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30C-014 11/19/2010 16:20 FAX 14135388753 OLDE HADLEIGH HEARTH PAT L1006 Nuv-zw -eicla 10:04R FROM: METRAS INS AGENCY 4135328522 TO: 53E8753 P.2 I f , _ �' . � CERTIFICATE OF LIABILItY INSURANCE - 71.-re a 13 1 201 PRODUCER (413) 536 -1491 •.„ THIS CERTIFICATE IS ISSUED AS A MATTER OF IMF I MATIC Metres Insurance Agency, inch ONLY ANC CONFERS NO RIGHTS UPON THE CERTIFIQ4P HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND a 2030 Memorial Drives ?7 A F Rf`3'Y THE IYLlI:14'15 E1 1 _"c ___ ®e MA 01020•- II}4SURJ:RS AFFQRO,NG CC1VERAGC Wax INSURED BERM Travelers Older Hadlei.gh Hearth 6 Home Canty, Inc. 1 RIe:R e 119 WillimaABlate St. IIIMTr111111111111111111111111111 t sus .Aa _ . y, South Hadle MA 0107E- SURER e; ` COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN I88UEO TO THE INSUR NAMED AROSE FOR THE POLICYPOLICY PRIOD INDICATED. NOTWITHSTANDING AI REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 'TM RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERM THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJE TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCK POLICE AGGREDATE LIMITS SHOWN MAY HAVE BEEN REDUCEb BY PAID CLAIMS. INt6R A D M . • . Y ., -.. - P i • p � t _ _ - " , _ R 1 3; t TYPE OF INSURANCE POLICY NUYRER • i5! MR • • • - MMID • ` LIMITS A OENERALLIABILITY Z6607910A71E1 0`/30/2010 08/30/2013. _ActlOCCL RE$T0�E $ ,0 100,0 ITI COMMEROEAI. GENERAL LIABILITY g i oeAZlif ee) i 100,0 Mill bM n CLAIMS OE DODUR / / / / MED BxP {Rorer OM ONION_ S 5 r 0 III PERSONAL $ PXN so UFIV $ 1,000,0 - ? / / / / seNERALAGGREGAYE B 2,000, 0 BE NI AG0 %EGA ppL�I$MT APPLES PER i �I�ODu - COMPI A[d© $ 2,000,0 POLICY III 2 IIII LOC / / / / _ A AuTOMM09ae UABIfY RA,2055066B 1 11/01/2011 assusre, timuc uln- ANY AUTD „ Mr scoldNM) 0 4.- IN ALL OWNED AUTOS 1 / / / / BODILY INJURY © BCHEOULEO AUTOS + (Pm pelscli 3 100, 01 I4I WAUTOS ,t/ / / / SODILYINJURY 4 300,01 - NON -OWNED AUTOS M lWaccldem} III a / / / / PROPERTY DAMAGE {Per mwdenl) d S 100,0( GARAGE LYIEIUTY _ NATO ONLY - EA ACCIDENT 3 11111 ANY AUTO 4' I / / / OTHER THAN F-4 . 0 $ ■ �r AUTO ONLY: ACS, 8 .■ A MmWMlUMDRELLALIABILTTY 26497614 0;/30/2010 08/30/2011 jEACLIQGCURFIENCE S 1, 000, D6 OCCUR 0 MAIMS MADE i' Ai0REaATE S 1 , 00 0,0 0 if 5 MI DEDUCTIBLE ;I / / / / S - RETENTION 810,000 d 9 A WORKSRSCOMPISMATION AND XRossi97R81 0; /12/2010 07/12/2011 Eilik1t -V-Iii eMrLOYERS" LL.EACHACG $ 100,00 ANY PROPRIETORIPARTN3R,EXECUTIWE , • � CPFt l EMSER EXCLUDEDT 4 / / / 1 100 00 yel. Gb�tl� �.0 t38EA9E . EA 6MPLaYE' i , SPECIAL PROVISIONS blow r !a,t E L _ OISEABE POLICY User $ 500, 0 0 OTHER I / / 1 1 / Ji'r / I / 1 1 DE$CRPTION OF OPERATIONS /LODArONiiiit ICLe3+F,X0LUSIONe ADDED BY ENOORSEMENl7s nAL pRo se10N1 l a • V . 'ERTIFICATE HOLbER NCELLATION ) - ( ) - , HOULD ANY OF THE AROSE DEBCRIRED POUCI!B OE CANCELLe0 BEFORE THE liEXPIRATION OAT! THEREOF, The !SWIM R18URQR WILL ENDEAVOR TO MAIL 1I DAYS WRI'TT$N HONKS TO The GERT7PICATE MOLDER NAMED TO THE LEFT, FLIT Bruce T . Wood tiPALuits To 00 SO £HALL IMPO$R NO QBLP7ATIQN OR LIABILITY OP ANY MO UPON THE 408 Florence Road 'I' H RIM ITS ADI! OR RBPREBEMTATIVEB. THOAIZ!D RSFIVISErrrATISS +��•.� E'] orence MA 01062- _ '. 23� Ter /' tt!/ — - e AC ©R0 COR> ORATION 196 ! 26 (Z007/OB) I!, F03•10 '0108).08 I, 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 jermits 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 =,= = ,l Office of Investigations • si ° 600 Washington Street Boston, MA 02111 .' ":.-;7 www mass gov /dig . • -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name (Business/Organiiation /Individual): O k d 'e- k a ct te,I.citn RAC 64, c rc Pct ho • - Address: t ( kx. 't t ■ cnar's Si fQe4 � - S . 0 � a S Phone. #: 913 .. 3�S - �, S L1 S Are you an employer? Check the appropriate'box: •Type of project (required): 1.0 I am a employer with - 4. 0 I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub- contractors listed on- theattached sheet 7. 0 Remodeling 2. ❑ I am a sole proprietor or partner- • ship and have no eowloyees These sub - contractors have .8. 0 Demolition working for me in any e andhave workers' - Y caPacitY. 9. Bull addition [No workers' comp. insurance -.. comp..InsnrAnce # _ .. Q re ed 5. 0 We are a corporation and its 10 ❑ Electrical repairs or additions f 3.0 I am a homeowner doing all work officers haexercsed their . 11. Plumb• repairs i hi �] ?rig epairs or additions myself [No workers' comp. right of exemption per MGL 12.[Q.Roof repairs insurance required.] t ' c: 152, §1(4), and we have no t , employees: [No workers' y 13 Other tkior ` _ )u.i'n i r i co insurance required.]. T l� �Q�QG 1Y1 K-1 er1 *Any applicant that checks box #1: roust also fiIl out the section belaw 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. CConuactors that check this box must attached an additional sheet showing the name of the subcontractors and state win:therot- not thoseentities have - employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. ram an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: t Veto a S • Sh 5:4V t CO . • Policy # or Self-his. Lic. #: I t a. E 5 l q,1 t3 i t Expiration Date: 0 1'1 U- 2 c� 11 Job Site Address: 9 d � r QO ' �:ity/ State / Zi ‘0t' L&I \ A 0- 1OCZ.- 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 ofMGL - c. 152 can lead to the imposition of cries u ial penalties of a fine up to S1,500.00 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 T Investigations of the DIA for` insurance c overage verification: - 7...77 - 777.7:7. _.: .. , - _ f do hereby certify under the pains -and penalties ofperjury that - the information pro'vided ov ..istrue_asd.carrect Signature: �ru �_ 1 � a�--- Date: L l 1 is • .1 2C l o Phone 0: 413 -12 55 _. 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 i• . Contact Person: Phone #: . SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : V ' 1 I ( X 84-1S c4 1 ( / ` C,, p t 15 License Number 5 11 tto (`, ��a- �`(ety 1' Jet titc(A .' �v)�t- ati / 2 L Address 1 413 53g 8L\ S Signature Telephone 9.;:Re•`is - d,Hom ; in " =raifemeintlCu ®` Not Applicable ❑ 5i . , i __,� � _. t ` �,. .wSEM ,._..... <- 0 �,�e. Ptc& d�z 5� 1to '\1') tyl,v C TS t y% 15 Company Name Registration Number 4 kCi iLiVO "Se t4 ��(2 og 113I I. 1 Address Expiration Date G,� SG �b1 1 c x(ts 1 1 n1�1 0101 S Telephone41 ~s 3 S�' I 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 L� di No ❑ lEitinenteluwneromxemotton 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 buildine 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 I 4 L " • �` ►� SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors CI Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [0] Other [I Brief Description of Proposed , - Work: rife p lace. w kttcX bQcL -iv LoOcc bLrr / n G Alteration of existing bedroom Yes , V No Adding new bedroom Yes v No / Attached Narrative Renovating unfinished basement Yes +/ No Plans Attached Roll - Sheet 6L f :Nerly = h use: alr tl r adr i io�a .Cc a ><s Ana.. r+ us�nc( cc m te.t a III ' nQ: 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 U3 , as Owner of the subject property ` ``,, hereby authorize trcle. ti°- ►o1 h � ftln and NI-, o to act on my behalf, in all matters relative to wo authorized by this building permit application. 'x1c,va.,m . 1 R 2010 Signature of Owner Date 3 1ft2.cre.. 1 1 a i , 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. ' 39-LiCe 1 , tjnob Print Name • cj_- i i f4 kg I Lo 10 Signature of Owner /Agent Date 1 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 5 2,63 a.cS_s — _ e T L a � �� .. Frontage -- _ _ .. ' Setbacks Front b Side L: i R:l ..i L: 1 R:? _.. 1 Rear Building Height W i _.. Bldg. Square Footage llgel 1 1 % I Open Space Footage ,, % (Lot area minus bldg & paved e ? I 1 parking) # of Parking Spaces Fill: l�- I�,.�..�...�,��o,or l (volume & Location) , - ------ , L_. A. Has a Special Permit /Variance /Finding ver been issued for /on the site? NO Q DONT KNOW ( YES 0 IF YES, date issued:; , IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW YES 0 IF YES: enter Book i P ag e I and /or Document # B. Does the site contain a brook, body of water or wetlands? NO e( DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO er IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO e IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , • , ;:. City of Northampton ° ®s - " 1 f . ,' � Building Department - � .,w i 4 * �, , 212 M Street a' s `2� NOV 1 9 2010 -# _ t. ' Room 100 �� t. Northampton, MA 01060 , orthampton, 4 - t ,. ,.. r � r� . phone 413-587-1240 Fax 413- 587 -1272 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 gog t-1oco...1C� P ct' Map Lot Unit - toCe-r)e -e ( 111A . ©lc 2- Zone ` Overlay District Elm St District CB .District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 'D5 auca T1(.1 L3ceiD I -1CYr5 Pi Qe.o.c4 C'E,-E,- i M/4ctC z Name (Print) Current Mailing Address: �} t�i4� – 7z'7- 4y�.G� Vi G2 l • (- Telephone Signature 2.2 Authorized Agent: pw p 2.uc : r. wcroQ 4 og F to cerc'_'' el - '[0 1 . 0106 Name (Print) Current Mailing Address: C _ — t~ � - L tt3 -- 129 . Signature Telephone SECTION 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 oU 'D tSconfl - • Building Permit Fee i4J32 viuwibtrc '*D e4c t541 109 cIas 1 tfl - 4. Mechanical (HVAC) 5. Fire Protection i ��' 6. Total = (1 + 2 + 3 + 4 + 5) it q 1 Z �-S , t C3" Check Number Ng( AgL5s This Section For Official Use Only Date Building Permit Number: ued Sig natur - � ll/ Building Commissioner /Inspector of Buildings Date k 1 =% BP- 2011 -0476 GIS #: COMMONWEALTH OF MASSACHUSETTS ' 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 -0476 Proiect # JS- 2011- 000780 Est. Cost: $4245.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784 Lot Size(sq. ft.): 54885.60 Owner: WOOD BRUCE Zoning: SR(100) //WSP Applicant: OLD HADLEIGH HEARTH & HOME CENTER AT: 408 FLORENCE RD Applicant Address: Phone: Insurance: 119 WILLIMANSETT ST (413) 538 -9845 WC SOUTH HADLEYMA01075 ISSUED ON :11/22/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK :CONVERT KITCHEN FIREPLACE TO WOOD 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 11/22/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner