36-221 (2) ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY)
09/15/2009
PRODUCER (413) 536 -1491 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Metras Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
2030 Memorial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Chicopee MA 01020- INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: Travelers
Olde Hadleigh Hearth & Home Center, Inc. INSURER B:
119 Willimansett St. INSURER C:
INSURER D:
South Hadley MA 01075- 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.
IEFFECTIVE POLICY EXPIRATION
R TYPE OF INSURANCE POLICY NUMBER DATE (MMDD/YY) DATE (MM /DD/YY)
LT INSRD
R INSRD LIMITS
LT
A GENERAL LIABILITY I6607910A718 08/30/2009 08/30/2010 EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 100,000
X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $
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 PER: PRODUCTS - COMP /OP AGG $ 2 , 000 , 000
n POLICY nisei: n LOC / / / /
A AUTOMOBILE LIABILITY BA2055C668 11/01/2008 11/01/2009 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS / / / / BODILY INJURY
X SCHEDULED AUTOS (Per person) $ 100,000
HIRED AUTOS / / / / BODILY INJURY $ 300,000
NON -OWNED AUTOS (Per accident)
/ / / / PROPERTY DAMAGE
$ 100,000
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO / / / / OTHER THAN EA ACC $
AUTO ONLY: AGG $
A EXCESS /UMBRELLA LIABILITY 2649Y614 08/30/2009 08/30/2010 EACH OCCURRENCE $ 1,000,000
OCCUR CLAIMS MADE AGGREGATE $ 1,000,000
$
DEDUCTIBLE / / / / _ $
RETENTION $ 10,000 $
A WORKERS COMPENSATION AND IEUB5197B81 07/12/2009 07/12/2010 WCSTAU OTH-
TORY LIMIT S � ER
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED? / / / / E.L. DISEASE - EA EMPLOYEE $ 100,000
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000
OTHER / / / /
/ / / /
/ / / /
DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
CERTIFICATE HOLDER _ CANCELLATION
( ) - ( ) - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
Adam Garretson FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
81 Winterbury Lane INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE 8ruc& P Pee'
Florence MA 01060- _/
ACORD 25 (2001/08) C) ACORD CORPORA
INS025(oloa).o6
1
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 ac4essQrykto , such use and/or farm structures. A
person who constructs more than one home in a two -year period shall not be cc..sidered 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
-- -- - – permits -in- conjunction_- to-the_buildingi erm .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
0
i" The Commonwealth of Massachusetts
'
Department of Industrial Accidents
— P Office of Investigations
600 Washington Street
� e
Boston, MA 02111 d i,
www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information / / Please Print Legibly
Name ( Business /Organiiation/IndividuaI): 0 I e �''� 1 e t y A 1�7 e ct r X11 I-4 m€ e e h - if' r
Address: 11 9 \J1;1Ii mun5 S -
City /State/Zip: Sc. 4 cA le (Y) 4- 0/6'7 Phone #: 4(3 5 3. g'- 914
r
Are you an employer? Check the appropriate box: Type of project (required):
i
1. 53 I am a employer with 12— 4. Q I am a general contractor and I
employees (full and/or part-time).*
have hired the sub- contractors 6. ❑ New construction
2. Q I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no. eloyees These sub - contractors have g. 0 Demol on
for me in any capacity. employees and have workers'
working Y p ty. 9 Builrii a addition
`5, o : workers' cornp. 7T}C71TSiT7ct ... co : .. z1T:£ .: -_.. __. �L_ - -V
required:] 5. Q We are a corporation and its 10.0 Electrical repairs or additions
3.Q I- am- a- homeowner- doing --all work — cet=s _have xerc ice_ �1-- �plu�nba�grepairs or additions
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'
13.121 Other i ucer� 4c e
comp. insurance required.]
4 n S+ .,0 a I o ri
`Any applicant that checks box #I 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.
1 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: / ru / e i e rs L u no I1 c e . ` c
Policy # or Self -ins. Lic. #: � E U T3 5/ y 7 5 g / Expiration Date: - 7 /2-/0
Job Site Address: p i vv, ii-i-'r berry Lan e City /State/Zip: no re/4(e' /),,4 c /0. -- ,
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 QRDER and a fine
of up to $250.00 a day against the violator. Ile advised that a copy of this statement may forwarded to the Office of
Investibations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of petitay that the informatiO rr provided_above iStrue_and_correct.
Signature: �� r Date: 9- 1S - 0 % .
Phone #: 13 :5.5 r 9 - Y > -
Official use only. D write in thi aiii tojbe completed by city or town gffciaL
City or Town: Permit/License #
Issuing Authority (circle ane):
I. Board of Health 2. Building Department 3. City/Town - Clerk 4. Electrical_ Inspector 5. Plumbino- Inspector
6.Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0 [�
Name of License Holder : ' 1 L(.3 oX / 0 7 P /
�r t t License Number
5 � cd le9 N S� Sa. cx_c/e MA' 0/ 4 - ��— 1/
Address J Expiration Date
= , 41 :3 538— 9r4
Signature Telephone
9. "Registered:! tome lmproverctent.Goritractor,,, , Not Applicable ❑
Dlde �l Qd f� � 1 Nle4 , li �eme aen-l-e r 14 / 9 F
Company Name Registration Number
11 W tti mctn5 9— / 3 — /1
Address Expiration Date
Se,. aril e j fY) I o l G 7 S Telephone 413 53Y N5
_ SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (ALGA_ 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 ❑
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, von 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
amp r I mance ,` °. a _ + ° Y - .- a s -GeneralLaws- Annotated.
Homeowner Signature
3
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [MI] Other [o]
Brief Description of Proposed
Work: t St 4 -A - fIC OF WOOD ST - 0115
Alteration of existing bedroom Yes 't /No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes ,./lo
Plans Attached Roll - Sheet
sa if Neir house -and. di addition to existing . -housrnq, hcomniete.the .foliav ring:
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 /Authorized
Agent hereby declare that the statements and information on the foregoing application are true an_ d accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner /Agent Date
r
,,
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 °
/o
(Lot area minus bldg & paved r
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 0 YES
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 T
Page€ � 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:-:
D :` ° AF tie any proposed °c tinges to or a itions o stgns intended for the property ? YES 0 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 0 NO 0
IF YES, then a Northampton Storm Water - Management Permit from the DPW is required.
City of Northampton Status o e ut
• Building Department Ctrt�L3rlyeyuayetmll N'
212 Main Street S `
e S� +cval lablE�
Room 100 g l ua ` t l t
2 1Ntitthampton, MA 01060
phone 413 -587 -1240 Fax 413 -587 -1272 Plntl alts A
•
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
ICI L.)! eti-67z6b2ley Map Lot Unit
Ff12.L P 0/0(1— ' Zone " Overlay District
Elm.St'District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: o 1 W I r'1 b Grr'f L�
scc� s_I�vL'egrr Flar-'etce __MA 1 0106 D-
Name P ' - Current Mailing Address:
Telephone ' 1 13 5 . g• 5 ^ 5 7 35
Signature �! ' ( / `�
2.2 Authorized Agent:
Name (Print) 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 5ooO (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) Check Number
This Section ForDfficial Use Only
Date
Building Permit Number: Issued:
Signature:
Budding-Commissioner/Inspector of Date
-81 WINTERSERKY BP - 2010 - 0299
GIS #: COMMONWEALTH OF MASSACHUSETTS
4= . :6 -22I 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 -0299
Project # JS- 2010- 000399
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784
Lot Size(sq. ft.): 94525.20 Owner: GARRESTON ADAM & STEPHANIE SILVERMAN
Zoning: SR(100) / /WP/WSP II Applicant: OLD HADLEIGH HEARTH & HOME CENTER
AT: 81 WINTERBERRY LN
Applicant Address: Phone: Insurance:
119 WILLIMANSETT ST (413) 538 -9845 WC
SOUTH HADLEYMA01075 ISSUED ON :9/21/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK :INSTALL WOODSTOVE
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 9/21/2009 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo