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42-043 (2) WORKERS COMPENSATION AND Et PLOVERS' UABILITY INSURANCE POLICY - INFORMATIO 4 PAGE INSURER: POUCY NO: 'k C$9022S NON INSURANCE COMPANY 4601 T0UCHTON ROAD EAST RENEWAL OF: y CB90225 SUITE 3400 JACKSONVILLE, FL 32245 -6000 NCCI Company No: : 6322 Account No: t ACE90225 ITEM 1. NAMED INSURED AND MAlUNG ADDRESS: AGENCY NAME AND AD TRESS: DUPFY WILLARD PAVING & AQUADRO & ASSOC$ INS AGCY INC (SEE NAMED INSURED ENDT) PO BOX 60137 P O BOX 357 FLORENCE NA 01062-0137 NORTHAMPTON, MA 01061 AGENCY PHONE NO.: ( 413) 586 -7373 AGENCY NO.: . 2 11107 LEGAL ENTITY: LIMITED LIABILITY COMPANY OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Local or. Schedule) ITEM 2. POUCYPERIOD: From: 03 -17 -2012 To. 03 -17 -2013 Effective 12:01 AMA. Standard Time at the Insured's mailing address. REM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Worke s Compensa:ion Law of the states listed here: MA S. Employers' Liability Insurance: Part Twc of the policy applies to work each s ate listed in Item 3,A. The sm to of liability under Part Two are: Bodily Injury by Accident: $ 500., 000 each accide' t Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 500,000 each empto± ae C. Other States Insurance: Part Three of the poicy applies to the states, if any, Gs ed here: all states except: ND, OH, WA, WY and states designated in ITEM 3A of the information page. 0. This Policy induces these Endorsements and Schedules: See Scheaute of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy wit, be determined by our Manuals of F uses, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classlfic .lion Schedule is subject to verification and c range by audit. Please see Classification Schedule. Total Estimated Minimum Premium $ 500 Annual Premium: $ 7,714 Audit Period: ANNUAL Date: 01-17-2012 Countersigneo by WC 0000 01A Copyright 1987 National Councilor Conversation w WAn a Page 1 at 4 The Commonwealth of Massachusetts rrint rarm ,.;. Department of Industrial Accidents c Office of Investigations 1 Congress Street, Suite 100 - _ .. Boston, MA 02114 -2017 *ale �' www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Duffy Willard Paving & Excavating, LLC Address:P.O. Box 60137 City /State /Zip:Florence, MA 01062 Phone #:413- 586 -1477 Are you an employer? Check the appropriate box: Type of project (required): 1. el I am a employer with 12 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ['Demolition working for me in aci employees and have workers' g any capacity. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. El We are a corporation and its 10.❑ Electrical repairs or additions q ] 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 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13. i Otherfill -in inground pool employees. [No workers' 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. :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. Insurance Company Name: National Grange Mutual Insurance Co. Policy # or Self -ins. Lic. # :WCB9022S Expiration Date: 3/17/2013 Job Site Address:669 Westhampton Road City /State / Zip:Florence, MA 01062 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 $250.00 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: I , Date /2 / 2012 I Phone m413- 586 -1477 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 #: o - i SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: . Not Applic ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone .9 Registered Home Improvemer t Contractor s ,_ z ,_ , ;„ ,,, i �;, r i v a.,,� e „= 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 ❑ ■ ■ iL E` iii a OwnerrEEe nptip'n 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 r 4 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) e r New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing f 1 Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [E] Siding [p] Other [f] / Des ription of Proposed r " Y work: e c t ore t 5 urr�++n �� -ice i l 1 P i ye ti d pew � r v.,t w � h . y — I t p4 /, Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a 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 = OWNERAUTHORIZATION TO BE COMPLETED WHEN OWN AGENT OR CONTRACTOR`AP.PLIE FOR BUILDING PERMIT i- 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 I, /1/vyt.Ci 5 A -.1 If Sorg , 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. Signori under the pains and penalties of perjury PA e(s 4 - .0 u scii Print amp /21,o//-.. Signature of Owner s t Date l • 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 fille ;l§y { Building Department Lot Size Frontage _. w Setbacks Front Side L:- R: L:. _.. R:_ Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved i I parking) I I ! # of Parking Spaces , Fill: ., _.. (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 Q 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 0 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. C �� 1) ©epa rtme t use ora(y '2 h it of N orthampton S atusof PertTit ; ��� ry "' s uil D epart men t G u t l n vew y1 m1, a , OCT 2Q 2 Room I 21 2 M ain Street S ew e rp t t cAala blit y � � ; 100 W ater/We ll Avarlabtl�t' , . - X - ,,7 .. DE P OF BUILDING INSPECTIO No , 01 1 0 3-587- 60 MA Two Sets of 5tructttral P ans NORTHAMPT 1060 "4 k ' rune 587 -1240 hampton Fax 41272 P . S IansMa 0 Other S pecif y F APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A O NE OR TWO FAMILY DWELLING S CTION 1 - SITE INFORMATION Thrs s ec ti on t o h e completed by office 1.1 Property Address { Y 4 r f t, i + �r ph l$ . 1 \ M ap ."'D-' t Lo# Unit ,4/ o �O relI C e ` Overlay D ,: Elm St. District CB Di ict SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT /Li .9f_t7t igen)" 6tc9 tc/e 2.1 Owner of Record: Name (Pn, Current Mailing Add ress: I--- ;,,,e..,-,.--- ��,,// C � Signature �/ r 3 / 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTR COSTS Item Estimated Cost ) to be Offic al Use Only . > completed by permit (Dollars applicant Building (a) ,`Buildm Permit Fee 1-10C9°' 2. Electrical (b) Estimated Total Cost of . , Cons truction fr (6) 3. Plumbing Building Permit F ee . " 4. Mechanical (HVAC) 5. Fire Protection 6. To tal = (1 + 2 + 3 + 4 + 5 �Ci CC- d 0 Check Number Th is Section For O ff icial Use Only D ate Building Permit` Is sued: Signa ture: Building Commissioner /Inspector of Buildings Dat • File # BP- 2013 -0371 APPLICANT /CONTACT PERSON JOHNSON FRANCIS & LUCY HARTRY ADDRESS /PHONE 669 WESTHAMPTON RD FLORENCE (413) 584 -9005 () PROPERTY LOCATION 669 WESTHAMPTON RD MAP 42 PARCEL 043 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out av �� Fee Paid Typeof Construction: DEMOLISH POOL & FILL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF}RMATION 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 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. 669 WESTHAMPTON RD BP- 2013 -0371 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 42 - 043 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit # BP- 2013 -0371 Project # JS-2013-000601 Est. Cost: $4000.00 Fee: $20.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 2504T00 Owner: JOHNSON FRANCIS & LUCY HARTRY Zoning: Applicant: JOHNSON FRANCIS & LUCY HARTRY AT: 669 WESTHAMPTON RD Applicant Address: Phone: Insurance: 669 WESTHAMPTON RD (413) 584 -9005 () FLORENCEMA01062 ISSUED ON:10/9/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: DEMOLISH POOL & FILL 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 10/9/2012 0:00:00 $20.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner