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36-222 e • e Sold. Amitsbed aralbastsged by ran nu Booa iAj , M-Kozne Servic:es,Inc 6/1374 The from Depot At-E613) Seivices 345A V-71trilw(19 Street,1:160 2 Woptgter, MA 01607 4 657-5 pa, o_tos) 756-11S23 41 fl C 104 IQ t'esTI LIOP 1 e$42 _ _ M.AssachttNetts - Department of Pt) Board of Bui:dirw, Re 2111m/oils and Standard. Cons!ruction Super''sor License: CS SL 98785 Restricted to: WS IVAN KOSOBUTSKYY 72 STAFFORD ROAD MONSON, MA 01057 Expiration: 4/27/2012 "mniksioner Tr-t: 98785 / e f y-LO yL9 ACORD M CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/20/09 PRODUCER 1- 404 -995 -3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION .,,.:*, USA, 3oc. (TN)Y AND COW' FA NO RIGHTS UPON THE CERTIFICATE H )) DLI' THIS (.E i :IFICATI DOES NO / ND, EX I END OR t,ume ' 't.cert' -- 1. -,t5 na;:. cc., AL. - I i COVERAGE AFFORDED BY THE I- it_IOIL .`, BE.L O'!0. 15 175 Piedmont Rd N], Suite 1200 1 Atlanta, GA 30305 Pak (212) 949-0902 INSURERS AFFORDING COVERAGE NAIC {f IRRSURED INSURERAA S'ea.'."ast Ins Co 26387 T:11) At -Home Servic•'�s, Inc. _- ___.._. __.. - -- - ---- .- .--- -- -._. _. - -- - - -- I INSURERS ERS Zurich American Ins Co 16535 2690 Cumberland Parkway ------------_- ---- _ _ ._---- - - - - -� --- - - -- -- - - - - - -- -- f tNSURERC_NATIONAL UNION FIRE INS CO O. PITTS 19445 Suite 300 Ltlanta GA 30 INSURERD:New Hampshire Ins Co 23841 NSURER E: Illinois Natl Ins CO 23817 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 AOD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF IN.U.ELANCE POLICY NUMBER DATE(MM /DDIYYI DATE(MM/DD/YY) LIMITS A GENERAL LIABILITY IPR 3757 608 - 02 03/01/09 03/01/10 EACH OCCURRENCE $4,000,000 X LIMITS OF POLICY ARE EXCESS PREMISES (Ea occurs 1,000,000 C OMMERCIAL GENERAL LIABILITY PREMISES (Ea occurence) $ CLAIMS MADE X OCCUR "OF SIR: $1,000,000 PER DCC" MEDEXP (Any one person) $ EXCLUDED — PERSONAL BADV INJURY $ 4,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'LAGG PRODUCTS - COMP/OP AGG $ 4,000,000 POLICY PRO- LOC X JECT B AUTOMOBILE LIABILITY BAP 2938863 - 06 03/01/09 03/01/10 COMBINED SINGLE LIMIT $1,000,000 X ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS — _ HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) ' X SELF INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE • (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ • ANY AUTO OTHER THAN EA ACC $ . AUTO ONLY: AGG $ A EXCESS /UMBRELLALIABILITY IPR 3757 608 - 03/01/09 03/01/10 EACH OCCURRENCE $ 5,000,000 X OCCUR CLAIMS MADE AGGREGATE • $ 5,000,000 • $ - DEDUCTIBLE $ RETENTION $ __ _ $ C WORKERSCOMPENSATIONAND 3566916 (CA) 03/01/09 03/01/10 X WC STATU- OTH- TORY LIMITS ER D EMPLOYERS' LIABILITY 3566915 (AOS) EL EACH A CCIDENT $ • ANY PROPRIETOR/PARTNERJEXECUTIVE 03/01/09 03/01/10 1, 000, 000 E OFFICER/MEMBER EXCLUDED? 3566917 (FL) 03/01/09 03/01/10 E.L.DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 OTHER D Workers Compensation 3566918 (KY, MO, NY, WI,WV) 03/01/09 03/01/10 F TX Employers Excess TNSC45694422 (TX) 03/01/09 03/01/10 Occurrence /SIR 25M/2M C Workers Compensation 4801323 (QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT - HOME SERVICES, INC. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 2690 CUMBERLAND PARKWAY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR SUITE 300 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25 (2001 /08) ckomraus_hd © ACORD CORPORATION 1988 11172180 r; •,l ( 0. , i f 1 , 2 i, •••c. , 7r e x t . t 4 o C(' f.,: u ) t 1 F ) s r f 4 _ r d • . 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Web dd Sergi me al w groped) de Ws proQdI re. • UnLt qualifies for CTJGRCY 9t1.R :7-. 7.. cagiort (i): uocti\ten, Noctr : ,� 4 ,;�; ^ • Cant.al, .9o.,t.h Cont.aL, llo,.tha.n- "' ' ■ f__Nf AG( STAR Ga 4ALd -id oaLLilca ps.1 la (a) • ,•• cc?LCn(ai) ONOltQT 5t1R: Nocte. . • Hoc tt Cant cal, 9..c Central, 9 ;111L ' IHD: Rain 00 /CLass 3 /32 " /K —Ra3 • ta)ttd. 91.-ea: 3C' r. C3 IND: fl2fuec :o 00 /V1drLo 2.31 ten /14,R43 DP : a.4 - TaieLLAo pcobado: 91.4 cn ,. 1 G ccac E�9�Cg ✓, C� 107 - . H3 Itoffa.la 2931120 re IM hobs] for pasile ENERti( Sir kte. To learn iron'AN' w.merq • " Goarda till altgveto paro ponbles nerrboEsns ENE16T S L' torn corroeu at de isio,'ttsile rerun eq stocQot : .. • \ gite -6ai;�; car or,2 - Board of Building Regulations and Standards 4 . - HOME IMPROVEMENT CONTRACTOR ,.: Registration: 126893 ., • ' Expiration: 8/3 /2010 Type: Supplement Card The Home Depot At -Home Service R ICHARD FALLONE i 2690 CUMBERLAND PARKWAY S c.....D+(,_ • l A . GA 30339 • ..__ __ - • The Commonwealth of Massachusetts Department of Industrial Accidents [)1 t ;i i 1f / O/3 Cn of /i7 o ci trp <,r,!3it ?; i,: a A._ /� Woz')c el..-•:y,' Comp C.l� oc ;.;: l.c anc. :� / c_fi 't,vit: 1 F n �P. 6.Lr /Gryit - z ;bIlIu:L; 3n '; s Nit t,_n1's ).. s Applicant licant inf o1 xna1"1oi3. _ ii ;: :lass Print. i'_ C eoibi' Name (Business/Organization/Individual). 6 I " V }} Address: ' giA' a _ of `:., , Cit /State /Zip: 3D� Phone. #: ..0 bilk N Apf i • Are yo an employer? Check the appropriate box: rk �1�/ 'Type of project (required): 1. I am a employer with '�C) _ 4. I a m a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub- contractors . 2. [ 1 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contractors have g. Ej Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9. ❑Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.1. 1 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 12.0 Ryf repairs insurance required.] t _ c. 152, §1(4), and we have no employees. [No workers' 13. Other l fi r ` 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: k err , 'l !1 k.. V - Li Policy # or Self -ins. Lic. #: 35(6&)<T (c Expiration Date: I I b . Job Site Address: .15 W,U0err k City/State /Zip: a 7 , _ ' ; _ Attach a copy of the workers' compensation policy4eclaration 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 —a _ ... - • - • : - :. _ ..e _ . . . _ ! ' • e '_ 9..o..9 - ' _ . .. 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 certi unwr e p' s an penalties of perjury that the information provided above is true and correct. Si_ ature: elm „L . A J[ 1 _ . Date: / . Phone #: 4 3 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 ❑ Name of License Holder: ` L) 1v . C 716— me 11 License Number Address / Expiration Date l Signa I Telephone S. Registered Home IriiprovementContractor {3. ,.... ... Not Applicable ❑ A WI rr- Company Name Registration N er ` j A . !IAA 3 / fD Address pp Expiration Date *epho a "� 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 ❑ ®Y: er MMOM The_current_exemption for "homeowners" 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 referenceto 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; Stated= oL�afi rl- State - of -Masacl,usctts= General - laws- Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Wi ws Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [D] Brief Description of Proposed � 4);,t--) Work: � � � �7.7es1'leU rdo. 0 l,- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a ° If.Nev►r.:hoclse an -o -aii lit onto a ` ' f #>iousing, `comp the fofl 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 _10 4r 2t , 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. a — Signature of Owner Date , as Owner /Authorized Agent hereby declare that the statements and in ormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the da and pe . of .erjury. i a * I -� Print Nam � / 'r . _. L� � . "1 - SO r."iL — ._ Signatu o • ner /Agent Date Section 4. ZONING Alt 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 parking) # of Parking Spaces Fill: i (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 = Page( ? and /or Document # _ f B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (3 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 Are third any proposed c anges to or a itlons o signs mtended eir t 'property ? YES 0 NO Q 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 Sta «f�,t Building Department Ouh� tray ' - " r 212 Main Street ew4iseplh vai 1 tfiv: AVVH 1 ' � Room 100 vla.. �1 rr "ta ® -� ` �h . , ' , p4 �� � . Northampton.; A 01060 Wk 4 � " �� 1� P � � o t .4r Plans, -4 > 't -, '.>,.. � phone 413 -587 -x2'40 Fax 413 - 587 -1272 '1a 1t la 1ertk i � 1 � {e Spec+ APPLICA ONTO 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 5 W t t A -_ly IA Zone Overlay District w r Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Re d: .---. P-->VV--- 0 5-- 14 1 tI 0 n(iokce_V-k Name (Print) Current Mailing Address: c am` (Ol > t ' Telephone Signature 2.2 Authori At, • • ent: Name (Pr / / Current Mailing Address: 11 :. ( ;;;? Signatur- Telephone SECTION - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building j,-,- (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction fromj6) 3. Plumbing Building Permit Fee - 4. Mechanical (HVAC) 5. Fire Protection .S.-r-67 r-- 6. Total (1 +2 +3 +4 + 5) Check Number . 7 J 5 This Section For Official Use Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 8 ;> BP- 2010 -0211 GIS #: COMMONWEALTH OF MASSACHUSETTS 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-2010-0211 Project # JS- 2010 - 000259 Est. Cost: $5787.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 169884.00 Owner: BAK WALTER E & CLARISSA G Zoning: SR(100) //WP/WSP II Applicant: HOME DEPOT AT HOME SERVICES AT: 85 WINTERBERRY LN Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 () Workers Compensation WORCESTERMA01607 ISSUED ON:8/24/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 8/24/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo