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23D-023 06/25/2012 08:22 14135675300 BERKSHIRE INSURANCE PAGE 01/01 AC R 0 CERTIFICATE OF LIABILITY INSURANCE 1 /2 0 l 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED — R�E�PRESENTATNE OR PRODUCER. AND THE CERTIFICATE HOLDER. - IMPORTANT: it the certificate holder Is en ADDITIONAL INSURED, the pollcy(les) must be endorsed. If UBROGATION 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 Rasey Pet=e7C Berkshire Insurance Group, Inc. u , ,,, (413)935- 12 00..14,t. 1413)367 - 5300 138 Longmeadow St. kpatereeberkehireinauraneegrO1Ap .eon _ INSURER(Z) AFFORDING C0 AGE NAIC A Longmeadow MA 01106 INSURER A I 'trave1era Pr- -art & CaSualt 25674 INSURED INmmete Granite State InSUXanCe Company )23809 ANL Maintenance Services Inc INSURERC: 52 Union Street INSURER D: INSURER S : . East. - ton MA 01027 I,$_ i. , F: COVERAGES CERTIFICATE NUMBER:11 /12 Master 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 REOUIREMENT, 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. _ eWSR AD►?L aUaa POLICY EFF EXP TYPE OF INSURANCE , .., ,. I NUMBER M,."AAu i, ..,•.•au1 GENERAL LIABILITY EACH occUnkENOE $ 1., 000, 000 © COMMERCIAL GENERAL LIABILITY :,.. �,� .I• L T�]>• f 100 , 000 A Ill CLAIMS-MADE Er OCCUR 680- 7A877555 10/27/20:«. /2012 IJriD (Any one penlo $ 5,000 PERSONAL B ADVINJURY a 1,000,000 • _ _ GENERAL AGGREGATE $ 2,000,000 Gf:N'L AGGREGATE UMIT PER; PROD OT • COMP • P AGO 8 2,000,000 X POLICY Ti . I LOC S `— AUTOMOBILE LIABILITY • INED SINGLE mom 1• 000 000 A III ANY AUTO BODILY INJURY (Per person) $ ■ AILOWNED E3 S� e SULED BA 7AB79053 10/ 27/ 201110 /27/2012 semrLYINJURY S © A UK S ���+ ti HIRED AUTOS © A F17TJ;G.-.,. '1r ( 3 I PIP-Seek S 8, 000 UMBRELLA LIAR OCCUR EACW OCINURRSNCE S III EXCESS UAB CLAIMS -MADE AGGREGATE $ III DEO III RE. 4 a 3 WORKERS COMPENSATION Certificate to be issued X Inc • STATU- OTH- AND EMPLOYERS' UABIUTY ANY PROPRIETO%PARTNER/EKECUTNE directly from carrier EL EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? El N I A I IMindaatelly In Ol) EL DISEASE - EA EMPLOYE = S i ts 1Ft PTIO OF OPERATIONS bolo" EL DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more ewe le required) Job location' 496 Elm St, Northampton, MA 01060 CERTIFICATE HOLDER CANCELLATION (413)527 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS, 212 Main Street Room 100 Northampton, MA 01060 AUTHORIZED REPRESENTATIVE Raseyr Peters /i7S'2 RE' 9 ACORD 25 (2010105) _. „ 01988.2010 ACORD CORPORATION. All rights reserved. 1NS025 (201005),01 The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts E , ti. Department of Industrial Accidents Office of Investigations .1+ 1 Congress Street, Suite 100 •. Boston, MA 02114 -2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization /Individual): -- ) y �" '11'! t 1 ( , Address: ' 5 A, 1,) 1 City /State /Zi.. .>k .1 Icy Phone #: ! 'a <��,cl / (a; Are you an employer? Check the appropriate box: Type of project (required): 1. aI 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 8. Eemolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ 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 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: r 11 4 l : C '�u Policy # or Self -ins. Lic. #: L C .. C1 4 - " "' tai Cj Expiration Date: / (7 ' ') C) 64— Site Address: L i " IL( ,c. ' City /State /Zip: a " 1C;tWf At (, o ;J 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 the pains nd penalties of perjury that the information provided above is true and correct. I � f ] Signature. i - �• '1/ Date f - _ ?S ° ../ Z- ..1 Phone #: k .) ., r '`1 , / / ci` c.3 (e ) 1 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 #: c the '.- �'])1 c�i u'..e� /( /'.iac/ti, is Office of Consumer Affairs and Business Regulation y^ I 10 Park Plaza - Suite 5170 .. Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 147727 Type: Private Corporation Expiration: 8/4/2013 Tr# 215232 AWL MAINTENANCE SERVICES INC. RICHARD KOLOSZYC 52 UNION STREET EASTHAMPTON, MA 01027 - -- - - - ----- Update Address and return card. Mark reason for change. [] Address El Renewal Employment ❑ Lost Card SCA 1 tS 20M•05/11 lo) I) /If , r f //+(.,7114 r ' 141,a(% /L;[ /7 Office of Consumer Affairs & Busi Regulation License or registration valid for individul use only r ;• ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: `4i " r 147727 Type: Office of Consumer Affairs and Business Regulation . V. 7 - '' , =I,n xpiration: 8/4/2013 Private Corporation 10 Park Plaza • Suite 5170 ., Boston, MA 02116 AWL MAINTENANCE SERVICES INC. RICHARD KOLOSZYC 52 UNION STREET .,„.. - ^ EASTHAMPTON, MA 01027 Undersecretary Not valid without signature • It , Construct c,r^, *,ip :.I :P."5e 104039 00 RICHARD KOLOSZYC SS MAPLE ST • EASTHAMPTON, MA 01027 104039 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 7‘'(: OS l ' C.. / U 6 3 License Number 1 y . I , ) L. Icx t pi OA (� 1 Via. �: � (' . ca Address Expiration Date 4 /3 tj - ?) ( / )(i, >07 Sign ture- - T 1Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Owl U / l r.5 /, I /)Cr_ /K /J k .) at) 06 'd / } ' G2 0/ Address Expiration Date Telephone "// 4 `i' / *3 2 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 Eti 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 Offi cial, 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 A)//:.) 6/25/12 1 (2560x3258) ;ECTION 5• DESCRIPTION OF PROPOSED WORK (check all soolicabia) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0 Or Doors ❑ Accessory Bldg. ❑ Demolition 12 New Signs (p) Docks (Q Siding IC]) Other (C7) Brief Description of Proposed Work: 4 _»i CI (j l OL I GO 1 c Alteration of existing bedroom Yes ✓ No Adding new bedroo Yes ✓ No Attached Narrative Renovating unfinished basement Yes . ✓ 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? d. Proposed Square footage of new construction. Dimensions e. Number of stones? 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 I. 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 7s • OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, _. / )/ Z I )/ Z4 S �`' LIC• 4! ) k , as Owner of the subject property r- / f / to act /, J .. • hereby authorize rI• I. - '' J ( ! )/ ( 1 i "i t I/ L(: ( S . (. r* ili..Sit /l�f . / an my,�jh If, in a i matters to wprk a�thp�i zed by this building perrgit ap$licatio/+. Signature of Owner Date I, • _' 2.2 2 d 1/L 7r --) A l ( , as Owner /Authorized Agent hereby declare that the statements and information on th+f foregoing application are true and accurate, to the best of my knowledge and belief. J Signed under the pains and penalties of perjgry. / < Print Name "' . Signature of Owner /Agent 7 Dal https: // mail - attachment .googleusercontent.com / attachment/ u/ 1 /?ui =2 &Ik =06fde192f0 &view=att&th =138... 1/1 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 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 Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES Q NO 0 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. WV 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 O NO cy IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 6/25/12 1 (2560x3259) ',. ...:..•REV ^ V E DeparUrneM use only City of Northampton Stotts of Permit: al 9 5 2012 B Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/WO Availability ct Northampton, MA 01060 Two Sets of Structural Plans phone 413 -587 -1240 Fax 413 -587 -1272 PkWSite Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION I 1.1 pronertY Addrest: Tele notion to be completed by office . / &►(. /� ^ `? rj 1- Ma p '- 1 � Lot 23 Unit g/" kV14 j PM-f i� c1 / d (p zone Overlay District Elm St. Dlstrlc C8 District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT g.1 Owner Recof*: 7,,o , .66///ill -� it-!'7 L / /.. lS(� Z ' ..73.7 jer5 e ��'�`r Name (Print) "^), C -1 J 1! Telephone Signature 3.2 Authorized Mont Na 're) Current Wiling Address: ) / :. (3 -S0 -lR3(47 - Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 2 ✓ 300- C) 0 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (8) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) .2--?)Cr)., 9- ' Check Number This Section F Official Use Only Date Building Permit Number. Issued: Signature: Bullding Commissioner/Inspector of Buildings Date hops: // mail - attachment .googlousercontent.com / attachment /u/1 /?ui =28ik =08fde 192f08view=att &th =138... 1/1 File # BP- 2012 -1171 , v ✓ .1 APPLICANT /CONTACT PERSON AWL MAINTENANCE SERVICES INC 4 ADDRESS /PHONE 52 UNION ST EASTHAMPTON (413) 529 -1936 e PROPERTY LOCATION 496 ELM ST MAP 23D PARCEL 023 001 ZONE URB(100)/ i THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid ttS 43 1 Building Permit Filled out Fee Paid Typeof Construction: Demo 1 car garage 19X0 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 FOLLOWING ACTION 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 Demolition Delay Signature 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.