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22B-108 A W 0 INSURANCE BINDER DATE (MM/DD /YYYY) (�.... 05/07/2012 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. - - - - -- AGENCY COMPANY BINDER # Neill & Neill Insurance Agency Inc Northland Insurance 662 Riverdale Street - -- EFFECTIVE EXPIRATION West Springfield, MA 01089 DATE TIME DATE TIME - _ - _ - - -- AM L � 12:01 AM 05/08/2012 12:01 PM 06/08/2012 ! NOON — -- --_ _ PHONE (413 ) 732 -4137 FAX THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY (N, N Co, Eat): (A/C, No): _ CODE: t SUB CODE: PER EXPIRING POLICY #: AGENCY PATRI -2 DESCRIPTION OF OPERAT1ONSNEHICLES /PROPERTY (Including Location) CUSTOMER ID: INSURED Patrick Kelly Roofing & Siding Roofing and Siding 12 Old Feeding Hills Road Westfield, MA 01085 COVERAGES LIMITS - - -- - - - - -. - -_ -._ _._. - -_ -.- ----- /F LE -- j- l TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS AMOUNT PROPERTY CAUSES OF LOSS BASIC 1 BROAD SPEC GENERAL LIABILITY Policy #WS127221 EACH OCCURRENCE $ 1,000,000 Effective: 10/19/2011 - 10/19/2012 DAMAGE TO 50,000 CLAIMS MADE v IL COMMERCIAL GENERAL LIABILITY RENTED PREMISES $ OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 . RETRO DATE FOR CLAIMS MADE: PRODUCTS - COMP /OP AGG $ 2,000,000 VEHICLE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO k BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS $ _ -- NON -OWNED AUTOS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ $ VEHICLE PHYSICAL DAMAGE DED I ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: STATED AMOUNT $ OTHER THAN COL ___ __ _ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ I ANY AUTO OTHER THAN AUTO ONLY : : EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ ' OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: - SE � LF - INSURED RETENTION $ Policy #WC2-31S-319318-025 V WC STATUTORY LIMITS WORKER'S COMPENSATION , , Effective: 06/12/2011 - 06/12/2012 E.L. EACH ACCIDENT $ 100,000 AND 100,000 EMPLOYER'S LIABILITY E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ 500,000 SPECIAL BINDER IS FOR PROOF OF INSURANCE ONLY FEES $ CONDITIONS / TAXES $ OTHER — -- - COVERAGES ESTIMATED TOTAL PREMIUM $ NAME & ADDRESS Patrick Kelly Roofing and Siding MORTGAGEE I ADDITIONAL INSURED 12 Old Feeding Hills Road LOSS PAYEE l . Westfield, MA 01085 LOAN # 4 4 4 e AUTHORIZED REPRESS w d , : ACORD 75 (2010/04) Page 1 of 2 © 1993 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD City of Northampton Massachusetts "e DEPARTMENT OF BUILDING INSPECTIONS +*, 212 Main Street • Municipal Building q Northampton, MA 01060 Jp "1/4‘ INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 w ho 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 any 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 /footingsjbefore 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 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 The Commonwealth of Massachusetts ( Department of Industrial Accidents t. . °t ro Office of Investigations • I- = ° = 600 Washington Street w ,,; Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): ph ( ( 1 k . k.el iy jZ00PIf chsid, J oI i Address: 12. 0 1 d Fe€J f 14;1 IS ci City /State /Zip.eStPieJ �f 06 g Phone #: 4t3 5 g Q(5 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. n I am a general contractor and I mployees (full and/or part - time).* have hired the sub contractors 6. n New construction 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. n Demolition working for in any capacity. employees and have workers' g Y 9. n Building addition [No workers' comp. insurance comp. insurance. required.] 5. n We are a corporation and its 10. n 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. VTRoof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.1 1 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: 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 $1,500.00 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 co ay of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificatio I do hereby c • fy if der e pains a pe'zalt''s o per,' ry that the information provided above is true and correct. Si ature. / h \ 5,-- '_ /7___......- / D ate: / Phone #: / 41 3 LS b ( s - 13 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. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: I I ' SECTION 8 - CONSTRUCTION SERVICES 1 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Pcm«i C 102.3 License Number [z of e LJ:( \17 H,LLs I <4 i( )- ' 7-61- 12 Address w a.dS ( � I ` fr' !+ Expiration Date na { ' c � 1 / T elephone clibvv\, r 9- Registered Home "Impcovment- Contractor ,P g„„ ,c,� `• U ,. s Not Applicable ❑ Porn; ck fret y �c�F� y (��d „ � �d,N (28 74 9 Company Name Registration Number R Z R. cl 1/ — 1 Address J Expiration Date (�/ M e /'1�" Olo Q ( Telephone 413 S6g q 7 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 ti No ❑ 11.x -Home OwnerExenption 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 n Addition n Replacement Windows Alteration(s) I I Roofing Or Doors C Accessory Bldg, I I Demolition 1 I New Signs [O] Decks [El Siding [O] Other [D] Brief De cription of Pro.os -• • t •-� Work: $ ' c - . r aid rel ';' A/S & 3 'y S � i,�y Jg 1 S c �' Aid Fel ✓ / Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a . If New house.and-or =addition to °e xisting housing, com the =follovt inq: 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 I, AP1 , as Owner of the subject property �, hereby authorize cA�,,CIG� ``( e \\ to my behalf, in all matters relativ o work authorized by this building permit application. Sig ture of Owner Date `5 �� r 1 2- I, k (\ N C...„ , as Owner /Authorized Agent hereby de are that the statements and information on the oregoing application are true and accurate, to the best of my knowledge and belief. Signedund�f I l' mild al if 1perjy�ry] I LL J r / Print Nam: �� lu .., 7, Signature of 0 ner /Agent Date ., 1 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information l� Existing Proposed Required bi+'Zoning�' 1 Wok This column t be filled y Building Dep rtment Lot Size — _._ Frontage _ . Setbacks Front Side L: _— R:. .v L: mY . i R:, 1 Rear i Building Height Bldg. Square Footage % Open Space Footage . _, (Lot area minus bldg & paved _ 1 parking) # of Parking Spaces Fill: . .... _ . __ (volume & Location) — ____ ° ... °° A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 Q Obtained , 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 t 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. • DepartmeRt use only RECEIVED City of Northampton Status of Per `' ` Building Department C rtment t�rb Gu t/Dnyeway Pe rftlt ; a� � golf yr� 212 Main Street Sewer /SepticVlia ,1- "� a . foN 11112 Room 100 Water(Well Availabili ty - 'A Northampton, MA 01060 T wo Se o fStrurturalPlans4 DEPT. OF BUILDING INSPECTIONS Ma s p NORTHAMPTON MA01.- 1 •. - , 13 -58 -1240 Fax 413 -587 -1272 PIot/Sl e Plans r ' n Othe �a _ APPLICATION TO CONSTRUCT ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed byloff 1.1 Property Address: x i 4 5P'Z S Map Lot 1 COR p k Zone Overlay District �ti �/V� Elm St I]istnct CB Di ' SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: a � � � � D A w � /� A R Jf,1� l- Ft 'till- S R;� / q h 4eA / / I Nam int) Current Mailing Address: J 4(3 _ .'30 of Telephone Signat re 2.2 Authorized Agent: ' - T •c koi 1 2 - o ld F�I,�9 141 ad WecL mil Name (Pri Current Mailing Address: -. 0 t D gs � .><:.,, 4 S6 9 • 6 1ci 3 Signatur- I Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS f aq Item Estimated Cost (Dollars) to be Official Use Only , j ' 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) Check Number s ® 1 ` ® I C This Sect For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date • 194 SPRING ST BP- 2012 -1017 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22B - 108 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2012 -1017 Project # JS- 2012 - 001751 Est. Cost: $8995.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PATRICK KELLY 102344 Lot Size(sq. ft.): 31319.64 Owner: HELMINCK ALOYSIUS G & R HAAS Zoning: URA(100)/WSP(100)/ Applicant: PATRICK KELLY AT: 194 SPRING ST Applicant Address: Phone: Insurance: 12 OLD FEEDING HILLS RD (413) 568 -9513 WESTFIELDMA01085 ISSUED ON :5/17/2012 0:00:00 TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE ROOF 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 5/17/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner