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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803
(800) 876 -2765 NCCI NO 40959
POLICY NO. WCC 5009644012010
PRIOR NO. NEW BUSINESS
ITEM
1. The insured Jeffrey Gougeon & James Locke dba Gougeon & Locke
•
Mail Address: 26 South Street Williamsburg MA 01096
Street No. Town or City County State Zip Code
FEIN 04-3054261
❑Individual Partnership ❑Corporation ❑Joint Venture ❑Association :Other
Other workplaces not shown above:
2. The policy period is from 12/06/2010 to 12/06/2011 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 100.000 each accident
Bodily Injury by Disease $ 500.000 policy limit
Bodily Injury by Disease $ 100.000 each employee
C. Other States Insurance: Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis. Rates
Code Estimated Per $100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 201683
SEE EXTENSION OF INFORMATION PAGE
Minimum premium $ 500.00 Total Estimated Annual Premium $ 6,191.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 6,588.00
Ei Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly
MA Assessment Chg.
$5,833.00 x 6.8000% $397.00
This policy, including all endorsements, is hereby countersigned by 12/10/2010
Authorized Signalise Date
GOV - GOV KIND PLACING CLAIM NAME SAFETY BERKSHIRE INSURANCE GROUP
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP p0 BOX 4$$9
MA 5645 7 502
PITTSFIELD MA 01202 -4889
WC0000 01A(11 -88)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / F Oct_ 1 ot Applicable ❑
Name of License Holder : . J>r1t �3 L-_ / 9 ` le 2.
License Number
GOUGEON Ssz LOCKE % Z. - 5 - / /
Address Expiration Date
26 South street
Signature X �'�' thiamsbu' p (, CJ
9. Registered Home Improvement Contractor: Not Applicable ❑
/OL 26) 2
Company NanQOVGEON St LOCKE O CKE R Number
26 South Si: t _. / L 2.-
Address ln Y'_7, Expiration Date
► • ! . 4 179 MA,
Telephone `^t' 93
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 rmit.
Signed Affidavit Attached Yes l 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" 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 ❑ Addition ❑ Replacement Windows Alteration(s) Er Roofing T
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [0]
Brief Description of Proposed /
Work: ke lt€CP U1'Gl".4v` 1�'�2 � 'f leirt � 1 t eiit 4.L1 4M r
.4fcc�\- re10 %,c:@ s`'�) 7 tit /5 B / 1 5
Alteration of existing bedroom Yes V No Adding new bedroom Yes Y No
Attached Narrative Renovating unfinished basement Yes 1/ 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? t',
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 CONTRACTO APPLIES FOR BUILDING PERMIT
LLV re4A gi01 , as Owner of the subject
property
hereby authorize O` I e
to act on my behalf, in all m. ers dative to work authorized by this building permit application. -y -ll
Signature of Owner Date
1 , f, ?!✓5 , aAuthorized
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.
J S 1 -C6t 4.
Print Name
tat? 5 l �
Signature o'rwner /ice Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Inco plet Inf on ; r r
Existing Proposed Require y Zpningg t
} t
&41‘a\)�� - This colu to b filled in by
V Building D artm t
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
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 ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO (0 DONT KNOW 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 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO a
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 - ..
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
#1 1 Department use only
(Pity of Northampton Status of Permit:
8 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
oFe uiu�t�trrsr�tc =cn orthampton, MA 01060 Two Sets Plans
L ptti�nt nor :•
• • - - 3 - 587 - 1240 Fax 413 - 587 - 1272 PIot/Site Plans of Structural
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
6. ( Ivitc 4i \Gi,rc C-( Map Lot Unit
N V , A t) i U6-0 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ii
1 2 F . . J ) .5 ( 7 1 ItiiCC U1 N eVG: ( (
Name (Print) Current Mailing Address: 5 8 6 etct 6 V
Telephone
�� 1v
Signature
2.2 Authorized Agent:
J An i S L c --(i -- 24 S -61/ 11 S� . ud'i r,(, t,ovtc e :---
Name (Print) Current Mailing Address:
(1 l' IEg -- e 1 ` , - Z' - ? , 3c1 •3/2-
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 2 1 7,.1 , (a) Building Permit Fee
2. Electrical ' ( Estimated Total Cost of
I Construction from (6)
3. Plumbing 2, "2...60 Building Permit Fee
4. Mechanical (HVAC) d
5. Fire Protection 0
6. Total = (1 + 2 + 3 + 4 + 5) 32, 1 '735 - Check Number J7SOCi #/9(0
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0950 .
APPLICANT /CONTACT PERSON GOUGEON & LOCKE
ADDRESS /PHONE 26 South Street WILLIAMSBURG (413) 268 -9323
PROPERTY LOCATION 61 MAYNARD RD
MAP 31A PARCEL 156 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid p /) (n
/
Typeof Construction: REPLACE KITCHEN CABINETS,FLOORING,REMODEL MUDROOM,REPLACE
SUNROOM ROOFING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Own Statement 001992
3 sets of Plans / Plot Plan
THE FO er/ OWING ACTION orLicense HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
-- .olition Dela /„
ro / // 1
_ : ature of C ildin_ 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.
61 MAYNARD RD BP- 2011 -0950
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 156 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -0950
Project # JS- 2011- 001557
Est. Cost: $32735.00
Fee: $196.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GOUGEON & LOCKE 001992
Lot Size(sq. ft.): 7056.72 Owner: SHATZ LAUREN J & AMY
Zoning: URB(100)/ Applicant: GOUGEON & LOCKE
AT: 61 MAYNARD RD
Applicant Address: Phone: Insurance:
26 South Street (413) 268 -9323 Workers Compensation
WILLIAMSBURGMA01096 - 9726 ISSUED ON :5/19/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REPLACE KITCHEN
CABINETS,FLOORING,REMODEL MUDROOM,REPLACE SUNROOM ROOFING
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 5/19/2011 0:00:00 $196.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
61 MAYNARD RD BP- 2011 -0950
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 31A - 156 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PER.NIIT
Permit # BP-2011-0950
Project # JS-2011-001557
Est. Cost: $32735.00
Fee: $196.00 PERMISSION IS HEREBY GRANTED TO:
Coast. Class: Contractor: License:
Use Group: GOUGEON & LOCKE 001992
Lot Size(sq. ft.): 7056.72 Owner: SHATZ LAUREN J & AMY
Zoning: URB(100)/ Applicant: GOUGEON & LOCKE
AT: 61 '. MAYNARD RD
Applicant Address: Phone: Insurance:
26 South Street (413) 268 -9323 Workers Compensation
WILLIAMSBURGMA01096 - 9726 ISSUED ON :5/19/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REPLACE KITCHEN
CABINETS,FLOORING,REMODEL MUDROOM,REPLACE SUNROOM ROOFING,
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: i - i .- / Rough: i� - 1 House # Foundation:
- /v Driveway Final:
Final: i x '� �~ f ` Final: ' /�
g i �"'
Rough Frame:
Gas: / Fire Department Fireplace /Chimney:
b. I i
i
n Final: OW 7 a // CNt
Final: T( ' 1-- I Smoke:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOJ ATION OF
ANY OF ITS RULES AND REG - • T 0
Certificate of Occupancy ,.,-, mature:
FeeType: Date Paid: Amount:
Building 5/19/2011 0:00:00 $196.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck - Building Commissioner