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35-154 'd:tj ,,- L (....,b. i6 3b << i L x top�, AG "o 0".• 4sacl„..,,es" ' AIL 11' 4 CI ct . I cL.,0- Gam 1 1 ()---E-1' ---E1--- N.,,--, I ,3c , 3o ta 0 II 1 i 1..--) I 's' j_t____,*___7..._,T... H v � . fl ,. t ....� ...�. � - - ST EP Su PAD.RT ` r FOUNDATION PLAN I _ � 4 . ' crj - - --�- +fib - o —7-NJ , ACORD CERTIFICATE OF LIABILITY INSURANCE o9 / /(M2009 PRODUCER 413.586.0111 FAX 413.586.6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Webber & Gri nnel 1 Ins. Agency, Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8 North King Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR g ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northampton, MA 01060 INSURERS AFFORDING COVERAGE NAIC # INSURED Theodore Towne, Jr. INSURER A: NGM Insurance Company 14788 21 Loudville Road INSURERS: WCAR- Savers Property Casualty Easthampton, MA 01027 INSUZER INSURER 0: INSURER E COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN SR I C TYPE OF INSURANCE POUCY NUMBER OA1E P DVE Y I EXPI 11fY mars GENERAL LIABILm MPI51046 06/29 /2009 06/29/2010 EACHOCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGt TO HEM tO ERAL PREMISES (Ea occurrence) $ 500,000 CLAIMS MADE I X) OCCUR MED EXP (My one person) $ 10 QOd A PERSONAL & ADV INJURY $ 1,000 00 GENERAL AGGREGATE _ $ 2,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2 ,000 ,000 POLICY I I IR n LOC _ AUTOMOBILE LIABILITY CANED SINGLE LIMIT ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABRRY AUTO ONLY - EA ACCIDENT $ ANY AUTO 01I-ER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS 1 UMBRELLA LIABILITY EACH OCCURRENCE $ I OCCUR I I CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AR0426328 07/07/2009 07/07/2010 ' WcY S its ER I IOTH- AND EMPLOYERS' LIABK.RY TOR Y I ANY PROPRIETOR/PARTNERIEXECUTIVE N E.L. EACH ACCIDENT $ 100,000 B EER EXCLUDED? (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes, describe wider SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY 04T/ SPECIAL PROVISIONS CERTIFICATE HOLDER • CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL E OEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FALURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATNES. **B** Evidence of Insurance * * * * * AUTHORIZED REPRESENTATNE Jenna Rodrigue, CISR /CINDY L.) ACORD 25 (2009101) 01988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • ACORpT. CERTIFICATE OF LIABILITY INSURANCE DATE PRODUCER (413) 527 -5520 FAX (413) 527 -5970 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Finck & Perras Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6 Campus Lane HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Easthampton, MA 01027 Rebecca Kubosiak INSURERS AFFORDING COVERAGE NAIC # INSURED Wal unas Plumbing & Heating, Inc. INSURERk NGM Insurance Company 14788 218 C College Highway INSURER B: Southampton, MA 01073 INSURER C: INSURER 0: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I TTRR �L TYPE OF INSURANCE POLICY NUMBER DATE POLICY MMIMID EFFECTIVE DATF I I I EXPIRATION LIMITS GENERAL LIABILITY MPF9633E 01/29/2009 01/29/2010 EACH OCCURRENCE $ 500, 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PRFMLSFS (FA ner uonrol $ 500 # 000 I CIAIMS MADE ® OCCUR MED EXP (Any Person) $ 10,000 A — PERSONAL 8 ADV INJURY $ 5 , Opp _ GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 1 POLICY n JE 9 n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ Tr ALL OWNED AUTOS _ BODILY INJURY $ SCHEDULED AUTOS (Per person) _ HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ — PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ D OCCUR rI CLAIMS MADE AGGREGATE $ �_ s $ DEDUCTIBLE $ — RETENTION $ $ WORKERS COMPENSATION AND WCK47067 01/29/2009 01/29/2010 X I T Ry TU- I 1° a EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 100,000 A _ANY PROPRIETOWPARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 100,000 If SPECIAL AL PROVISIONS below E.L. DISEASE - POLICY LIMIT - $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Ted Towne 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Attn • Evelyn Towne BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 75 Parson Apt. V OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Easthampton, MA 01027 AUTHORIZED REPRESENTATIVE tz i Rebecca Kubosiak /BECKY T�J��R ACORD 25 (2001/08) © ACORD CORPORATION 1988 a CARE) ® CERTIFICATE OF LIABILITY INSURANCE s (MWDD ) 9/28/2009 PRODUCER (413) 935 - 1200 FAX: (413) 567 - 5300 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION , Berkshire Insurance Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 138 Longmeadow St. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9m ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 1 Longmeadow MA 01106 INSURERS AFFORDING COVERAGE NAIC # INSURED — — — INSURER A All America -,_ ^ 20222 - - - -- Dan Whiteley Inc. INSURER B: Central Mutual Insurance Co 20230 52 Cottage Street INSURER C -- — INSURER D: — --- - - - - -- --- ----- - - - --- EasthamRton MA 01027 INSURER E: - - —� - - -- COVERAGES 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, TTIE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDRIONS OISUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR kNSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POUCY EXPIRATION - -- - - — DATE IMMIDD/YYYYI DATE (MINUDDIYYYYI OMIT GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY - PREMI E TO RENTED REMISES (Ea oaaarence> $ 100,000 A CLAIMS MADE [X OCCUR CLp 7938625 7/1/2009 7/1/2010 MEDEXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1, 000 GENERAL AGGREGATE $ 2,_000 GEN'L AGGREGATE UNIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,_000 , 000 X POUCY 8 LOC AUTOMOBILE UABIUTY ANY AUTO (�� COMBINED SINGLE $ 1,000,000 B ALL OWNED AUTOS BAP 8616026 7/1/2009 7/1/2010 BODILY INJURY S 20,000 X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY s 40,000 X NON -OWNED AUTOS - - - - -- — PROPERTY DAMAGE S 5 , 000 (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ — ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABIUTY EACH OCCURRENCE $ 1 000 - OCCUR I I CLAIMS MADE AGGREGATE $ 1 , 000 E B _ DEDUCTIBLE CXS 8376975 7/1/2009 7/1/2010 - _ S X RETENTION $ 0 $ B WORKERS COMPENSATION X STATU- OTH- AND EMPLOYERS' UABIUTY Y / N T ORY LIMBS ANY PROPRIETORIPARTNER/EXECUTWE EL EACH ACCIDENT $ 1 00 000 OFFICER/MEMBER EXCLUDED? N I r (Mandatory InNH) WC 7938626 7/1/2009 7/1/2010 EL DISEASE - EA EMPLOYEES 1,000,000 H yes, desalbe under — SPECIAL PROVISIONS below EL DISEASE - POLICY LIMIT $ 1 , 000 , 000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Electrical Wiring CERTIFICATE HOLDER CANCELLATION tetowne@ aol . COm SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION Towne Builders DATE THEREOF, THE ISSUING INSURER WILL. ENDEAVOR TO MAIL 10 DAYS WRITTEN 75 Parsons Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Apt V Easthampton, MA 01027 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Norma Laforest /NJ ` - --- ACORD 25 (2009/01) ®1988 -2009 ACORD CORPORATION. All rights reserved. 1NS025 (200901) The ACORD name and logo are registered marks of ACORD ACORN, CERTIFICATE OF LIABILITY INSURANCE I aA (MMOON YY PRODUCER (413)586 -0111 FAX (413)586 -6481 CAD CONFERS IS ISSUED ED A RIGHTS UPON O F CERTIFICATE Webber & Grinnell Ins. Agency, Inc. ONLY 8 North King Street HOLDER. THIS CERTWICATE DOES NOT AMEND, EXTEND OR ng ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northampton, NA 01060 INSURERS AFFORDING COVERAGE NAIC # Its Theodore D Towne, Inc. INSUmJtA: NCI Insurance Company 14788 75 Parson Street, Apt V INSURER a Easthampton, RA 01027 -2529 IBC INSURER D: INSURER E: COVERAGES 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, TIE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. p{,�N TYPE OF POUCYNLMBER SpT �YY) UNITS GENERAL UABLITY CPF67106 05/26/2009 05/26/2010 E00100amMcE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES P (E l oc urrence) $ SO CLAIMS MADE n OCCUR IM P. EXP (My one person) $ 5 000 A - PERSONAL & ADV INJURY $ 1, 000,000 GENERAL AGGREGATE $ 2,000,000 GEM. AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/0P AGG s 2 , 000 , OOd I POLICY f n LOC UABILITY COMBINED SINGLE LIMIT ANY AUTO $ � - ALL OWNED AUTOS BODLY INJURY SCHEDULED AUTOS (Per Person) s - HIRED AUTOS _.._ BO00.Y INJURY $ NON-OWNED AUTOS {Per accident) PROPERTY DAMAGE (Per accident) GARAGE LA WRY AUTO ONLY - EA ACCIDENT $ - ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS IUMBREIJ.ALIABILITY EACH OCCI $ OCCUR n CLAIMS MADE : AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION ZY 1 a AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PA RTH€ERJEE7EECUTIVE Y ( t " I � E.L. EACH ACCIDENT $ OFFI ERIhEMBH2 EXCLUDED? ( (Mandatory o y in NM EL. DISEASE - EA EMPLOYEE $ . • MS below E L DISEASE - POLICY LIMIT $ CITHet CEICRIMON OF OP@ W11ONS/ LOCATIONSIVETIExCLUS1OMSADD ED BYENDOR YTI SPECIALPROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOME DEBC EED POLICES ES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WLL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIIIBLITY OF ANY KIND UPON THE Imo, ITS AGENTS OR REPRESENTATIVES. * 0 * 0 * Evidence of Insurance 0 * 0 *0 AUTHORIZED REPRESENTATIVE 5� .�.; --- I Jenne Rodrigue, CISR/3ER ACORD 25 (2009101) 1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • 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 excess 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 — -- permits_in- conjunction.. to- the- buildinng permitissued, 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 Massachusetts = Department of Industrial Accidents 1 = :41 l Office ofInvestin ations • • op= k� 1.--, g 600 Washington Street Boston, MA 02111 ,. . ' www.massgov /dia • Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 'TO (A✓ 4 (fit, i L p E R s Address: 7 5 Pf4R S6 N 5 17: , City /State/Zip: E`R S T I�fi'hr Pro N , !'Z 1 . o (6y Phone. #: 6 ->` - 906 t7 -- q -6 p4 Are you an employer? Check the appropriate box: Type of project (required): /' 1.0 I am a employer with 4. 14I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors • . ❑New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have. no P'i p1oyees These sub-contractors have 8. ❑ Demoli ion working for me in any capacity. employees and have workers' 9. 0 Buil�li addition [No workers' comp. insurance comp. insurance_$ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am omeowner -d ing-all work oLuc_ers_havc �c_ cied, then —U.-El-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 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. I 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: N 6 /f1 Policy # or Self-ins. Lic. #: / L{' '7 FR Expiration Date: ..5 d ( .1 O Job Site Address: ?? s City /State /Zip: -• ;�„ Attach a copy of the workers' compe < nsation 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. to 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 infornsation provided above _Lttrue_and_correcG - -_ _ Signature: - G=wy+C Date f S . /6 _ Phone #: Official use only. Do iiot write in thie.area, to be completed by city or town offtciaL City or Town: Permit/License # Issuing Authority (circle one): -'1. Board of Health 2. Building. Department 3. City/Town Clerk 4 Electrical I • ector 5. Plumbing Ins. ector _ __ 6. Other Contact Person: Phone #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: q Not Applicablle ❑ Name of License Holder : .��' >'#4PYZ( CJ o [ ` 1^4.1 License Number �// � / i J Address Expir�ti Date Signature Telephone 2 ./4-4 4 -1 1 " ( %at) 741r-tila- 9....Recjistered:Honie hnpiouemerittonicaetor .. . ,., Not Applicable ❑ Company Name 2 Registration Number 7 -WYIe. 1 X4.3: /4 /l/J L 12 / C7 Address p Expi ion D to 75 ��,p,r -' Telephone S27 -/06 at Z c� q 3 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 X No ❑ _T_he_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 ort arnpton *romance a e . • • . • " . ... • - -s-General-Laws-Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition [ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. El Demolition El New Signs [D] Decks [C] Siding [D] Other [D] Brief Description of Proposed r • Work: Or X t ri Alteration of existing bedroom _ Yes X No Adding new bedroom Yes k No Attached Narrative . Renovating unfinished basement ' Yes No Plans Attached Roll - Sheet Ga if NevitIlous aricitr 'additiorrto e�tisfiEnq tioerslnq cvrri(ilete`ti f ©lfo vrng: a. Use of building : One Family n Two Family Other b. Number of rooms in each family unit: Number of Bathrooms a c. Is there a garage attached? N0 d. Proposed Square footage of new construction. 8, . Dimensions 7 X ( e. Number of stories? 0. -ne- f. Method of heating? ' 1_____ Givc. Fireplaces or Woodstoves /V, Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 2/i,.,„, i. Is construction within 100 ft. of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes X No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? A 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 , 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 - 124 tg as j 7Authorized 9 A ent hereby declare that the state and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under t pains and penalties of perjury. Z Print Name 'TL�Gb d i.E -_p .w OL Signature of Owner /Agent Date ' 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.. ._ __ _ __ _,. ___....__ _._ w . .. Setbacks Front - � Side L :µ i. :_ __ L' ___ R:_ Rear :.___..2 Building Height Arlif Bldg. Square Footage % f ? 7 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 �) DONT KNOW 0 YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW _ YES 0 ~ IF YES: enter Book' i Page! ` and /or Document tt 4µN; B. Does the site contain a brook, body of water or wetlands? NO 1,a4 DONT KNOW 0 YES 0 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: ? __a .. -- - - DT AF t ere any propose• c anges to or a' •itions of intended` or t1i property ? YES 0 NO cfp 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ,De aCimebti i3ra0t City of Northampton ism ,7 :44i# z i, Building Department Cxt m , D e * a r 4" t r` 212 Main Street $a „ ? , ors ar � , v pt W h� x f Room 100 a o f i f, "' — 2010 Northampton, MA 01060 - . , . ,:% - ¢ 144 i- 14 0 phone 413- 587 -1240 Fax 413- 587 -1272 to � � � 00 y3� 4 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 17 la Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: __ __________ __11%.t!th.,_ a'LX/4f,- ? , '2 P7a.-7) y.,,i , Name (Print) Current / Current Mailing Address. PA i4 �d L l C ct-1 Telephone Signature 41A.449,__, . ,VJ 2.2 Authorized Agent: `- p v /4_ p� R 5 7,-. 1 A 40 41 Name (Print) Current Mailing Add ess: zqc-‘rif IC.:---- Signatu Telephone .5 o&a — A4.4-- Qi SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building bO (a) Building `Permit Fee 2. Electrical LITO (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee / * 4. Mechanical (HVAC) 5. Fire Protection a 019 r-- 6. Total = (1 + 2 + 3 + 4 + 5) <<j' a S6 Check Number ° �J5 0 . This Section ForOfficial Use Only Date Building Permit Number: Issued: Signature: ...� �� -v' / i 10 Building Commissioner/Inspector of Buildings Date ' 2 RYAN RD BP-2010-0650 GIS #: COMMONWEALTH OF MASSACHUSETTS Map :Mock: 35 - 154 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 -0650 Project # JS- 2010- 000946 Est. Cost: $5250.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THEODORE D TOWNE 000724 Lot Size(sq. ft.): 14244.12 Owner: ASCHER PAMELA Zoning: SR(100) / /WSP II Applicant: THEODORE D TOWNE AT: 792 RYAN RD Applicant Address: Phone: Insurance: 75 PARSONS ST APT V (413) 527 -9060 WC EASTHAM PTON MA01027 ISSUED ON:1/8/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT FULL BATH 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 1/8/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo