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25C-077 City of Northampton r , Massachusetts f DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • ilunica.pal Stiliciang Norrhami. k 01060 . Property Address. Contractor e Name: rn" / ' Address: City, State: Phone: Property Owner _- Name: , Address City, State: _ - - - - -- (contractor) attest and affirm that the building intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that have provided the property owner with a copy of this affidavit, Contractor signature Date ACOR° 02/13/2012 ® CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) 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 COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(lea) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions 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 CONTACT Paychex Insurance Agency, Inc. NAME: PHONE FAX 150 Sawgrass Drive LAIC. No. Exti: (AIC, No): E-MAIL Rochester, NY 14620 ADDRESS: 877 - 266 -6850 INSURER(S) AFFORDING COVERAGE NAIC a INSURER A : GUARD INSURANCE GROUP INSURED INSURER 8: MASS SMART HOMES LLC INSURER C: 34 Sherman Street INSURER D: Fairfield, CT 06824 INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLISUBR POLICY EFF POLICY EXP LIMITS LTR INSR - WVD POLICY NUMBER IMM/DDJYYYYI (MM/DD/YYYY) I I GENERAL LIABILITY EACH OCCURRENCE $ _ COMMERCIAL GENERAL LIABILITY DAMAGE 70 RENTED CO PREMISES (Ea occurrence) $ _ CLAIMS -MADE I OCCUR MED EXP (Any one person) $ PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ _GEN'L AGGREGATE UMIT APPLIES PER: 1 PRODUCTS - COMP/OP AGG $ LOC $ POLICY ,PF Q I COMBINED SINGLE UMIT AUTOMOBILE LIABILITY (Ea accitlert) ANY AUTO • I BODILY INJURY (Per person) $ ALL OS OVVNED SCHEDULED • BODILY INJURY (Per accident) $ HIRED AUTOS NON -0WNED PROPERTY DAMAGE $ AUTOS (Per accident) I UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ i EXCESS LIAB CLAIMS -MADE AGGREGATE $ _ I DED I RETENTIONS I $ WORKERS COMPENSATION x NC STATU- OTH- A AND EMPLOYERS' LIABILITY TORY 1 WITS FR YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N I N/A MAWC344522 02/21/2012 02/21/2013 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1.000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1.000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Community Action EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE J POLICY PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO 393 Main Street OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS, OR Greenfield, MA 01031 REPRESENTATIVES, AUTHORIZED REPRESENTATIVE ,M ©1988 -201 CORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts trz . Department of Industrial Accidents qua Office of Investigations W +n 600 Washington Street , 9 Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly l &ifi� ,, /' Name (Business/ Organization /individual): 5 i,4/ ,r 4)r2 _ Address: — / K � � j / C 01)' Cit /Stat /Zip: Phon Are you an employer? Check the appropriate box: Type of project (required): 1 e I am a employer with 4. C] 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. ❑ Remodeling ship and have no employees These sub - contractors have g. 0 Demolition working for me in any capacity. employees and have workers' insurance. 9• ❑ Building addition [No workers' comp. comp. insurance p. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2.0 Roof repairs insurance required.] t c. 152, §10), and we have no employees. [No workers' 13 Other /, /5 1 . //c 1v comp. insurance required.] Any applicant that checks box 111 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: -t' r (CI,: ' / v, S t ' T ? / _ �'�'. (7 - Policy # or Self -ins. Lic. #://7.4 14/C- , ; ` /V L 2 _ Expiration Date: Job Site Address: / l C�' / 1`% City /State /Zip.„a �f , �, � 1 0/ J Attach a copy of the workers' compensation policy declaration page (showing the policy number andtion 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 paps and penalties of perjury that the information provided above is true and correct. Signa '� 1 Date: PhonL#: c C� !S r✓ v ?/ 7 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): I. 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 OT 8.1 Licensed Construction Su ervis - - 7 Not Applicable 0 Name of License Holder``....! l r• ci � 1 - (.26L)1.‘ (.26L)1.‘ License Number - r h- ; f —5 71 , --/ C7 -- j — / I3 Address \ Expiration Date _ / Signat re T / /77/ 9. Rnstered" k( ome ;lm•rovement.Contraactor.7 °p 7� .�� k tl , r �, r, � , _, Not Applicable ❑ /Wr9 -. CC" .: � 7 7 ' 7" t)//1( l 7 J 57 Company Name S7 N ame 1/ y — r r yyS' Registration Number , c "CGi r °,in / .�n roi,i,,AL 79L r - T .L .l Z C - 2 / — ii- -, 2. 0 i / r) Address Expiration Date Telephone v 73.- 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 ❑ No ❑ � i om . ' w eer , ' henipti o n 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 • J SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) „ . . New House n Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [EJ Siding [O] Other [0] Brief Description of Proposed , -6-`1/1 v � G n Work: _....G ii s'.- - I v ] 1 K, Alteration of existing bedroom Yes ■,�' No Adding new bedroom Yes tom' No Attached Narrative Renovating unfinished basement Yes ty No Plans Attached Roll - Sheet sa if ; e :• ouse and or >addition to; 4ezistingwhousinq ,:complete,ihe,:following; 1.-"''' 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 WH BEN OWNERS:AGENT OR CONTRACTOR;.APPLIES FORBUILDING PERMIT I, G, - . / _.. c % , as Owner of the subject property hereby authorize ( A/ 5 ..5 5✓�4 I /76/7/7/ to act on my behalf, in a I matters relative to work authorized by this building permit application. Signature of Owner Date I,� l� u G / ✓'G^ / 1 s 5107 ' T 0'4, j , as Owner /Authorized Agent hereby declare that the 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. Print Name _ Si nature of OwnerlAgent D -te RECEIVED . APR I 0 2012 i Department use only City of Northampton Nb ,1 .is-,1t Pear it Building Department CurbCut/Driv4way5Pernlit 212 Main Street Sewer/SetprcAriailablltty . Room 100 W at e awe�II Avaljability Northampton, MA 01060 T a Set SfructuralPlans phone 413 -587 -1240 Fax 413- 587 -1272 Piot/site P. Other Specif APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION.1 -SITE: INFORMATION 1.1 Pro ert Ad Tess: This section to be completed by office ,,,,<",- ,. /e , ' 5 .Map...... ••:: . . • Lot .• Unit ..5 (A i C ( `) / Zone Overlay District Elm St;.District -. CB District CT 2 PROPERTY OWNERSHIPIAUTHORIZ SEION ED AGENT ,.N`9 2.1 Owner of Record: 3 _ ----) ' /CGn - eve' , Pai p , ` ,, Telephone ell; . t / / 9„✓ .� 2.2 Authorized Agent: V�-4"�!- /�„. { X14 s . i 'g7 vn S . / cr-is / 1,,< s I S7 /� Name Print) Current Mailing Address. U 71 gnature Telephone ...,.......:,...,...........,:..::.,.:.............,......_........ E CTION 3 = :ESTIMATED •CONST.RUCTION'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 •aUilding Penult Fee 4. Mechanical (HVAC) 5. Fire Protection B. Total= (1 +2 +3 +4 +5) :•;CheckNumber 5 This:' Section:For Use:Only .. Building PerrriitNuniber:: • •• . Date Issued: signature:; - Building !Commissioner /Inspector of Buildings • Date i File # BP- 2012 -0887 ' c e. • , e APPLICANT /CONTACT PERSON JOHN PERRIER ‘C,- ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860) 930 -7794 (- PROPERTY LOCATION 300 BRIDGE ST f 060"n ` �h�� MAP 25C PARCEL 077 001 ZONE URB(100)/ &Y `IL ;6\ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out i 5 ' 0145 Fee Paid Tvpeof Construction: INSULATE & AIR SEAL f New Construction (� `1l(,z 11`5 E J( � tfC� Non Structural interior renovations /y ( t E Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 105319 3 sets of Plans / Plot Plan THE FOLL NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION PRESENTED: pproved 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 �e 1' . S . e of Building e i ial 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. 300 BRIDGE ST BP -2012 -0887 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 077 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2012 -0887 Project # JS- 2012- 001553 Est. Cost: Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN PERRIER 105319 Lot Size(sq. ft.): 5401.44 Owner: SQUIRES JOSEPH D & MICHELLE L Zoning: URB(100)/ Applicant: JOHN PERRIER AT: 300 BRIDGE ST Applicant Address: Phone: Insurance: 59 EAST MAIN ST (860) 930 - 7794 WC STAFFORD SPRINGSCT06076 ISSUED ON:5/14/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: INSULATE & AIR SEAL 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 5/14/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner