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23C-083 :N77 ) 1 . ,------- ( t 1 .......-- _.----- \ \ . _..,, 1 sOli i 1 NOTICE OF ASSIGNMENT DATE OF NOTICE: 06/18/12 PREPARED BY: Evelyn Cobb EXT 522 * * SERVICING CARRIER ASSIGNMENT * * LETTER ID: 3791094 The Workers' Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street • Boston, MA 02110 (617)439 -9030 • FAX (617)439 -6055 • www.wcribma.org e a NOTICE OF ASSIGNMENT EMPLOYER: COMBO I.D. STATUS OF EMPLOYER ROBERT SADLOWSKI DBA NO PROBLEM SERVICES 000855662 Individual PO BOX 796 EASTHAMPTON, MA 01027 COVERAGEGROUP 0899693 Coverage under this assignment The Waiver of Our Right to applies to Massachusetts Recover from Others Endorsement operations only. For coverage is available on Pool policies. outside of Massachusetts, contact Contact your agent for details. the appropriate Pool or Plan for that state. AGENT FINCK & PERRAS INSURANCE AGENCY INC INSURANCE COMPANY: OR DENISE M BLAIS LM INS CORP PRODUCER: 6 CAMPUS LANE INVOLUNTARY MARKET OPERATIONS EASTHAMPTON, MA 01027 P 0 BOX 9090 DOVER, NH 03821 (800) 653 -7893 AGENCY FEIN: 042 3 91561 CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED CODE TOTAL ANNUAL PREMIUM REMUNERATION CARPENTRY- DETACHED ONE OR TWO FAMILY DWELLINGS 5645 $5,000 8.68 $434 CARPENTRY - DWELLINGS - THREE STORIES OR LESS 5651 $0 8.68 $0 CARPENTRY NOC 5403 $0 9.61 $0 ROOFING NOC & YARD EMP, DRIVERS 5545 $0 30.99 $0 EMPLOYERS LIABILITY 100/100/500 9845 STANDARD PREMIUM $434 LOSS CONSTANT 0032 $50 EXPENSE CONSTANT 0900 $250 TERRORISM CHARGE 9740 $2 TOTAL POLICY MINIMUM PREMIUM $500 TOTAL ESTIMATED PREMIUM $736 DIA ASSESS. 5.9% $26 TOTAL EST. PREMIUM PLUS ASSESSMENT $762 INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $762 THIS IS NOT A BILL COMMENTS Coverage effective 12:01 AM on 06/15/12 Subject to 03/11/12 Anniversary Rate Date. Coverage under this assignment is contingent upon compliance with the carrier's requests to complete the scheduled audit and payment of any additional audit premium. Noncompliance will result in cancellation of current coverage. The Workers' Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street • Boston, MA 02110 (617)439 -9030 • FAX (617)439 -6055 • www.wcribma.org City of Northampton _ . M assachusetts, it ,�' c 4 ' .. 4 At ! A M. DEPARTMENT OF BUILDING INSPECTIONS . # -. x , ' ° 212 Main Street • Municipal Building � , , .,y ti Northampton, MA 0106 ¢Ny INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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 permits 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, 1-1-�{� ( 41 understand the above. (Home dwner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date ��uC i9 g /,-- Address of work location £i 2 L/SS Si fZo ,ee4‘.e :CIA 0 /o — _ • The Commonwealth of Massachusetts • ~ - � — ~ — Department of Industrial Accidents Office of Investigations �. 600 Washington Street 4t Boston, MA 02111 e .. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): /0 ,/ 1Z0eL€7 . Address: Z ; G • City /State /Zip:_62? J /4 . Phone #: l %S S l -, f 4 7 Are you an employer? Check the appropriate box: Type of project (required): 1. [ I am a employer with 4. n I am a general contractor and I 6. New construction employees (full and /or part- time).* have hired the sub contractors listed on the attached sheet. 7. n Remodeling 2. n I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. n Building addition / [No workers' comp. insurance comp. insurance.$ required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions q ] f oficers have exercised 11. Plumbing repairs I am a homeowner doing all work h id their C g airs or additions 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. U 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: G .271,6& L€I L Policy # or Self -ins. Lic. #: Expiration Date: epAYi Job Site Address: CO? / S S' kkierti -r' t..) City /State /Zip: VV VI 0 /0C_ 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. Z do her ertify under t ' ins and penalties of perjury that the information provided above is true and correct. Signature > Date: `p,/ < /Z Phone #( /,�) i ( 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): Board 0 Health l 2 . Building 3 Cit Cl 4. Inspector El In 5. Pl In 1. L11 L lllg L a rtm : lll�.i Plumbing Inspector 6. Other • Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Num r Address 'xpiration Date Signature Telephone 9.`Ttegistered Home:lmproveent Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone , 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 buildin ermit. • Signed Affidavit Attached Yes No ❑ 1 L J - o x 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 ® It SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) ., New House n Addition n Replacement Windows Alteration(s) I I Roofing Or Doors El Accessory Bldg. 1 1 Demolition n New Signs [0] Decks [C] Siding [El] Other [ ] Brief Description of Proposed Coa fe..S Work: s , fie r:.5 Cy . •C: L:� f ri ' Jr: ! ' C Alteration of existing bedroom Yes X No Adding new bedroom Yes (\-- No Attached Narrative Renovating unfinished basement Yes / No Plans Attached Roll - Sheet 6a.flf W house and or addition to existin housin • ‘CO m foliowin•: a. Use of bui : "ng : One Family Two Family Other b. Number of rooms ', each family unit: Number of Bathrooms c. Is there a garage attache.? d. Proposed Square footage of ne ..nstruction. 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 cons tion 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 .. 0�Ze C ge,et/a , as Owner of the subject property _J hereby authorize N' to act on my behalf, in all matters relatve to work authorized by this building perm appli tion. Signature of wner/ Dat • 0(1 ce 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. y c P c. g, rye.© Print Name Signature :ne, .gent r a te " A A Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by 'i oning This column to be filled in by Building Department — 7--- _, - 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 S eclat Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book , Page' I and/or Document # B. Does the site contain a brook, body of water or wetlands? NO (4 DON'T KNOW 0 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 d 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 d IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, e cavation, 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. ,,_ , a Y)— '... . 4 �, � , Degartmemt use onl City of Northampton Stat s of Pe t ,i � � � � tt �' Building Department Crb Cut%Dnti °it -1 ., It ` 212 Main Street Sewer /Sep t ic'`. AVallab1I 1 . 7 ,, t ',, 4,� s -° ° r r JUN 2012 'i. 1 Room 100 Wate`r/We11 Availabillty � r Ire" 8 P�ii� tu i t 3 ?.., t . 1F Northampton, MA 01060 Two Se of Str Plans 413- 587 -1240 Fax 413 587 - 1272 PlotlSiiflarrs . '_ , 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: ' ' n� A ( ? t 3S Map �' ' .: Lot l � Unit „ ..., .... a 1� + r - off% V v ` Zone Overlay Distract ` b ` Elni St. .Di s trict ' CB ±nct SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: !/ ,J o Lice C'. 8 7'�.4fV:.b � ! t / i. S 5 ' f e `ce ..44 L'/ &J.. Name Print) r / Current M Address � ej _�r / � tGtl t rz Tel one - Signatu 2.2 Authorized A ent: /� cc c C. [7 E TA £r ,/i ss S1 ric,<'ewtr 4 (j'6 A Name Current Mailing Address: ( <1.1) 5 9 - SO/3 Signature, Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS ! Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant = (a)' Building Perrriit Fee 1. Building /7 Yt,� 2. Electrical ///000 (b) Estimated Total Cost of � Construct from (6) 3. Plumbing < CO Building Permit Feer 4. Mechanical (HVAC) -C .b , 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 30C2, 00 . C heck Number T his Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 4sP • ,,,,,,,„,,_, 5 f, U /1-7, File # BP- 2012 -1147 APPLICANT /CONTACT PERSON BERTRAND DONALD G & JOYCE C ADDRESS /PHONE 62 BLISS ST FLORENCE (413) 584 -5013 0 PROPERTY LOCATION 62 BLISS ST MAP 23C PARCEL 083 001 ZONE URA(100) /WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid eO Building Permit Filled out Fee Paid Typeof Construction: Collar Ties, Headers, Small Closet, window replacement New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE F ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON RMATION 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 o ' '. • -lay ,-- Si t • . re 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. 62 BLISS ST BP- 2012 -1147 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23C - 083 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- 2012 -1147 Project # JS- 2012- 001963 Est. Cost: $29300.00 Fee: $175.80 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 21257.28 Owner: BERTRAND DONALD G & JOYCE C Zoning: URA(100) /WSP(100)/ Applicant: BERTRAND DONALD G & JOYCE C AT: 62 BLISS ST Applicant Address: Phone: Insurance: 62 BLISS ST (413) 584 -5013 0 FLORENCEMA01062 ISSUED ON:6/21/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: Collar Ties, Headers, Small Closet, window replacement 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 6/21/2012 0:00:00 $175.80 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner