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D I , [ i -- , 1 s . 2_ 3 5 \ _),v'\ ) 9 C � 1 c5' /V 1 �'t44 S r __ l '< .a 't 1 J( 4 . 1 - ,Pit .2 / - ;7 1 I � z a H 1 I --- ji r--- 1 ) 1 1 I . , ...___,y/,-,7_, 1 Trc ,, ,s,i4 / L-- ...' ,( ] , _:___._ , Mdd-V 71--e05 \ 1 -70 C,.rod a - jd . -vtia tV • ---5 5 d n' g 1 Peerless RENEWAL / ► Insurance Mcnthcr of L bcny Mutual Group Forming a part of Policy Number: CBP 5943880 Coverage Is Provided In PEERLESS INDEMNITY INSURANCE COMPANY Named Insured: Agent: WILLIAM GEMMELL DBA WSG KING & CUSHMAN INC RENOVATIONS Agent Code: 6200791 Agent Phone: (413) - 584 -5610 TOTAL ADVANCE PREMIUM FOR ALL LIABILITY COVERAGE PARTS $ 8 8 0. 0 0 COMMERCIAL GENERAL LIABIUTY COVERAGE PART DECLARATIONS LIMITS OF INSURANCE Each Occurrence Limit $ 1 , 000 , 000 Damage To Premises Rented To You Limit $ 10 0 , 0 0 0 Any One Premises Medical Expense Limit $ 15 , 000 Any One Person Personal and Advertising Injury Limit $ 1 , 000 , 00 0 Any One Person or Organization General Aggregate Limit (Other Than Products/Completed Operations) $ 2 , 000 , 000 Products/Completed Operations Aggregate Limit $ 2, 0 0 0, 0 00 LOCATION OF PREMISES Location Number Address of All Premises You Own, Rent or Occupy 001 100 CARDINAL WAY HAMPSHIRE FLORENCE MA 01062 PREMIUM Class Classification Description Code Rates Advance Premium Premium Territory Prods/ All Prods/ All Base Code Comp Ops Other Comp Ops Other MA LOCATION 001 91340 CARPENTRY - CONSTRUCTION OF RESIDENTIAL PROPERTY NOT EXCEEDING THREE STORIES IN HEIGHT 28,600 017 $ 14.161 $ 14.875 $ 405 $ 425 PAYROLL PER $1000 22 -19 (12/02) INSURED COPY 02/25/2012 5943880 NPC650P 2812 PGDMO60D J27765 PCAOPPN 00034837 Page 25 ., ,...___*„..,._,= ig -6704,wwittveaa tdeazioackaea = _ I Office of Consumer Affairs and usiness Regulation =_�� 10 Park Plaza - Suite 5170 "h - •' Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165392 Type: Individual Expiration: 2/8/2014 Tr# 221094 WILLIAM S. GEMMELL WILLIAM GEMMELL ___ _ -__ -- 100 CARDINAL WAY FLORENCE, MA 01062 — - - - - -_ Update Address and return card. Mark reason for change. ❑ Address i Renewal [_ Employment Lost Card DPS -CA1 0 50M-04/04-G101216 \ Office o co u M irs di en ss egu a License or registration valid for individul use only a 6 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to �j Registration: 165392 Type: Office of Consumer Affairs and Business Regulation :y`_ = Expiration: 2/8!2014 Individual 10 Park Plaza -Suite 5170 = p Boston, MA 02116 - _ AM S. GEMMELL WILLIAM GEMMELL // 100 CARDINAL WAY „"----7,55 p - . , / FLORENCE, MA 01062 — � � -- - -� " - --` -- - - - - - - Undersecretary NI valiI ithout signature L\ The Commonwealth of Massachusetts ( Print Form 1 r Department of Industrial Accidents _ t.�.. Office of Investigations 1 Congress Street, Suite 100 rj Boston, MA 02114 -2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information /� Please Print Legibly Name ( Business /Organization/Individual): /1 L L ,,„ S is y��� L OJ ' ,Ats, - v. s 0,0" Address: /0 Q DJnv74 City /State /Zip: ft o / 6E'' 1 ` 0 /Ok Phone #: / 3 SF1RF 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 employees (full and /or part- time).* have hired the sub - contractors 6. ['New construction 2. g: I am a sole proprietor or partner- listed on the attached sheet. 7. 12, Remodeling ship and have no employees These sub - contractors have 8. 0-- Demolition working for me in capacity. employees and have workers' g any P tY 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.❑ 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' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f 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 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: i i�� ��_` — Date S Z--3 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. 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 Su • - rvisor: Not Applicable ❑ Name of License Holder : - - - -- - C --�• C.��� 1 License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ W I 141 Company Name Registrati n umber Wi (?. /e0 1M o>)1 e 2,0/ Address / Expira on ate lb C In wit✓/ t- �' T Q 1 Cecelephone nr* © v ° 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 j No ❑ 11. - Home Owner Exemption 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" ertifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, S d Local Zonin•d State of Massachusetts General Laws Annotated. Homeowner Signature PAM /14 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) la Roofing 0 Or Doors 0 g Accessory Bldg. ❑ Demolition l — New Signs [D] Decks [(L Siding [0] Other [0] Brief Work: i 0 t% a)(-1.1n �� z--.5 1 t I/ pC G > � 2E 2L �" w , '- -7_3 ' x 2 J -1 AJ657,✓ Alteration of existing bedroom Yes i l . , 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 existing housing, complete 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 CONTRACTOR APPLIES FOR BUILDING PERMIT I, l f r rN I h R 1 e/L , as Owner of the subject property r, hereby auth "ze W1 L-L J/}r / �t: ��� ,h %L vox' ,,49--,-, ] to a an in all matters relative to work authorized by this building • -rmit application. p ignatu Hof •! er D. e I ► .i , as Owner /Authorized Ag-i r- i y declare that the statemen s 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. / - 1 /9-r✓l 6 --- tg CW Print vari 111 > < Si.. "re of 5 er /Agent Da Section 4. ZONING AU 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 ji Side L: 13 R: �, L: R: 2S Rear Cb 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 ever been issued for /on the site? NO 4'ir _ DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW (0 YES IF 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 ® NO �1 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO 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 ® NO nr IF YES, then a Northampton Storm Water Management Permit from the DPW is required. f� REC Department use only City of Northampton Status of Permit IL z 5 2012 Bu Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability DEPT. of su,C, .r ,,,;s'ECTIONS Room 100 Water/Well Availability NORTHAMFiON, MA 01060 orthampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify 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 32- VV► I P 9 L . Map Lot Unit l F-1...0 � � P ' Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 5 r P i k , / 6 Pic.___ ig. 1 4 1 / I),n�6-- - r. Lw,C / NamAi4''nt) Current Mailing Address: ��I, � - Telephone " / > � �� � .31.1--2__– Sig at ' e 2.2 Authorized Agent: Name __ ' 1, Current Mailing Address: M01--'14111%. LP/ 3 51 .3"7 _ Signature ‘ Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 4 , / !�/7- (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) —S-3. 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) If 3 Check Number /167 T his Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date �ONIl ( "K — File # BP- 2012 -1046 1JE 6D p- 26 D 6TP ( `-S a N APPLICANT /CONTACT PERSON PICK STEPHANIE EMM DEL K ca NSTruka o ,,,1 Y / ' ( 1 C ADDRESS/PHONE 32 MIDDLE ST FLORENCE (413) 586 -5652 () PROPERTY LOCATION 32 MIDDLE ST ((I'LL i5 l Lt ' 1 0 p l / " O 2 ' — 2 - 1S - MAP 23A PARCEL 127 001 ZONE URB(100)/ 2 6 20 THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out )�� Fee Paid //e Typeof Construction: REPLACE DECK W/23'6" X 8' & NEW STAIRS New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan i TH FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ORMATION 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 1 „ <a ----- e--/-/ 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. 32 MIDDLE ST BP- 2012 -1046 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A -127 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Deck BUILDING PERMIT Permit # BP- 2012 -1046 Project # JS- 2012- 001804 Est. Cost: $4324.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WILLIAM GEMMELL 165392 Lot Size(sq. ft.): 14853.96 Owner: PICK STEPHANIE EMM Zoning: URB(100)/ Applicant: PICK STEPHANIE EMM AT: 32 MIDDLE ST Applicant Address: Phone: Insurance: 32 MIDDLE ST (413) 586 -5652 0 FLORENCEMA01062 ISSUED ON :6/1/2012 0:00:00 TO PERFORM THE FOLLOWING WORK :REPLACE DECK W/23'6" X 8' & NEW STAIRS 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 6/1/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner fi