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32A-267 (3) A i,ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER ‘.- OLICY NUMBER NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. 0090063 -00 WC 009 -93 -6606 3072 013 -82- 1110 -00 INCORPORATED UNDER THE LAWS OF • k k VAN I A ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO.: COZY HOME PERFORMANCE LLC C H A R T I S 74 LYMAN RD NORTHAMPTON, MA 01060 -4228 A Chartis company EXECUTIVE OFFICES: ?FF EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 175 Water Street New York, NY 10038 MA U I# : PRODUCERS NAME AND ADDRESS KEATING GROUP OF MA LLC WORKERS COM PEN SATION AND EM PLOYERS 144 TURNPIKE ROAD LIABILITY POLICY INFORMATION PAGE SUITE 150 SOUTHBOROUGH, MA 01772 -0000 'NSURED IS PREVIOUS POLICY NUMBER JMITED LIABILITY COMPANY ( RENEWAL 007453941 • OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 1 :1 EM 2 POLICY PERIOD 12:01 A.M. standard time at the insured's mailing address FROM 11/02/10 TO 11/02/11 • HEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. f The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK 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 EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 HEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Oassifications Code Number Total Remuneration $100 OF Re Premium © Annual ❑ 3 Year muneration © Annual ❑ 3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES /ASSESSMENTS /SURCHARGES $549 tXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $338 MA MINIMUM PREMIUM $500 MA TOTAL ESTIMATED ANNUAL PREMIUM $8,729 Indicated below, interim adjustments of premium shall be made: El Semi- Annually C Quarterly [1 Monthly DEPOSIT PREMIUM 09/14/10 PARSIPPANY 82 g / Issue Date Issuing Office ✓ Authorized Representative WQ 00 00 01A ./996/ (Rev'd 04/081 a• The Commonwealth ofltrassachusetts Department of Industrial Accidents Office of Investigations • .34 600 Washington Street Boston, M4 02111 www.mass.govidia -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lepiblv Name (Business/Organion/Individual): C r A__ I Address: L - 0(c7C ' >1 P : City/State/Zip: / v (-2( / I Phoneg: L/($ • 7 ( _ Are you an employer? Cheek the appropriatebox •Type of project (required): I am a employer - vvith - 4. D I am a general contractor and I 6. 0 New coristruction have hired the sub-contractors employees (fall and/or part-time). 2..0 I am a sole proprietor or partner- listed on the:attached sheet: 7. 0 Remodeling ship and have no. employees These sub-contractors have .8. 0 DeMolition working forme in any capacity. emba_yeesandhave workers' . • 9 taBliStimg [N wor corap_. insurance - comp...intratacei: required.] , 5. 0 We are a ...azation and its 10-0 Electrical repairs or additions 3. 0 I am a homeowner doing all work officers have xercis their r . 11.0 Plumbing repairs or additions myself [No workers' comp. nett of exemption per mo., 12.0 Roof repairs insurance required.] t • ,c. 152, §1(4); and we have tici 13.0 Other employees. [No workers' • • comp. insmance reqtiiced.j. • *Any applicant that checks box AL must also fill out the section belowshowing theirWoriocrs' -compensation policy information. Homeowners who submit this afftdaVit inclicating they a e doing all work and demi hire outside contraCtcas must submit a new affidavit indicating such_ 1 C.ontractcas that check this box mvstattached an additional sheet showing the name of the subcontractors and state whethernr not those-entities have employees. If the suh-contractorshaie croployeea, they must provide their workers' comp. poRcynumber. lam an employer that &providing, workers' compensation insurance for my employees Below is the policy and job site information. - Insurance Company Name « f t ; C.- ----,--) • / Policy # or Self-ins. Lic. #: \/ (--- Expiration Date: - ( Job Site Address: City/State/Zip: - - Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage . as reqUife3 tilde Se 25KfNIGL c 15Z cai lead to the thoi1i�n of' ainiJ -. Penalties of a fine up to S1,500.00 and/or one-year imprisonment, as well as Civil penalties in the form of a STOP WORK-ORDER and a &_e of up to $25000 a day against the violator Be advised that a copy of this statement may be forwarded to the Office of Under the Ctial ofTpetjutythat the iitfOrtnationprovidid_Woviktnt;Oet Sienature: • - Date _ Phone ff : ____.; •• tei / - Official use only. Do not write in this area, ti, 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 .I..spector 5. Plumbing Inspector 6. Other I Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ 1 /14A... Name of License Holder : , ,j ee) 2� License mber y � ��� Address �� M Expiration Da e C Signature Telephone 9. Registered Home Im rovement Contractor: Not Applicable ❑ Company Nam, Y Registration Number Address Expiration Date a Telephone 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 build 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 ' L x SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition El New Signs [D] Decks [lI Siding [D] Other[D] Brief Description of Propo /Ls c _ I , � f {� ""'' ✓)�`v t�� Work: / dam+ 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 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 J , as Owner of the subject property C �� hereby authorize i / v 4�' ` P *tcq / to act on my behalf, in all matters re ative to work authorized by this bud it a der gT pe application. Signature of Own Date `Z t `{, 2A 11 L , as Owner /Authorized Agent hereby declare that the s atements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed u der the pai anlpienalties .f perjury. mip Print Nam 3 /'s it Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incom. ete 111 f ltaod• -- • ^� Existing Proposed Required . Zoning This column be filled it f, Building - . rumen iE a 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 0 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 Page and /or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW ® YES i 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 there any proposed changes to or additions of signs intended for the property ? YES 0 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 ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only • E I I ity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability N rthampton, MA 01060 Two Sets of Structural Plans Off MA D O ' • -- :;Z 'i'' 41 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify 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 r V t' S Map Lot Unit l O f■1 C- Z'Y) Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: (bL , - L ;r '2 Crate O t 060 Name, • rint) , Current Mailing Address: 4 = Telephone - 0 ,� Signature 2 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 (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) H t3 3 ' () Check Number '19/ This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0734 APPLICANT /CONTACT PERSON MARK LANTZ ADDRESS /PHONE 74 LYMAN RD NORTHAMPTON (413) 320 -7611 PROPERTY LOCATION 2 GRAVES AVE MAP 32A PARCEL 267 003 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /n/ ,� Fee Paid / j�� V Typeof Construction: AIR SEALING,INSULATION OF ATTIC FLAT - REPAIR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 102169 3 sets of Plans / Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 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 „...,,,w Demolition Dela Sig _ ature of Building Offici • 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. 2 GRAVES AVE • BP- 2011 -0734 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 267 CITY OF NORTHAMPTON Lot: -003 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2011 -0734 Project # JS- 2011- 001225 Est. Cost: $1405.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Coast. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): Owner: SHADONIAN CHRIS Zoning: Applicant: MARK LANTZ AT: 2 GRAVES AVE Applicant Address: Phone: Insurance: 74 LYMAN RD (413) 320 - 7611 WC NORTHAMPTONMAO1060 ISSUED ON:3/23/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:AIR SEALING,INSULATION OF ATTIC FLAT - REPAIR 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 3/23/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner