a employer with it) 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 0 Building addition
[No workers' comp. insurance comp. insurance.t
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 #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.
Insurance Company Name: 'A•3 \ —
Policy # or Self -ins. Lie. #: U-= �� S� L CI Expiration Date: 1(0 (.' t
Job Site Address: Ocr--€ -3 City /State /Zip: it 1 / C�1f i� C �-
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
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-.- B— r-d-o- Heallth 2— B- uilding Department 3. City /Tuwu Cleik__4..Llectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable / ❑
(
Name of License Holder : ` U ‘ G h / v ! ,e7 ?
License Number
g Li II) QV'S � e7(
Address Expiration Date
Signature Telephone
9.: Registered Home Improvement Contractor: = Not Applicable ❑
Company Name Registration Number
Address q > Expiration D t o
Telephone 73
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 (` No ❑
1 � 3o Owner; gxa afao>r
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
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition [l Replacement Windows Alteration(s) Fl Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [l] Decks [D Siding [D] Other A
Brief Description of Proposed -
Work: i IV S(A,LAT 10 ,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa.. =Nemiliot se -ankt r_ "`.iciditaa t 6 -exist ng housing, oniplgte 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 CONTRACTORAPPLIES FOR BUILDING PERMIT
I, Oe- ` (,S._S Ct L 6 Ct Z ( P > kr , as Owner of the subject
property -
- hereby authorize j A\ aY\ (..) -4 \ ca v vi` bsivv 40 /13 v‘,S k t G i- 00 P1
to actpn m beh. , in all matte rel.tiveR ork authorized by this building permit application.
7 .
0 /
AI , I .1' 0
Signature of Owner Date
P i - G 1(� 0) G`V�. , as Own r /Authorize
Agent reby declare that the statements and information on the foregoing application are true and accurate, to the best o edge
an elief.
Signed ` under the pains and penalties of perjury.
1 l G\� 0`1 J) IA
Print Name
l
Signature of 0 er /Agent Date
7
•
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
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 er be issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:.
IF YES: Was the permit recorded at the R: •istry • Deeds?
NO (3 DONT KNOW a YES 0
IF YES: enter Book = y Pa and /or Document #
B. Does the site contain a brook, bo• of water or wetlands. NO DONT KNOW 0 YES
IF YES, has a permit been or eed to be obtained from t - Conservation Commission?
Needs to be obtained Obtained
, Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe siz: , type and location:
D. Are there any prop. ed changes to or additions of signs intended -for t' - 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.
J � .0
ik
13ePartrn t la
erse
City of Northampton 5 o f Iit�
Building Department �tltrcte�Permt
212 Main Street Seer NSlpte laic
Room 100 af "I"-1 "I"-1 4*
M A 01060 � x
a .' . Ll � .... is Northampton, }
phone 413 - 587 -1240 Fax 413- 587- 1272 lotirSit lance "` h
Qec S�eify ' .:
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY IWELI1NG ,
� 1
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Addresss: (�
C r `e �� f r J Y� J f Map Lot Unit
r r F'ii 14 Zone Overlay District
Elm St. District CB District
SECTION 2 -- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: I- p
Name (Pi. t) `-'} f Current Mailing Address: 3 Zd q
t L r. A 4 -am Telephone
Signa i re V-
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
[tern 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 4(0 �. ��
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
-- TFiis Section For Offlciartise - Only ,
Building Permit Number: P 49 ( l T Issued:
ed:
Signature:
Building Commissioner /Inspector of Buildings Date
ACREBROOK DR BP-2011-0114
GIS #: COMMONWEALTH OF MASSACHUSETTS
4apIigck:,29 -08Q . 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 -0114
Project # JS-2011-000203
Est. Cost: $835.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101878
Lot Size(sq. ft.): 16422.12 Owner: Melissa Lodzieski
Zoning: URA(100) //WSP Applicant: URBAN & SONS INSULATION CO INC
AT: 45 ACREBROOK DR
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732 -3922
SPRINGFIELDMA01104 ISSUED ON:
TO PERFORM THE FOLLOWING WORK: Insulation
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 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck - Building Commissioner