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44 WASHINGTON AVE BP- 2011 -0329
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 200 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 -0329
Project # JS- 2011- 000540
Est. Cost: $75600.00
Fee: $453.90 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 1 1238.48 Owner: POSTEL ROBERT J
Zon'n :
'LIP Applicant: POSTEL ROBERT J
AT: 44 WASHINGTON AVE
Applicant Address: Phone: Insurance:
44 WASHINGTON AVE (617) 669 -3680 0
NORTHAMPTONMA01060 ISSUED ON :10/13/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN,REMOVE
WALLS,REPLACE BEDRM W /2ND FLR BATH, REMODEL BATH
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: 1- / f J/j ., , Rough: e ,, / / € o / House # Foundation:
Driveway Final:
Final: 1 ^ 4 ✓ Final: b / ?6, (Voriligiii u ' ( k '
fr`'>✓J Rough Frame: 1.49-
o //
Gas: Fire Department Fireplace /Chimney:
K g %l Ci v# A k i
Rough :,5Z /i �c;t , g. Oil: I nsulation: //
Final:7.g nil C Smoke: 0 k/Hillay Final: Ok J —(% 1 f C ifi
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND
AllOir7; lemoot:* y aw
Certificate of Occupy ignature:
FeeType: Date Paid: Amount:
Building 10/13/2010 0:00:00 $453.90
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck - Building Commissioner
11/2/2010 11 :27:50 AM 8740 2 02/02
CERTIFICATE OF LIABILITY INSURANCE DATE(NA4/DD/YYY)
11/02/2010
-
THIS CERTIFICATE IS ISSUED AS A PLATTER 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 BOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poliC', must be endorsed. If SUBROGATION IS W= .IVED, subjecct
to the terms and conditions of the policy certain policies may require an endorsement. A statement on this certific.tn does not
confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER I CONTACT -- - --- "'- --
NANL:
Finck & Perras Insurance , PnDNC Fax —
6 Campus Lane (A/C RD. EAO): (A/C. NO): I
E -MAIL
Easthampton, MA 01027 ADDRESS:
PRODUCER
NSTRICER IDA.
INSURED (S) AFFORDING COVERAGE NAIL M 1
INOUAED INSURED A: A.I.M. Mutual Insurance Co
Benjamin M Greene INSURER B: -1
47 Chapin Street INSURER C;
Easthampton, MA 01027 INSURER D: 1
• INSURER E:
INSURER F. i
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER.:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERN, OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OH MAY
PERTAIN. THE INSURANCE AFFORDED BY WE POLICIES DESCRIBED HEREIN IS RUBSECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN
MAY HAVE BEEN REDUCED HY PAID CLAIMS. '
I "T I POLICY NumnER POLICY EFF POLICY EXP rIMIT
-�• TYPE OF INSURANCE NN R R m
NOnDO) (NNDR)
GENERAL LIABILITY .
EACH OCCURANCE 1 S
❑ COMMERCIAL GENERAL LLABr. I:Y DPAAGE TO DE . NTEDrrencel 6
O ❑ CLAIMS MAD ❑ OCCUR —. —. —.
❑ NED FA' (Any one person) 6
❑ PERSONAL 6 NOV SKINNY 6
GEN'L AGGREGATE LIMIT APPLIES ER:
GENERAL AGGREGATE I
0 PCC.: CT E FRCJE -V 0LOc PRODUCTS - COMP /OP MD 6
6
AU'rolgre LF LIABILITY =MINED SINGLE LDIIT 6 - -1
. ❑ANT AUTO (ea accident)
❑ BODILY IN7URY' (per person) I 6
ALL 04NED AUTOS
❑SCHEDULED AUTOS BODILY DITURY (per acsldent) 1 6
MOM'S DAMAGE HIRED AUTOS' - (Per aaiAentl 6 ••
• ❑ .. .-
❑ NOS-0.ED AUTOS 6
0 I 6
U MOSDELLA L IAR ❑ OCCUR _ EACH OCCURRENCE 16
El MCC! SS LIAR 0 CLAIM MAPS AGGREGATE 1 6
El DEDVCTI BLE
6
0 RETENTI ON 1 6
WORKERS CONDENSATION �1R cC srw- O -
AND EMPLOYEES LIABILITY �l I 2 °'R �Tt OM-
AND EA
THE PROPRIETORJPARTNERS/ E.L. EACH ACCIDENT t 100, 000
A EXECUTIVE OFFICERS An
❑ Inc]. ® excl 6014003012010 E.L. DISEASE - EAEIOLDIET 6 500,000
10/26/2010 10/26/2011
L.L. DISEASE - EA ENPL OTEE 6 100,000
1
COHMENIS / DESCRIPTION OF OPERATIONS OR LOCATIONS:
BENJAMIN M GREENE IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY.
CERTIFICATE HOLDER CANCELLATION
ROBERT POSTEL
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE I
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IV ACCORDANCE WITH THE
44 WASHINGTON AVENUE POLICY PROVISIONS.
NORTHAMPTON, MA 00160 Aurnoaf ZED RENAL
f
3 /% 02 TO
"° The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
s. o `' . r 1 L.v i
600 Washington Street
v
X ~, Boston, MA 02111
�N. A . www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): )Q'C\ / Yee.
Address: 4 ci.Q ` vr
City /State /Zip: \; &,5 L1/4.r.(1 sf\ N1 I G) CC Phone #: 13 3 ` cr`6 Z (_
Are you an employer? Check the appropriate box: Type of project (required):
1. 2 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. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling
ship and have no employees These sub contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3. ❑ I am a homeowner doing all work g P
myself. [No workers' comp. right of exemption per MGL 12. ❑ 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.
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: A , 1� , r V1�,i- \.c: L n S C,, A
Policy # or Self -ins. Lic. #: r-> 4 (3 O 1 Z C; 1 C) Expiration Date: 0 I / C:G
Job Site Address: 4 „I J V Of (\ inwloiity/State /Zip: lr■ (
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 1 pains and penalties of perjury that the information provided above is true and correct.
Signature: p , Date: /Yea v ( is Q 0
Phone #: 3 � I 4 - 6 1 C A Z b
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 #: