Loading...
36-136 ACORD r . CERTIFICATE OF LIABILITY INSURANCE DATE 04/05/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION James J. Dowd and Sons Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 10300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE Holyoke MA 01040 INSURED • INSURERA:NOrGUARD Insurance Company Stephen P . Camp INSURER B: 46 East Street INSURER C: INSURER D: Easthampton MA 01027 INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE (MM /DD/YY) DATE (MM /DD/YY) GENERAL LIABILITY EACH OCCURRENCE _ $ — COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $ CLAIMS MADE 7 OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ _ GENERAL AGGREGATE _ $ _ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 7 PRO - POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ _ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE _ $ _ OCCUR CLAIMS MADE AGGREGATE _ $ DEDUCTIBLE _ $ RETENTION $ $ A WORKERS COMPPEENSTTIONAND STWC131305 04/04/2010 04/04/2011 X TORYLMIUS O ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS CERTIFICATE HOLDER X ADDITIONAL INSURED; INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. LL/M-€4- AUTHORIZED REPRESENTATIVE /� s ACORD 25 -S (7197) � yVr(, ©ACORD CORPO 1988 TM1 INSO25S (9910)31 ELECTRONIC LASER FORMS, INC. - (800)327 -0545 Page 1 of 2 . iaironowevecta 9l Infiecof thasu'Iner Affaiti & iiiiiitessiigillii trtiiigc HO ME IMPROVEMENTCOtthiAbTati , illicgi R Eigistration; ,,, ,43504 Eipitati ow 1-134012 Tr# 0*5' Tpe n y y . 11# caft41 comsTRuci10, NI STEPHEN CAMP 4 EAST ST. - - .41.1-------- EASTHAIVIPI 01027 Undersi`cretary O "- Massachusetts - Department of Public Safct■ Board of Building Regulations and Standards Construction Supervisor License License: CS 82531 Restricted to: 00 STEPHEN P CAMP . .- 46 EAST ST EASTHAMPTON, MA 01027 Expiration: 11/23/2011 ( onimissiimer . Tr#: 8573 Stephen Camp Construction 46 East St. Easthampton, Ma 01027 (413)527 -7124 Submitted To: Carmen Maldomado Phone- 341 -3647 Address : 12 Longview Drive Date 5 -20 -2010 Florence, Ma 01062 We hereby submit this estimate for - Installing Doors The job is to frame in and install a sliding glass door. I will remove the single door and the storm and install the new ones. The siding will be removed and re- installed as needed. The interior will be trimmed with new trim provided. All doors and wood will be supplied by customer. Price is $ 600.00 for labor only Contractor Supervisors License number 082531 Home Improvement contractor Registration number 135204 I propose to supply materials and labor -in accordance with above specifications. This proposal may be withdrawn By us if not accepted within 30 days Authorized Signature 1 I - Acceptance of proposal SignatureG� /Mil/ 01 - 4 ae • e2" 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 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 iermits 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, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location 3 • .. 4 The Commonwealth of Massachusetts Department of Industrial Accidents -!' i� r Office of Investigations G� =WILL: . r_ 600 Washington Street 1= y Boston, MA 02111 ' �4 - , www.massgov /dia -Workers' Compensation Insurance Affidavit Builders / Contractors /Electncxan.s/Plumbers Applicant Information - Please Print Legibly Name ( Business /organization/individual): 5f of I 'i C - , / • • Address: e i 6 ' ' 5 . City /State/Zip: � i ^ .J ) . rvx— - Ne. a Phone. #: 5 7- 2 c.,.5� 2Y Are you an employer? Check the appropriate • box: •Type of project (required): / 1. gl I am a employer with a - 4. 0 I am a general contractor and I s have hired the sub- contractors 6. ❑ New construction employees (full and/or part- time). 2_ 0 I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no employees These sub - contractors have. . 8. 0 Demolition working for me in any employees and 'lave workers' y �P�t1'• 9 . Bud addition workers' 'eon insinsurance rran CQIDp- mcnra nrr # _ .. � __ ... required.] 5. 0 We are a corporation and its 10 0 Electrical repairs or additions officers havexercisecl their 11 Plumbing repairs or additions 3.0 I am a homeowner doing all work .r ❑ lumb' r myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t ' c. 152, §1(4), and we have no . . employees. [No workers' 13.0 Other comp. insurance requited- }. • *Any applicant that checks box #.1 must 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. - :Contactors that check this box must attached an additional sheet showing the name of the sub-conttactots and state whether ew not those entities have employees. If the sub - contract rs have employees, they must provide their workers' camp. policy number. Iam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: 0 cis, 617, ' Policy # or Self-ins. Lic t #: g 2 3-- -?/ Expiration Date: - //" 2 3 / Job Site Address: / a , 44 .6.,., D Y'' lr'C City /Stafe/Zip <t5�/ -2 Z:?/6 Attach a copy of the workers' compensation policy. declaration page (showing the policy number and expiration date). Failure to secure coverage. as regtafed' under .Section 25A ofMGL 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 3250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the ()Mice of Ei estieations ofthe DIA for insurance coverage venfcafion I do her_ certr under the auss and enalties o _ ----- _ — �_, .fy fper1rcry that the information provuledlrZrnve it trne_asdrnrrert _. . _ Sianature: pa e, —/ /P . - , Phone #: X27 Z - • • ff 3' completed . _ y c . i _,..�_ _ - O trial use only. Do not write in thin area, to be b or town offciaL City or Town: Permft/Licease # - ._ •,_•, Issuing Authority (circle one): .'1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical Inspector 5. Plumbing Inspector 6.Other F . Contact Person: Phone #: SECTION 8 - -- CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvisor. Not Applicable ❑ Name of License Holder : C.44 '( 2 5 j J License Number £S 27- G1 Address 4 Expiration Date r2-7- 2/2-y gnature Telephone 9 ' � . � . ° `�..�.t(��� a,,:�..r © c, ai. ,,.� , <a�?r . ��, ",�� .',sT''zt Not Applicable ❑ v v f f S 3 1 - 2® y Company Name Registration Number u. 7 / 3 - / Z Address Expiration Date Telephone J 2 7 7 /2/ SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.152 § 25C(61) 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 budding permit. Signed Affidavit Attached Yes No No ❑ 1et �1R�li 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 w SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacemen4indows Alteration(s) ❑ Roofing D Or Doors {l�� Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D) Other [D] Brief Description of Proposed - Work: ,1 /a,Cg Fz, c Csi is7'"..cs DOOde5 G' f /,nt,✓ 1 t to-tly Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet t a � W. ^ .�.. , ' ; 2 1 , , , 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 , 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. Signature of Owner Date , as Owner /Auth or ed Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of mmynowledge and belief. Signed under the pains and penalties of perjury. J-/ Print Name Signature of Owner /Agent 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 _i Frontage 1 9 Setbacks Front i i = ' , Side L: I R: II — I R:! 1 t i I Rear 1 ! 1 Building Height Bldg. Square Footage L1 1 1 % r n = ( € i Open Space Footage (Lot area minus bldg & paved 1 1 1 1 % i j i L__,....` parking) 3 £ # of Parking Spaces Fill: I € , i (volume & Location) x A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 I IF YES, date issued: i IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW 0 YES 0 IF YES: enter Book 1 I Page I and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT 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 0 IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: i I 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ..City of Northampton ° s m Buil • g Department a ` 212 ain Street �� g �C 1 a y 4 oom 100 1 � � � 7- � • . m j � � rthampton, MA 01060 �� de hone 587 - 1 240 Fax 413 - 587 -1272 r _ € APPI.ICATION 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 Map Lot Unit Z L e t/s �,.� D r Zone o r Overlay District ElnrrSt CB District SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Ca✓A►. / n t o / - ld t -1 if< D �• Name (Print) Current M ress: Vl �t„v1 / Telephone 3 ` ` ,/ Y ` V if Signature � 2.2 Authorized Agent: 5 C C KG s 7 4- s 'I pi / Name (Print) J Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION:; COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building v (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 16 00. oa Check Number 3d - S This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date H LONGVIEW DR r BP - 2010 - 1133 GIs #: COMMONWEALTH OF MASSACHUSETTS Map :dock: 16- 136 `' 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- 2010 -1133 Project # JS- 2010- 001661 Est. Cost: $600.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN CAMP 082531 Lot Size(sq. ft.): 15028.20 Owner: MALDONADO MIGUEL & CARMEN Zoning: URA(100)/ Applicant: STEPHEN CAMP AT: 12 LONGVIEW DR Applicant Address: Phone: Insurance: 46 EAST ST (413) 527 -7124 () WC EASTHAM PTON MA01027 ISSUED ON :6/11/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL 2 REPLACEMENT DOORS 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 6/11/2010 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo