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32-013 (2) ACORO CERTIFICATE OF LIABILITY INSURANCE OP ID TK DATE (MM /OD /YYYY) DECUM -1 08/26/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION LV Toole - Lee ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 195 Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 319 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lee MA 01238 Phone:413- 243 -0089 Fax:413- 243 -4221 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: NorGuard Insurance Company INSURER B: Arbella Protection Decumanus Green Design Joseph Karry INSURER C: selective Ins Co of Southeast 29 Edgewood Drive INSURER D: Lenox MA 01240 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 ADD'L -1 DATE EFFECTIVE POLICY EXPIRATION LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE (MM /DD /YYYY) ' DATE (MM /DD /YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 10 0 0 0 0 0 10 HEW ED _- - -- -- -- C X COMMERCIAL GENERAL LIABILITY S1887295 04/06/09 04/06/10 PREMISES (Ea occurence) $ 10000 CLAIMS MADE X I OCCUR MED EXP (Any one person) $ 5 0 0 0 PERSONAL &ADVINJURY $ 1000000 GENERAL AGGREGATE $ 3 0 0 0 0 0 0 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 3 0 0 0 0 0 0 POLICY X JECT PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT B ANY AUTO 71851400003 05/28/09 05/28/10 (Ea accident) $ 1000000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY $ X 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 / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR L CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WCSIAIU- I IOIH- AND EMPLOYERS' LIABILITY ITORY LIMITS X �, ER YIN �� A ANYPROPRIETOR /PARTNER /EXECUTIV DEWC012842 01/23/09 01/23/10 [ EL EACH ACCIDENT $ 500000 -- _ - - -- - f yes, in NH) I(Mandatory L. DISE - EA EMPLOYEE $ 500000 OFFICER /MEMBER EXCLUDED? i SPECIAL PROVISIONS below i it E L. DISEASE - POLICY LIMIT I $ 500000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / 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 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 Town of Northampton Main Street REPRESENTATIVES. Northampton MA 01060 AUTHORIZEDREPRESENTATIyE John E. Toole lob—' ACORD 25(2009/01) ©1988-2009A ORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 7 7rC . , 7 .; 'f .rrt-et/('4 t lr :.: q tr c(Leoe 3 Board of Building Regulations and Staadar :h +. =E HOME IMPROVEMENT CONTRACTOR Registration: 159641 t/ e9 Expiration: 5/15 /2010 Tr# 268296 Type: Private Corporation DECUMANUS GREEN DESIGN BUILD INC. JOSEPH CARRY 29 EDGEWOOD DR. LENOX, MA 01240 Administrator Nlaaathusctt% - 1)clr uttitcrtt n( Yulilii •,i1Ct Rio Ird ut Buildin�� 12i ulatimis and standa+'!� License: OS 90239 Restricted to: 00 041 JOSEPH B CARRY 29 EDGEWOOD DR? LENOX, MA 01240 E.tt; aanun 11/28/2010 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Ilo.ston. MA (12111 3I'W)V. lnasS.gov /tha '4Vorkers' Compensation Insurance Afidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name i 1,u,me', t )rt!ant /atton Lodia td uall; ' sun? v �� �,v� 0Q, "— ,ii_ -- Address: e\go ne, '0R. — — Cit /state /Lip: � !J�( ?_ ��? I - — Ph i#: _ .�'I = �� — —_ — _______ Are you an emploer? Check the appropriate box: Typed project (required): I X1 am a emplo‘cr with 2 --- -- 1 . ❑ I am a general contractor and I 6. ❑ He y construction employees (Cull and/or part-time).* have hired the sub contractors >. El f am a sole proprietor or partner- listed on the attached sheet. 7. fl Remodeling These sub - contractors have ship and have no employ ces X. ❑ Demolition «orlon for nie in auy capacity. employees and have workers' e r b 1. ❑ Building addition I am a homeowner doing all work P� INo workers' comp. insurance comp. insurance- required. � ( _ � 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 1 t _ ` Plumbing repairs ihein irs or additions _ my self. INo workers' comp. right of exemption per MGL 12 Roof repairs required.) = c. 152. *10). and we have no �`�"� employees. 'No workers' orkers 13- Other xt,JUNTIC _ _ _ comp. insurance required.) ` vat. sprrticant that , hceks hog 1 must also till out the , cction hdow showing their e';of km: conzpat,atton nulicv information. i t.nn..•.•o ncrs \% hi s.uhm t this .aflidas it indicating the■ are doing all work and then hire outside contractors trtust submit a new :dESda' it indicating such. t, act .rs that check this h,s must attached an additional sheet showing the name oi'the sub - contractors and state ''. nether or not those entitles has ,mipl.ts cc' it the sub- cutitract•ws have employees, they must pats ide their workers' comp poticv number. I am an emplover that is providing workers' compensation insurance for nay employees. Below is the policy and job site information. 7 Insurance Company Name _V'4 _(? ‘ _ Ce,_ -_ -- -- — -- Policy It or Self -ins. Lie. is Ctrikb 1 2 - Z ._____ -___. -- - - - -_. ___- Expiration Date: 1 2 lob Site Address: - 7 Ca6_, cOq'h _- - C'it+iStateiZip: ��4rImr/ C/ / 0b i o Xttaeh a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Faihlre to secure cov erage as required under Section 25A of MGT. c. 152 can lead to the imposition of criminal penalties of a floe up to 51.509.110 and/or one -wear imprisonment- as ww ell as civil penalties in the foam of a STOP WORK ORDER and a fine of up to 5230.00 a day against the w iolator Be advised that a cope of this statement may be forwarded to the Office of his estigations of the DIA for insurance cow erage verification. / i/o herein' certifi• um ' ft p it . and penalties of perjury that the information provided abry eee is true nand corre --t. iHlI :tlure Dale: --[/ J 1 C'l>>)e 113_ 261-04; — — - - - - Official use only. Do not nrite in this area, to he completed ht' city or town official ('ity or Town: PermitiLicense # _� _ Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cityfl'owsn Clerk 4. Electrical inspector 5. Plumbing inspector 6. Other ('ont ;lct Person: Plume #: A 9 i SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: r Not Applicable / Name of License Holder : �V f l � t.t1, \: 1 �( / 7`) Z 3 U asap!, r `' License Number 29 Edg ,vw ' DG° 11 ifl7e5M Lenox ' ' (' 1 240 Address Expiration Date j /r L' /)3 061 '-0 Signature ir Telephone 9 :, Registered .Homerlm "rovementCoritractor .,,E.' , th, ,,. , .,, , -: , Not Applicable ❑ 0,a4r in. 6ce�� w - ar c_ 15 Company Name g ' Registration Numb r l�l 54144?? fig , S is'/ e 9) b • Address � Expiratio Date Telephoner/ 01 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 ❑ ri:" ? 73 n .de illi , M The_currentexemption for "homeowners" was extended to include Owner 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 1083.5.1. 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 _—_.__,t ,_ -° -ws- Annotated. `port ampton +r•mances e . I . .- .,� .i I °,� - - 0 _ ,- . ' - - - ral- La Homeowner Signature a a SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [E] Other [ Brief Description of Proposed ' r Work: , `� I �J 3 ■ 40 - t114/11/ / I , f) li Li Wie Alteration of existing bedroom Yes X No Adding new bedroom Yes , ,/ N Attached Narrative Renovating unfinished basement e XNo Plans Attached Roll - Sheet Sa iL Nernr:house andor:adoit orfo existinci • hour &nci:eali piefie the fotiouvincr a. Use of building : One Family X 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, 1:17(*()3 , as Owner of the subject property hereby authorize /' t a n my beha f ' a ma r elative to work thorized by this building ( pe it applica ' ture of Owner Date I, , l� C'� , as Owner /Authorized Agent here h declart the statements anti information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains _ fef perjury. Print Name r. or I M 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 _ _. ___._. _._ .,_____. °._ ._.. _, _...• '_ ..._ °_ _. °__..._.. Frontage Setbacks Front Side L w_ . R: L:. _. R Rear Building Height Bldg. Square Footage % 7 Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Fin in ever been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:``. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book r-- Pagel F and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 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 IF YES, describe size, type and location: , fef) . dre t e any proposed "changes to or ad pions: of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb .(clearing, grading, a vation, 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 ermit from the DPW is required. , F • City of Northampton Sta , �, M�� 3 � Building Department t D e :; t P �` 212 Main Street S gl t �k fi 4 s io `�19, , . � . Room 100 _ ,- Northampton, MA 01060 ., A x 4,1/4 - phone 413 - 587 -1240 Fax 413 - 587 -1272 Sit � �� "�' - i , 6 4 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 12 J ,0 5. (tj h (tA Map Lot Unit N�C'ibn1 .()13 ; 11 Z one Overlay District Elm -St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: o 7---- - - 7_ C icy III Name (Print) Current Mailing tc s: r 1_ _ 1---{ 3 Telephone SS Signature 2.2 Authorized Agent: V 2 7 6 / it(e� -t �) 0-74 Name (Pri 1(X--)Q-1)h � Current Mailing Address: v l /,v � ( / )3 l / � /6 Signature Telephone SECTION 3 - ESTIM ,- TE ® e - - .� T CTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (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) ' , - 4 // 4() Check Number 1 �7D ✓ This Section For Official Use Only Date Building Permit Number: Issued: Signature: . Building Commissioner/inspector of Buildings Date - 1 File # BP- 2010 -0371 APPLICANT /CONTACT PERSON JOSEPH CARRY ADDRESS /PHONE 29 EDGEWOOD DR LENOX (413) 281 -0046 PROPERTY LOCATION 125 CROSS PATH RD MAP 32 PARCEL 013 001 ZONE SC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /7'96 /J!' Fee Paid J Typeof Construction: INSTALL ATTIC & BASEMENT INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 90239 3 sets of Plans / Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF, tM ATION 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 Peiniit 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 De1a ,,, /a/94, Signature of Building Official 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. 125 CROP BP- 2010 -0371 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32 - 013 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 -0371 Project # JS- 2010 - 000493 Est. Cost: $1864.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH CARRY 90239 Lot Size(sq. ft.): 114127.20 Owner: KOS DOROTHY Zoning: SC(100)/ Applicant: JOSEPH CARRY AT: 125 CROSS PATH RD Applicant Address: Phone: Insurance: 29 EDGEWOOD DR (413) 281 -0046 WC LENOXMA01240 ISSUED ON:10/8/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC & BASEMENT INSULATION 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 10/8/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo