31C-006 (2) TRAVELERS WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
OVERPRINT PAGE
POLICY NUMBER: (IHUB- 1434N42 -8 -10)
INSURED'S NAME: BAYSTATE HARDWARE & ACCESSORIE
POLICY EFFECTIVE: 02 -20 -10 POLICY EXPIRY: 02 -20 -11
NEW /RENEWAL: R SOLICITOR: SAI: 5292J1135
RESPONSIBILITY: I MSI: I SIC CODE: 1751
PAYMODE/ DIRECT BILL CODE: B AUDIT FREQUENCY: A REINSURANCE:
WATCH FILE: 0 SURVEY CODE: 2 NEG COMM:
PROGRAM CODE: 257 NBR OF POL IN SAI: AGENCY BILL: N
AMS BINDER #: PARENT FEIN: 208152999
PKG POL NBR: UNKNOWN
STATE PREDOMINANT CLASS & SYMBOL (* indicates if selected as Policy predominant)
ST POLICY ST ST POLICY ST
ST SYMBOL PREDOM CLASS ST SYMBOL PREDOM CLASS
MA IHUB *
THE INSTALLMENT SUMMARY BELOW REFLECTS THE ORIGINAL POLICY PREMIUM ASSOCIATED
WITH THIS TRANSACTION THIS REPLACES ANY PREVIOUSLY RECEIVED SCHEDULES.
YOUR NEXT BILL WILL REFLECT THESE CHANGES.
ACCT EFF GROSS COMM
MO DATE AMT RATE
03 -10 02/20/10 332.00 #(35) .0000
03 -10 02/20/10 4436.00 .1050
TOTALS $ 4768.00
#(35) MASS SURCHARGE - WORKERS COMPENSATION
OFFICE: SPRINGFIELD MA 354
PRODUCER: P A PRYOR INS AGENCY INC CLP51 RATER: KM
ISSUE DATE: 03 -04 -10 CHANGE EFFECTIVE DATE: 02 -20 -10
WUNT6H96
TRAVELERS 411. WORKERS N COMPEN ATI
s o
AND
EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (IHUB- 1434N42 -8 -10 )
RENEWAL OF (IHUB- 1434N42 -8 -09)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
1 NCCI CO CODE: 13439
INSURED: PRODUCER:
BAYSTATE HARDWARE & ACCESSORIE P A PRYOR INS AGENCY INC
120 NEW STATE ROAD 847 SPRINGFIELD ST
MONTGOMERY MA 01085 FEEDING HILLS MA 01030
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 02 - 20 - 10 to 02-20-11 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) 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: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY .
DATE OF ISSUE: 01 -13 -10 NC
OFFICE: SPRINGFIELD MA 354 DIRECT BILL
PRODUCER: P A PRYOR INS AGENCY INC CLP51
TRAVELERS J WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
EXTENSION OF INFO PAGE - SCHEDULE WC 00 00 01 ( A)
POLICY NUMBER: (IHUB -1 434N42 -8 -10 )
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
13439 -MA
:NSURED'S NAME: BAYSTATE HARDWARE & ACCESSORIE
RATE BUREAU ID: 999999999
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
;LASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM
_OCATION 001 01
'EIN 208152999 ENTITY CD 001
3AYSTATE HARDWARE & ACCESSORIE
120 NEW STATE ROAD
AONTGOMERY, MA 01085
:ARPENTRY- INSTALLATION OF
=INISHED WOODEN FLOORING 5437 82212 5.93 4875
:LERICAL OFFICE EMPLOYEES NOC 8810 15300 .12 18
HA MANUAL PREMIUM $ 4893
DEVIATIDN PROGRAM CREDIT(9037) 5.00% $ 245
TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 4648
TENTATIVE EXP MOD: .97 MODIFIED PREMIUM 4509
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 4509
.00% ARAP MODIFICATION PROGRAM (0277) NONE
EXPENSE CONSTANT(0900) 338
TERRORISM (9740) 29
MA WC SPECIAL FUND AND TRUST FUND 342
TOTAL ESTIMATED PREMIUM 5218
DEPOSIT AMOUNT DUE 5218
DATE OF ISSUE: 01 -13 -10 NC SCHEDULE NO: 1 OF LAST
The Commonwealth of Massachusetts
;_ Department of Industrial Accidents
", . "!- Office of Investigations
" 1 1 ; 600 Washington Street , ll
� 4
_ ;7 Boston, MA 02111
t www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization /Individual): A 9 L le 1Z1) itiAiZE 8 A(c 6.3s6r7/ES 7 I IAA..
.
Address: 120 NE IA) J77)7 R0 {{ 1)
City /State /Zip: (10 rJ 1 6-6 i`y1E k ' ; x`14 A Ul o'd 5 Phone #: 4 //3 ego /- v7/ g
Are you an employer? Check the appropriate box: Type of project (required):
1. 1 1 am a employer with 2 4. ❑ I am a general contractor and 1 6. El New construction
employees (full and/or part- time).* have hired the sub - contractors
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. ❑ 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
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. El Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.1 Other {Ertl p lak kt;c/4AiaK. (me
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: j T [( 1 V L L t • 2 5
Policy # or Self -ins. Lic. #: I H U[') /9 3 Diu Li 2 - q - Ex piration Date: % - 2 (J '26) % 1
Job Site Address: 3 2 4) A D r1 U ( Ali t) e City/State /Zip: / Djfl fl th')l p i )!U (44 0 / U 0 6
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 cerh under t pains and enaalties of perj ry that the inf provided above is true and correct
Si ature: 11 / / i W l "' � / ( Z /L Date: (i1 f . L ° � ,
gn r
Phone #: LJ /,) Y6) 2" (/, /
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �,// Not Applicable 0
Name of License Holder : -� A— C rt (lGZ; J l 5 — 29 5
License Number
Z`Ati � 1 - RC/ /i C/ f �rrkie ` IIA /t 6 // ') - . //
Address _ I ,----- Expiration Date
,yam � �L � a '/73
Signatur Telephone
11 9. Registered Home Improvement Contractor: Not Applicable ❑
Ila S 4 - `
/ t_ ;ILA.t e__ Q / CCe' ' SSC; t-5 i3>4: / 77
C pang Name ' Registration Number
' 44 7
-: ,: - ,/t..1 -6 .71,1 Oil C�yI E /' // 4/.. „„ r`' .. / - 3 C /
Address .A ' Expiration Date
Telephone z 4.3 GY( -' ,9- 4/.`?/3
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 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) Roofing n
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [Eff
Brief Dwriptiog of Pro used L / �j� / /
Work: Cc ;I i U` C- io C ( (� //yel - 'Ls `ji ^Gr I '1 'G �t°t✓ICLIG`, r AGL
Alteration of existing bedroom Yes / t /No Adding new bedroom Yes V 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?
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 CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 5 i r� �. �� t% ? � k s S S , as Owner of the subject
property
hereby authorize -ex_`i d v'1
to act on my behalf, in all matters relative to work authorized by this building permit application.
7 1611 7)
Signature of Owner Date
I, _ -\ cu sro cz ; , 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 d penalties of perjury.
ctSL /1 6Z ;';'i S
Print Nam
Signa r, of Owner /A! • nt 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 0 DONT KNOW 01 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 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO e 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 O , 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 o NO
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 O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curie - putJD i °° P' nt
212 Main Street sewer/ ti �-Avbi y �� � ' '
Room 100 Water 6el`Availability
Northampton, MA 01060 Two Sr t,'of Stru,�yral Plrs 2010
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/SitetPlans ` JJ LL
Other Spe
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
t>\-r d A tjAVkl Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: i W \
S 1n v.. 1n VN -z._ DNS' S S 3 2 (1 S' c�. V -2'`1
Name Print Current Mailing Address:
Telephone s .
Signature
2.2 Authorized Agent: / 0 /
eirirr
Name ( rint) Current Mailing Address:
44441..- 1/ 3 ' 4:7
Sign re Telephone
S TION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 4 jJ 7 7:7, G J -.. (a) Building Permit Fee
2. Electrical i 1 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
r r
6. Total = (1 + 2 + 3 + 4 + 5) - q 77 , co Check Number4 .22b5 b0,00
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0016
APPLICANT /CONTACT PERSON JASON HARRIS
ADDRESS/PHONE 120 NEW STATE RD MONTGOMERY (413) 862 -4718 0
PROPERTY LOCATION 32 WARD AVE
MAP 31C PARCEL 006 001 ZONE RR(71) /URA(29) //WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid d?. $5
Tvpeof Construction: CONSTRUCT TEMPORARY WHEELCHAIR RAMP
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 75795
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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
7/7/0
Si: re of Building 0 icial 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.
•
AVE BP- 2011 -0016
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Bie k:
k:31c1061, 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 -0016
Project # JS- 2011- 000027
Est. Cost: $4877.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JASON HARRIS 75795
Lot Size(sq. ft.): 54450.00 Owner: PETERSSON ROBERT T & SUZANNE S
Zoning: RR(71)/URA(29) //WP Applicant: JASON HARRIS
AT: 32 WARD AVE
Applicant Address: Phone: Insurance:
120 NEW STATE RD (413) 862 -4718 () WC
MONTGOMERYMA01085 ISSUED ON: 7/7/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT TEMPORARY WHEELCHAIR
RAMP
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 7/7/2010 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo