32C-116 Peerless
Workers Compensation And Employers Liability Insurance Policy Insurance.
Member of llbcny Mutual l Group
RENEWAL
Transaction Effective: 04/16t2010 INFORMATION PAGE DIRECT BILL
Policy Number: WC 8421701 Prior Policy: 8421701 Date Issued: 04/08/2010
Coverage Is Provided In PEERLESS INSURANCE COMPANY - A STOCK COMPANY NCCI Number: 11355
1. Named Insured and Mailing Address: Agent:
LAFOGG AND HATHAWAY CRAY DOWD INS AGENCY INC
CONSTRUCTION INC PO BOX 2010 101 UNIVERSITY DR
29 NASH HILL ROAD AMHERST MA 01004-2010
PO BOX 193
WILLIAMSBURG MA 01096
Agent Code: 6200731 Agent Phone: (413) - 538 -7444
Federal Employer ID Number: 043069522 Filing Number: 000361379 I SIC Code: 1711
Other Workplaces not shown above: REFER TO ADDITIONAL WORKPLACES SCHEDULE
Entity of Insured - CORPORATION
2. Policy Period:
The Policy Period is from 04 /16/2010 to 04/16t2011 , 12:01 AM Standard Time at the insured's mailing address.
3. A. Worker's Compensation Insurance:
Part One of the policy applies to Worker's Compensation Law of the states listed here:
MA, VT
B. Employers Liability Insurance:
Part Two of the policy applies to work in each state listed in 3.A. The limits of liability under Part Two are:
Bodily Injury by Accident $ 5 0 0 , 0 0 0 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 states, if any, listed here: All states except North Dakota, Ohio, Washington,
Wyoming and states designated in item S.A. on the Information Page;
D. Endorsements and Schedules:
This policy includes these endorsements and schedules: See Extension of Information Page
4. Premium:
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
Code Total Estimated $100 of Annual
Number Classifications Annual Remuneration Remuneration Premium
See Extension of Information Page
POLICY PREMIUM TOTALS
Total Estimated Standard Premium $ 2, 266. 00
0 9 0 0 Expense Constant $ 3 3 8. 0 0
Total Estimated Premium $ 2 , 60 4.0 0
Total Assessments/Funds /Surcharges $ 161. 0 0
Total Estimated Cost $ 2, 7 6 5. 0 0
Minimum Premium $ 900. 00 Deposit Premium $ 2, 765. 00 Adjustment Period: ANNUAL
Date: - (>2 "/( Countersigned by: f <.
Authorized Signature
Copyright 1987 National Council on Compensation Insurance.
25 -190 (07/08) (WC 00 00 01A) INSURED COPY PGDM080D J23280 PCAFPPN 00032852 Page 11
�lassachusctt. Dcpurtmcnt rrf Puhlic ,afc„
Board of Buii(liry, Re2ulatir: and Standardh
Construction Supervisor License
License: CS 102397
Restricted to 00
JOAN LAFOGG
PO BOX 193
WILLIAMSBURG, MA 01096
Expiration: 12/5/2012
( °r#: 102397
Restricted to: 00
00 - Unrestricted
1G -1 2 Family Homes
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
Refer to: WWW.Mass.Gov/DPS
' The Commonwealth of Massachusetts ,,
r -- Department of Industrial Accidents
„; Office of Investigations
.7 600 Washington Street
J;1''' Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information CC ,/ /� Please Print Legibly
Name ( Business /Organization/Individual): La & /7(,�? 4ellolc !, 0/15 � it2- /!0/7, . / h�C
Address: Re), D /9:3 n //i feat/
City /State /Zip: 6), /ha, t/Z Phone #: (9/2) i - ,. / 7
Are you an employer? Check the appropri a box: Type of project (required):
1. Z am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ 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. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
r 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. d,n piui Insurance Company Name: P &-er /e SS wai e_
Policy # or Self -ins. Lic. #: WC- 1 /0 , / 70 / Expiration Date: 1/ //t/cQ 0 /1
Job Site Address:.5 Cp✓1 Z SMe.k City /State /Zip: Ni o lr,yit�1 144 0140
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 ORDER and a fine
of up to S250.00 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 certify ui�i ler the ins d penalties of perjury that the information provided a ove is rue and correct.
Signature: � �►C. 3 Date: / 2_ o` C
v
I�/® r
Phone #: (11,3 oc � — c v: r7
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 #:
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW '(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, „ , 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 and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of_perlury . _. _ A ... . _.. .. _ _.
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : .. , e , La[ 09 .. _ . .w. _. ......... License _J s18 Number
? c ._ (i 3._ W.r J1rai u,- Aht 01 ialo..5 4.61A
Address ) Expiration Date
7
Signature ./ Telephone
SECTION 13 - 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 0 No 0
Version1.7 Commercial Building Permit May 15, 2000 0
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name (Registrant): ..__.._.._.______ . .......... ..
Registration Number
Address ..__
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
_,.,_.... _______ ...... .... _.... ,_________ . .. _..._ Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
•
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
M
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 0
IF YES: enter Book 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 Obtained 0 , 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 I 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.
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other
Brief Description Enter a brief description here.
Of Proposed Work:
,Le -r _._._. 5nc...,r_. , .. , ±,✓i_ r- set�?
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly El A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 CI
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B 1 ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C 0
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 1 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑
U Utility ❑ Specify:
M Mixed Use 2 Specify
S Special Use ❑ Specify:
..... __ . -. . -.
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group: :.__._._
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34). __,.._
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf) 5/4 ,v +l"__
, 4 1 s i
1 5i
2 , .,..._. .. 2 nd
3 rd
4
Total Area (sf) > Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ED Municipal 0 On site disposal system❑
.. Version1.7 Commercial Building Permit May 15, 2000
i Dep use Qr iy ii*K.
`° City of Northampton Statusrtaf er�I1t# A ,,
Building Department ±Curia ut/I:)ftyw ay Permit i4 4,
212 Main Street S wer/sep tc Avatlarghty ' `
'Y xt .- Y
,
Room 100 F1llfater/t /eirAvaifabtll �` ,t� q '' '
N \ h 01\ Northampton, MA 01060 •Two S ets o Struct
1 phone 413 -5 7 -1240 Fax 413- 587 -1272 PIotISite Plans '' ,,. .
Other 5peclfy < ,,
APPLICATION TO CONSTRUCT; REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
`35 C ` n St. Map Lot Unit
N% •i' I {'laW I) iii M 4 0 I d 6c) Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
f - 2/ / 1< 5)d/ .Se.. , . ._S1.! H_.. atk!' ., , ._...._, , . ,....,w._,
Name (Print) Current Mailing Address
/
rd-ii /V �
IC £?A,.So/1L4 3.
_„,.._ _CC r`/ ._. � ., _ N ..!_/ � i
Signature ✓ -- �_�,. -= ecr - Telephone 9/3 5�b -C'1 y i`
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) M,..,._....._ w.. .,._...___ _.,.,,
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) /6 000,= Check Number 003 •e 055 _
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
• s
File # BP- 2011 -0637
APPLICANT /CONTACT PERSON LAFOGG & HATHAWAY CONSTRUCTION INC
ADDRESS/PHONE P 0 BOX 193 WILLIAMSBURG (413) 268 -3897
PROPERTY LOCATION 33 CONZ ST
MAP 32C PARCEL 116 001 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 .��j V,/ / �
Fee Paid / JV T
Tvpeof Construction: TEMPO' SHORING IN BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 102397
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IATION PRESENTED:
A pp r oved 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
r /ry it
Signature Building Officia 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.
` 4
BP- 2011 -0637
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- 2011 -0637
Project # JS- 2011- 001037
Est. Cost: $10000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LAFOGG & HATHAWAY CONSTRUCTION INC 102397
Lot Size(sq. ft.): 15986.52 Owner: SANSOM FRANK T & SARAH BEAUMIER
Zoning: URC(100)/ Applicant: LAFOGG & HATHAWAY CONSTRUCTION INC
AT: 33 CONZ ST
Applicant Address: Phone: Insurance:
P O BOX 193 (413) 268 -3897 WC
WILLIAMSBURGMA01096 ISSUED ON:1/14/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:TEMPORARY SHORING IN BASEMENT
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 1/14/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner