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36-280 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 05/08/2012 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 POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 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 Laurence R. Forrest NAME: Forrest Insurance Agency PHONE 413 858 2680 FAX 4 13 858 2685 (A/C, No, Est): (A/C, No): 603 North Main Street E-MAIL ADDRESS: East Longmeadow, Mass. 01028 PRODUCER CUSTOMER ID it: INSURER(S) AFFORDING COVERAGE NAIC a INSURED INSURERAArbella Protection Insurance Company Window World Of Western Massachusetts, Inc. INSURER B : 1029 North Road INSURER C Westfield, Ma. 01085 INSURERD: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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 REQUIREMENT, 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. INSR ADOL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR AND POLICY NUMBER (MM/DD)YYYY) (MMIDD/YYYY) UMITS A GENERAL LIABILITY 7500046889 04/09/2012 04/09/2013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES SES (Ea occurrence) $ 100,000 _ CLAIMS-MADE X OCCUR MED EXP (Any one person) $ 5 , 000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $2,000,000 - 7 POLICY JEa LOC $ AUTOMOBILE LIABILITY 61352400004 05/12/0212 05/12/2013 COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ 250,000 ALL OWNED AUTOS BODILY INJURY (Per accident) $ 500,000 A X SCHEDULED AUTOS PROPERTY DAMAGE $ 100,000 HIRED AUTOS (Per accident) NON -OWNED AUTOS $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION y fi a t e Of Insurance WC STATU- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER Y / N ANY PROPRIETOR/PARTNER /EXECUTIVE to follow. E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION City Of Northampton SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 212 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Northampton, Ma. 01060 ACCORDANCE WITH THE POLICY PROVISIONS. Attention: Building Department AUTHORIZED REPRESENTATIVE © 1988-2009 ACORD CORPORATION. All rights reserved. • ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD ACS CERTIFICATE OF LIABILITY INSURANCE DATE q/201 " 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 POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 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 FORREST INSURANCE AGENCY CONTACT NAME: 603 NORTH MAIN STREET PHONE (A/C. No, EMI: (413) $5$ 26$0 FAX (A /C, No): (413) 858 -2685 E LONGMEADOW, MA 01028 E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Liberty Mutual Insurrn _ INSURED INSURER B WINDOW WORLD OF WESTERN MASSACHUSETTS INC INSURERC: 1029 NORTH ROAD INSURERD: WESTFIELD MA 01085 INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: 13054597 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 REQUIREMENT, 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL UABIUTY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES occurrence) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS - COMP /OP AGG $ _ POLICY P RO-- LOC _ $ AUTOMOBILE LIABILITY _.(O acc.Icident) SINGLE LIMIT $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE _$ HIRED AUTOS AUTOS (per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION WC2 -31 S- 377947 -0112 5/7/2012 5/7/2013 WC STATU- (R- AND EMPLOYERS' LIABILITY ✓ TORY LIMITS ANY PROPRIETOR /PARTNER /EXECUTIVE Y / N E.L. EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? I Y N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 100000 0 yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF NORTHAMPTON THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET NORTHAMPTON MA 01060 AUTHORIZED REPRESENTATIVE )4(r Jeff Eldridge ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD CERT NO.: 13054597 CLIENT CODE: 1481715 Anne Chandler 5/9/2012 5:16:47 AM Page 1 of 1 This certificate cancels and supersedes ALL previously issued certificates. SECTION 8 - CONSTRUCTION SERVICES X8.1 Licensed Construction Supervisor. �y ,,11 �' �� Not Applicable ❑ 2 Name of License Holder : G Y i,) L /��� p \ y�-�,� J License Number izI.S -I V (k 1 ! V `. 5 1 I Address Expiration Date ng N ry) c))0 Signature Signature Telephone r 1 2 0k� 1 Registered Home Improvement Contractor: Not Applicable ❑ Q.o -' ( 6u5 '2 . 1(., 5 (0 4 1 1 Company Name '1 Registration Number 1\J nttcW WO(\( 6-6 w M ‘ nc. l i 5 l 14 Address Expira o S Date t J LCl Norm 0 y'U (S 1 ti t 161 Telephone 4 1 R - J 1l' 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 buil ing permit. Signed Affidavit Attached Yes No ❑ 11. - Dome 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 Eil Addition n Replacement ndows Alteration(s) I I Roofing I I Or Doors Accessory Bldg. 1 ' Demolition 1 I New Signs [D] Decks [I =J Siding [Q] Other [p] BrorkDescriptionq Prmsr cc . f � a , n 6 6 � C 5*Lw M C' C3t,+1/ r II l' 3U VI \,N,, Y 1 J Alteration of existing bedroom Yes No Adding new bedroom 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 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 . 1. 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 1, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application_ L S-ei c > olt) Signature of Owner Date 1 (Zv (t L, V" J I _k 4 , as Owner /Authorized Agent hereby declare that the stattifnents 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. RCr>a,a 6vi5Ytikj Pyint Name n � kv / 1 Signa e of Owner /Agent j Date 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 O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained L J , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO 0 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 O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • rn rte' t.. - DE pat ment u,'4 Iy ' . g "� __ City of Northampton �s of � ; � „ . Building Department Ourb JUL 2 5 2012 212 Main Street �iwe Avails t Room 100 ate�N� ell Avalla Northampton, MA two Sets of S truu.r terry �' p -- RTHAM _ , ..AO 0 hone 413- 587 -1240 Fax 413- 587 -1272 01060 ct Plat/$ Pk rt Other;. - *� x z 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 P Address: 1 RD S Map Lot Unit - Of - C fl CC , rn r 01 0(c)2- Zone Overlay District E St. D C8 District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: wocCiS '12- Name (Print) Curren tlin A d CSat, C. CiC ep a — � Tel ephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Siglia ure 'r Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 3 Z 1. Building r 6 a • J (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Filumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2 +3 +4 + 5) V - e — Check Number C99 -i1 0 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date v . 15 WOODS RD BP- 2013 -0101 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36 - 280 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit # BP- 2013 -0101 Project # JS- 2013 - 000153 Est. Cost: $3280.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT E BUSHEY JR 57011 Lot Size(sq. ft.): 30274.20 Owner: WEIR ROBERT E & EMILY H Zoning: Applicant: ROBERT E BUSHEY JR AT: 15 WOODS RD Applicant Address: Phone: Insurance: 1029 NORTH RD (413) 485 -7335 0 WC WESTFIELDMA01085 ISSUED ON:7/25/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & STORM DOOR 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 7/25/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner