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ISSUED BY THE STOCK INSURANCE COMPANY HERE3N CALLED THE COMPANY AGENT NUM3ER POLICY NUIVEER
GRANITE STATE INSURANCE COMPANY 0095250 -00 WC 002 - 35 - 6255
13102 -------- - - - - -- 013-66-0909-00
INCORPORATED UNDER THE LAWS OF • 1. I.
ITEM 1. NAMED INSURED: MAILING ADDRESS !DENT FICATION NO.:
ATLANTIC CONSTR INC
160 ELM ST
WESTFIELD, MA 01085 -0000
EXECUTIVE OFFICES:
70 PINE STREET, NEW YORK N.Y. 10270
SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610
1.D# MA UI #: PRODUCERS NAME AND ADDRESS
BERKSHIRE INS GROUP INC
WORKERS COMPENSATION AND EMPLOYERS ; p 0 BOX 725
LIABILITY POLICY INFORMATION PAGE 136 ELM STREET
WESTF ELD. MA 01086 -0000
INSURED IS PREVIOUS POLICY NUMBER
CORPORATION RENEWAL 004297177
OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610
ITEM 2 POLICY PERIOD 1 2:t1U1 A.M. standard time at the insured's
mailing address FROM 09/06/09 To 09/06/10
ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA
8. Employers Liability Insurance Part Two of the policy applies to the work in each state listed in item 3.A.
The limits of our liability under Part Two are:
Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ ; 00.000 policy limit
Bodily Injury by Disease $ 100.000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, it any, listed here:
SEE ENDORSEMENT - WC200306A
D. This poiicy includes these
SEE EXTENSION OF ITEM 3D. OF THE INFORMATION PAGE - WC990612
ITEM 0 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.
Estimated Total Rate Per Estimated
Remuneration Premium
Classifications Code Number Imo[ m
1111 Annual D 3 Year u Q Annual 3 Year
SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754
TAXES /ASSESSMENTS /SURCHARGES $75
EXPENSE CONSTANT [EXCEPT WHERE APPLICABLE BY STATE) $338 MA
MI*IIMUMPREMIUM S267 MA TOTAL ESTIMATED PREMIUM $1,39/3
It Indicated below, interim adjustments or premium shall be mace:
0 Semi - Annually Quarterly Monthly DEPOSIT PREMIUM
•
09/11/09 ASSIGNED RISK 66
Issue Date Issuing Office Authorized Representative WC OD 00 01
39967 (Revd 0410a)
L' d 199 L b£L £ Lj7 II!r 2 90:20 60 L 1 AoN
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
- -_ —pets -inn- conjunction , to _thebuilding_pernutissued,_ 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.
Address of work
location
, vb. -
The Commonwealth of Massachusetts
----e--4--- ,„ Department of Industrial Accidents
= ... zitr E ■
. k.,
so_15,
......=.,.. .
' Office of Investigations
600 Washing,ton Street
Boston, MA 02111
Y. www.rnass.govidia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AI olicant Information Please Print L - • iblv
_
4 T j C ri
Name / (Business/Organization/Individual): (....p.. a r r, c:, 4LS N :4----(---- -
Address: / ,
c-- Tie n" / r
City/State/Zip: b ol_../J if(-1, 0/6)rithone #: (ti ( 'S ) 7 <-4 '7 ----'7119d
i -
1 ‘
Are you-an employer? Check the appropriate box: Type of project (required): i i
1. 521 am a employer with '2) 4. 0 I am a general contractor and I
6. Ill New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7• 0 Remodeling
2. 0 I am a sole proprietor or partner-
These sub.-contractors have
ship And have .no et.-431oyees 8. 0 Demolition
'
working for me in any capacity. employees and have workers 9. 0 Builc1i g addition
t
[No workers' comp. insurance comp. insurance.
required.] 5. El We are a corporation and its 10.0 Electrical repairs or additions
s)fficeu hair.&ercised_their_ --1-1-.1:1--Plumbing repairs or additions
3. 0 1 a.m alomeowner-doing-all--work-
right of exemPtion per MGL
myself [No workers' comp. 12.0 Roof rrl •,,
insurance required.] t c. 152, §1(4), and we have no , A-fr,..5 I ,.,•,)
en3ployees. [No workers' 13.2rOther -5 t'..—.•57
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.
1 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.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
_ __ information.
Insurance Company Name: CPA 1 irt, 5 / r' 1 4 1 /t-'‘2" r:/ A 4-c. ft (---0 "
Policy # or Self-ins. Lic. #: ILI C...' 1 00 •-) - S :.> - (;-• d— P--) Expiration Date: - 0" C• /0
/
,.••■ ••, /- i , - r • --, ,. •-;•,,,,, 7
Job Site Address: / r / C/ L, 0 7' C-4.,-/ #ttl -). 2 j City/State/Zip: b/(7;4 / 1 47:f 1
• 7
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage . as repired - under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/jo ne . , inpriso ... . . well as civil penalties in the form of a STOP WORK ORDER and a &...e
of up to $250.00 a day • . • n • theioat. . :e,:fr, j . ed that a copy of this statement may be forwarded to the Office of
Investieations of the 2 ,if. -. , ..c. ce e're ferification.
I do hereby ce ; " e p , , e r ' s of peduiy that the infonnation providedabove is_true_antLcorrect._____ __
i
e 416 - -__
SignaOff7zciale:: q ( use o:1.17 D
y. D ithi iii thT.fa ii a, tci icor:TM by city or town L /417 LI
Phone it 67 e.--(961
6. Other
Contact Person:
I I
nt 3. City/Town
Phone #: c atInspector 5. Plumbing Inspector
#r )
isi inoe:raiityth(c2ir. (circle oneng: Department 4iceEnsieeetri#
1 a • ,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su . ervisor: --� Not Applicable ❑
Name of License Holder : 4 ' A 1O A ' 7' If
..�
-License-Number
/ v, , 14 & „e' ei.`' C5 ` (.7
Address Expiration Date
C ” )
Signature Telephone 7/ I CTS /I P
( ( 7 ' .)c - Y e i "e
• gistered,Ho i 'Imp o A en #Contractor ', i Not Applicable ❑
( 4 ( { PL<,�'l /e6i0
Company Name Registration Number
Addres Expiration Date
/ % � f O / Telephone ? ° -. 2 l d ---- / (4 / 1(71-6)--
r c '
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 buildi5g permit.
Signed Affidavit Attached Yes No ❑
: H ome Exemption
The_current_exemption 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 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" c ertifies and assumes responsibility for compliance with the State Building Code, City of
o any on "e ro inane- s, a e • n. .0 . . s •General L- a-ws= Annotated.
Homeowner Signature
t
R N . r
„ 1
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) [J Roofing n
Or Uoors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] / Siding [l ] Other.�li�
IIN"a bItiU. CALL:-! slidm
Brief Description of Proposed -, , - f ry r y/aci:
Work:, dZtP`-1 ` - C/ 6 /,,e -1 J/t• - '° i�t-4,e.x i ild,:,rL d. r -_C� ,4 ='(
Alteration of existing bedroom Yes No Adding new bedroom Yes �� No
Attached Narrative . Renovating unfinished basement ✓ Yes No
Plans Attached Roll - Sheet
oa lutslaiii h USe`a id0r addition istinet housing," "complete ttie following:
a. Use of building : One Family V Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? 41
d. Proposed Square footage of new construction. 6 Dimensions
e. Number of stories?
f. Method of heating? 6!`! %',zN ' Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction ./// c- i f ` %' ,te
i. Is construction within 100 ft. of wetlands? Yes I✓ No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade 7 t4' (
k. Will building conform to the Building and Zoning regulations? Yes No .
1. 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
1, _ , as Owner of the subject
property
hereby authorize ,� /LC- - _- » -
to act�a ma er relative to work authorized by this building permit application.
Signature of Owner Date
✓��- -�
1, G ' t -
- z, : • C r- 4.- 7 - , as Owner /Authorized
Ag -fit hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sig • -. iier the . and pone i s of pe '
;J-/ 14 ;/ / h= - ,1 ,, 4. i t
P' tName i
Sign. C e of S -(le 'gent ■ er Date
.i
4
1
s
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. __. R.'. .. L: ,...._, R ; ,__.....,„,
Rear .._._..____
Building Height
Bldg. Square Footage 1 F % 1 "'
Open Space Footage
(Lot area minus bldg & paved
packing)
# of Parking Spaces —•
J,,
(volume & Location) __. _ — L ...••._._.___
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:. 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page: i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO e 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
IF YES, describe size, type and location:
— ? D %ire t ere any proposed'c anges to or a rtions o Signs ntenZed or the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, g rading, exca tion, 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 Permit from the DPW is required.
A 1
.., &
, ', " ' ',-, 044 -W , Age,"4t:417, .,„„fA ,As. lc
City of Northampton LA . ': ',.• : ., ,,%, ,, ,-:•.5.:, , ,,i-c ,,,, ir.f ,, ,;, ,,,
ism if-'.'ot...r0ititits:i-,44. -A.,::::., , ,,:.`' , -,, , ,'''',-T - ' ',•' ;7' ''' `-' - - ,"'-1...
,,,,,,WalifAk,:l at-,
_.---':' ' - - --- Building Department
, 'Y'..' 'tom° :TVA
. ,
,..
212 Main Street
Boom 100 ii;"1"= ' 41. :iii4;
astfir: ,l'o ZiL*
.i • ... es ., i A • •. 1 ,,, , , 0 , - - 47 - ,*) , ° lig tt1L ,_ .' - Atr;;',:,-,,,:‘,-,V,T,:itVMPX::',7,',k."',":',
phone 413-587-1240 Fax 413-587-1272 . , .7.,.n•: jq, 7, .,, :,,, ,, ,,, , ,,, ,, ...L;,:ik: , 14-;,... p ?,..:„,9 :'
,, ,,-- ), , ,Nitt-ot.*- , ,-41.: ,,.. ,, ,,,,, ,,,,,,,,,,,
, .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION '1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
..--, /
/ 0 0 /(A- -' / L C i A cqi. 5 t- 4 e, , 'J '
Map Lot Unit
.... '
, i '
y I ( 0 i ) : , ..
• 1 / 1 Overlay
Zone Dittict
......
Orn...pt^District. CB District
.SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
,•,.
•
Name (Print Current Mailing Address: .,., ,.7 ___,
t5 Y - 3 42
10 / Telephone
Signature
2,2A1g_ horized A./:
--(---) de
I , ,,,, ' ,
... -., -, .... A
I t! 1 !: . ..., . c I a -- ..., . ---- ,---, ---
:me 1 ,
,,,... 1 Current Kaili.ng_hoscidry)s•, 4 ,,.. / / 0 ""7,
' 4 . i 411 /-" 1 7 7.' ) C - >i - ' q '-' 0 -5 7
$ i 'fir- or elephone
SECTION 3,- ESTI ' .:ED CONSTRUCTION COSTS: . •.,-
Item Estimated Cost (Dollars) to be . Official Use Only
completed by permit applicant
1. Building ,
L.../ / _ _ L
- ____— (a) Building (al•Buildina '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) . Check Number r/) 02
- - - - - ----7 — ttlisieCifinl'F OrOffiCiai Use Only
. . . .
Date
Building Permit Number: i ..Issued:
Signature:
Buildino.COmmissioner/Inspector of Buildings • . Date
t
File # BP- 2010 -0545
APPLICANT /CONTACT PERSON ATLANTIC SERVICES INC
ADDRESS /PHONE 66MOUNTAIN VIEW ST EXT LUDLOW (413) 589 -0599 0
PROPERTY LOCATION 100 WILLIAMS ST
MAP 32C PARCEL 281 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Pernut Filled out 501602 �,
Fee Paid
Typeof Construction: INSTALL LALLY COLUMNS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 014869
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
Dem ition Delay
o C A
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.
r
BP- 2010 -0545
GIS #: COMMONWEALTH OF MASSACHUSETTS
MiAlt&ttf'ittirftr 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 -0545
Project # JS- 2010- 000770
Est. Cost: $9465.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ATLANTIC SERVICES INC 014869
Lot Size(sq. ft.): 5532.12 Owner: GARY - KERSTETTER GREGORY & JANET C/O ETHAN A KOLEK
Zoning: URC(100)/ Applicant: ATLANTIC SERVICES INC
AT: 100 WILLIAMS ST
Applicant Address: Phone: Insurance:
66MOUNTAIN VIEW ST EXT (413) 589 -0599 0
WC
LUDLOWMA01056 ISSUED ON:11/20/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL LALLY COLUMNS
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 11/20/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo