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32C-090 ® y 1 ' °R° DATE (MM/DD/YYYY) C ERTIFICATE OF LIABILITY INSURANCE 6/15/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Christine Sullivan NAME: Aquadro & Associates POE Aquadro (413)586 1A No ) ,(413)584 0859 E -MAIL 355 Bridge St., P. O. Box 357 ADDRESS: PRODUCER 00003656 CUSTOMER ID #: , - - -- Northampton MA 01061 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA:Preferred Mutual Insurance Co 15024 ■ INSURER B : Charles Amo, DBA: Choice Builders INSURERC: P.O. BOX 716 INSURER D : 9 Lilly Pond Lane INSURERE: ,,Ggshen MA 01032 -0716 INSURERF: CbVERAGES CERTIFICATE NUMBER:CL1061502196 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I - -_. __ - - - -- ADDL SUBRi T _ - POLICY EFF POLICY EXP VEX ---- - - - - -- LTR ! TYPE OF INSURANCE INSR WVD POLICY NUMBER LIMITS (MM /DD/YYYY) (MMIDD/YYYY) '. 'GENERAL LIABILITYI, EACH OCCURRENCE $ 1, 000,000 ■ _ - hOAMAGETORENTED 3OO OOO X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) I $ l 'A ' ! CLAIMS -MADE X OCCUR TBA 6/15/2010 6/15/2011 MED EXP (Any one person) i $ 5 , 0 00 PERSONAL &ADVINJURY i $ 1,000,000 S'. GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 1 PRODUCTS - COMP /OP AGG $ 2,000,000 it 'POLICY I POLICY ! JE 0 f 1 LOC $ 1 : 11,1 AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT (Ea accident) $ II ANY AUTO BODILY INJURY (Per person) $ CI, ALL OWNED AUTOS )1 BODD ILY INJURRY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS , • (Per accident) -+ , • NON -OWNED AUTOS ! $ C '1 i $ 1 UMBRELLA LIAB I _ OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ ! DEDUCTIBLE $ -- ifaL .__j; RETENTION $ 1$ WORKERS COMPENSATION 1 WCSTATU- i 10TH- AND EMPLOYERS' LIABILITY Y / N 1 l TORY LIMITS1 1 ER ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A ' (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $_ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ■ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE -- THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF NORTHAMPTON ATTN: BUILDING DEPT NORTHAMPTON, MA 01060 6 0 AUTHORIZED REPRESENTATIVE Johanna Kostek /JLK ACORD 25 (2009/09) ©1988 -2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD I r Mae Deartment o� P u S Board ass o BuildinttS " n 7 SRI e;ULtion a nd blic Standfet.Jrd C tl0n SuperV15Or Li cense License: CS 44171 Restricted"to: CHARLES AMO PO BOX 716 GOSHEN, MA 01032 Expiration: 9/12/2011 �--�' Tr#: `8 Jfce anr»za e a4 0a4dadeuae Office of Consumer Affairs & Bdsiness Regulation re= HOM E IMPROVEMENT CONTRACTOR Registration X 59345 Type: XS = � �, Expiration 24+12012 Individual C • ' LES AMO a � t I CHARLES AMO 19 LILY POND LAN e, a7 GOSHEN, MA 01032 Undersecretary 1 M1 . 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 jermits 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 . The Commonwealth of Massachuse ==.2r----- Department of Industrial Accidents . P k --=.•=z- N Office of Investig,ations , • 600 Washington Street Boston,111/1 02111 -v...„ www.mass.gov/dia • . -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers - - Applicant Information Please Print Legiblv Name (Businese/Organization/IndivirinaD: : • Address: ,. . . - City/State/Zip: - Phone.#: • Are you an employer? Check the appropriate box: Type of project (required): / 1. 0 I am a employer with 4.. 0 I am a general contractor and I iistruction employees (full and/or part-time).* have hired the sub-contractors 6. 0 New co listed on the attached sheet. 7. 0 Remodeling •2. I■1! I am a sole proprietor or partner- ship and have no =ployees These sub-contractors have .8. 0 Demolition working for me in any capacity. eipployees and have workers' - 9. - 0 Buildini additiOn - [No workers' comp. insuiance required.] , 5. 0 We are a corporation and its 100 Electrical repairs or additions 3. 0 I am a homeowner doing all work officers havetzercise4 their . 11. El PhIming repairs or additions .1 b myself [No workers' comp. lien Of exemption per MGL 12.0 Roof repairs . - c. 152, §1(4), and we have no , insurance required.] t • employees. [No workers'- 13.0 Other comp. insurance requited.] • *My applicant -tbat checks box #.1 roust also fill out the section below showing their workers' compensation policy information_ t Homeowners who submit this affidaYit imficating they are doing art work and then hire outside contractors must submit anew affidavit indicating such. . 1 Contractcas that check this box must attached an additional sheet showing the name of the sub-contractors and state whetheror not those entities have . , employees. lithe sub-contractors have employeeS, they must provide their workers comp. policy number. .1 am an employer that is providing workers' compensation insurance for my einployees. Below is the policy and job site information. . Insurance Company Name: ' . • . Policy # or Self-ins. Lic. #: Expiration Date: . . Job Site Address: City/Stain/Zip:* Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverake . as required tinder Sect OfMGL•c. 152 can lead to the iinpOsitiini of Crininil penalties of a fine up to 51,500.00 and/or one-year imprisonme4 as well as civil penalties in the form of a STOP WORK-ORDER and a Lie of up to 5250.00 a daY against the violator. Be advised a copy& this statement may be forwarded to the Offic.e of Thivestnuatiolisofthe for insurance coverage Verification. _ I do Iterecertin under th . . .an penalties of perjury that infornuttionprovided:itboveittrzzeizzidr:orm Signatre: Date: 1 ; I ( c f 1 'c.; i () - Phone 0: t: ( t -. - L 4. f) - 1-3 l'i___. . - - • • . . - 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. Cityfrown Clerk 4. ElectricalInspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: • - - — SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone ° ReAtstect.�ttrci�t8rifl+o�c#ar: Not Applicable ❑ Company Name Registration Number Address Expiration Date 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 building permit. Signed Affidavit Attached Yes ❑ No ❑ Z i ettl tiMUOn 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, Sta d Local Zoning La s and State of Massachusetts General Laws Annotated. Homeowner Signature 4-014- (f SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing in Or Doors ❑ Accessory Bldg. ❑ Demolition El New Signs [0] Decks [p Siding [110 Other [0] Brief Description of Proposed Work: �0—kA � c. )0 f , i d i v-1� -t n_cLi l (+15 b o tA-4 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6 n itifitS > `. ffi ffi; ffi « t 0 . •, 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 4 , S �� A Iz�dr as Owner of the subject property n �y i� A hereby authorize l x`22 � I/LA -to to act op my behalf, in all m tters relative to work authorized by this building permit ap li tion. tit tO Signature of Owner Date , as Owner ° uthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of m • •.ledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner /Agent Date 1 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 ? ! 3 , Frontage I i 1, Setbacks Front f I 1 i 5 --°- ---„ a Side L:; 1 R: I I. 1 R: s 1 Rear i I = 1 Building Height 1 1 Bldg. Square Footage F-1 1 I% 77 7- I 1 Open Space Footage , % (Lot area minus bldg & paved 1 i ? s parking) # of Parking Spaces i — Fill: 1 0 ll 4 (volume & Location) C i � A. Has a Special Permit /Variance /Finding ever &een issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:1 IF YES: Was the permit recorded at the Registty of Deeds? NO 0 DONT KNOW 0 ; YES, 0 1 IF YES: enter Book I Page Y and /or Document # � B. Does the site contain a brook, body of water or wetlands? NO Ok DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ,Date Jssued ` C. Do any signs exist on the property? YES 0 NO (4 i IF YES, describe size, type and location: P D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO C. 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. 1 I ob of C�fcji`9 ampton d � 141.1it6ng Department 212 Main Street ffi ��� 5 rn � ha Room 100 x.. Nbttrri n MA 01060 �� , . phone 413 - 587 -) 240 'Fax 413- 587 -1272 r' c r r APPLICATION TO CONSTRUCT, ALT R, 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 - 3 vl(S� kJ Map ? Lot Unit Zone, Overlay District Etrn St District , CB D strfcf SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Rec O A t Name (Print) Current Mailing Address: Telephone Signature 5 (' 7, 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 «C 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 0 7 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 1, File # BP- 2010 -1151 APPLICANT /CONTACT PERSON CHARLES AMO ADDRESS /PHONE P 0 BOX 716 GOSHEN (413) 268 -9322 PROPERTY LOCATION 33 WILSON AVE MAP 32C PARCEL 090 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /� Fee Paid 1� Tvpeof Construction: REPAIR ROOF & SIDING FROM TREE DAMAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 44171 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 Demolition Delay C>4- 2.2.710 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. 33 wILS," f , BP- 2010 -1151 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C - 090 `$ 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 -1151 Proiect # JS- 2010- 001687 Est. Cost: $12000.00 Fee: $72.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CHARLES AMO 44171 Lot Size(sq. ft.): 13764.96 Owner: AQUADRO FAMILY TRUST Zoning: URC(100)/ Applicant: CHARLES AMO AT: 33 WILSON AVE Applicant Address: Phone: Insurance: P 0 BOX 716 (413) 268 -9322 GOSHENMA01032 ISSUED ON:6/23/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR ROOF & SIDING FROM TREE DAMAGE 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 6/23/2010 0:00:00 $72.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo