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31A-024 (3) Y ttn>fp o c., :,�,TO, __ R � s `E Crif� of poi fI 1 �t11tpton I * —)= r�w`+ ), 1 �p �. j E . .alasexchrtcctfa —t 1.= DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, Mass. 01060 r WORKER'S COMPENSATION CNSURA.NU): AI'I AVIT . e- - -- 0i' vim -tta (li ccuscrJpermi ctcc ) v.ith a principal place of businessiresidencc at: A ft 0(°6° 1-G �i • n/ t'c,�- Gm /�6t Pn' 17) ho n c `) ' i2 J" - / L (sn ty /statchi p) Me- do hereby certify, under the pais and penalties of perjury, that r n 04 am an employer providing the followint worker's cornocns2.non covemge for any employees wor!ong on tins job: A ( k 4 yc 4v ital.t.row 4. ea { w12-evobitiga iZdl - 7 ID I t.? (IASw -._ucc Corn ny) (Pclic; Nuf r) (r= : Datc) ( ) I am a sole proprietor, general contractor or homeowner (c1sc e one) and have hired the contractors listed below v,'ho hzve the following worker's comoen aeon pohcies: (Name of Copt: acto-) (Ins!rancc Company/Folic,. NumLY:) 11-1 D,tc) (Name of Contrzctor) (Insurance Company /Policy prancer) (E ou-zuon Date) (Name of Contractor) (Insurance Company/Poticy tvumbr) (Espiruoo Date) (Name of Contractor) (insurance Compaay/Poli Number) (L-\pLrvtioo Date) ( o 'c+i addi:: oca.' c +xci if oc to c>:hv& inforav -boo p ruin 1g to all oacri.r_'. -or3 ) ( ) 1 an a sole proprietor and have no one working for me. ( ) 1 am.a home owner performing all the work myself. NOTE: ple_s. be awar t vt _te bocnno"vcra ubo cooploy peons to w r - • - :c on c R.,,I.0 work oa . d••�th g of act trocc thca t!- , till in wait the botmov re3ido or oa floc Esvanda o�p.:rtrwsr. tbcdn rT on( I n drolly occs:ducoi to be •ploy�s undo tbc d :1'3 c c itcc Act (GL 152 1(5)), a.ppli�tioo by a bommravcr far : 1.i v or permit rn:y c.idnox t t Irgal .tams of en croloyer under ch. Wortc,o.". CompocnaLiou Acc 1 .sodcsi...ad tha a copy of thi..>-•r may be foriv-mr-cie.d to ttw Dopam .tceu of lc>dutr,al Arocicci1 otf oo a of 4:. for the 4' coven c ve ifietioo and ttu f_ihn - e to roam coverage tr,des so Lion 25A of MOL 152 can Iee-d toth.: i OSdioa ofavvin-! penalties oocta iag of a f l o c of trip to S 1.500.00 a - t d f e x a a { u i s o u m e ri of up to ooc yr.= t a.il p i i ci to t form of a Stop Work Order and e Ern o(S I00.Q0. thy L pinst c IC-2 /je...----*■....... For cScp..- ten =:-mil u.c only /0//// L tit Narnbcr Iti�p;,_ I�tL — S' atun: of LiccnscrfPcnruttcc Dace INSURANCE This supersedes and corrects DATE(MM/DDJYYYY) A�+OR Binder B12030516257 03/05/2012 1 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. AGENCY COMPANY BINDER Webber & Grinnell Ins. Agency, Inc. Peerless Insurance B12030516258 T E 8 North King Street DATE EFFECTIVE TIME D TIME Northampton, MA 01060 03/01/2012 12:01 X � 03/31/2012 X 1201 AM PM NOON PHONE , 586 0111 FAX 13 . 586, 64 81 THIS BINDER IS ISSUED TO EXTEND COVERAGE (A/c, No EM (Nc, No _ IN THE ABOVE NAMED COMPANY CODE: 6200843 SUB CODE: PER EXPIRING POLICY # . AGENCY 00022778 DESCRIPTION OF OPERATIONSWEHICLESIPROPERTY (Including Location) CUSTOMER ID. INSURED Construct Associates, Inc. 36 Service Center Rd, Northampton, Ma 01060 Attn: Kim Clairemont 36 Service Center Road Northampton, MA 01060 COVERAGES LIMITS TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS % AMOUNT PROPERTY CAUSES OF LOSS Business Personal Property 1,000 80 50,000 BASIC BROAD X SPEC BI /EE Included 72 GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X DAMAGE TO COMMERCIAL GENERAL LIABILITY R ENTED PREMIE $ 300 000_ CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 00 000, RETRO DATE FOR CLAIMS MADE PRODUCTS - COMP/OP AGO $ 2,000,000 VEHICLE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) -; $ X SCHEDULED AUTOS PROPERTY DAMAGE j $ Included X HIRED AUTOS MEDICAL PAYMENTS $ 5 , 000 X NON -OWNED AUTOS PERSONAL INJURY PROT I $ UNINSURED MOTORIST $ 250/500 Underinsured $ 250/500 VEHICLE PHYSICAL DAMAGE DED ALL VEHICLES X SCHEDULED VEHICLES X ACTUAL CASH VALUE X COLLISION. _ 500 STATED AMOUNT ! $ X OTHER THAN COL _ 500 GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY; _. _.. _... EACH ACCIDENT $ AGGREGATE I$ EXCESS LIABILITY EACH OCCURRENCE $ 1,000,000 X UMBRELLA FORM AGGREGATE..__.. -... - .$ .__ 1 OTHER THAN UMBRELLA FORM RRO DATE FOR CLAIMS MADE SELF - INSURED RETENTION $ 0 ET WC STATUTORY LIMITS WORKER'S COMPENSATION - E.L. EACH ACCIDENT $ AND _.. __.. EMPLOYER'S LIABILITY . _ E.L. DISEASE - EA EMPLOYEE $ E . DISEASE - POLICY LIMIT $ SPECIAL CONDITIONS / __.,.. _.._ ... _ . �..... _... OTHER TAXES $ _ .___.. ... _... COVERAGES ESTIMATED TOTAL PREMIUM i$ NAME & ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS. PAYEE LOAN # �I AUTHOR /\ IZED REPRESENTATIVE L ) n n Richard Webber, CIC /BARBG ' � (u � l l Page 1 of 2 © ACORD CORPORATION 1993 -2007. All rights reserve' ACORD 75 (2007101) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803 (800) 876 -2765 NCCI NO 26158 POLICY NO. WMZ 8006549012012 PRIOR NO. NEW BUSINESS ITEM 1. The insured Construct Associates, Inc. Mail Address: 36 Service Center Road # 202 Northampton MA 01060 Street No. Town or City County State Zip Code FEIN xxxxx4920 ['Individual ❑Partnership Corporation ['Joint Venture ['Association ❑Other Other workplaces not shown above: 2. The policy period is from 07/01/2012 to 07/01/2013 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500.000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. 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. Classifications Premium Basis Rates Code Estimated Per $100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 092088 SEE EXTENSION OF INFORMATICN PAGE Minimum premium $ 500.00 Total Estimated Annual Premium $ 22,298.00 As indicated interim adjustments of premium shall be made: Deposit Premium $ 5,840.00 ❑ Annually ❑ Semi Annually ❑ Quarterly ® Monthly MA Assessment Chg. $25,278.88 x 4.2000% nn $1,062.00 This policy, including all endorsements, is hereby countersigned by 07/16/2012 Authorized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY Webber & Grinnell Insurance STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Agency MA 5437 8 802 8 North King Street Suite # 1 Northampton, MA 01060 WC 00 00 01 A (7 -11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. . , 1 RUCTION la> R tC 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 440b e /It/ " 79 d7.a License Number 76 Jr iA - Cebeide it4 IQ y - e - t s" , 0 Address 1 Expiration Date 4 Signature Telephone Si ( 9 „a n,....a .iiai®a ,f yii, , ,,F." ^..i.1,, - 'A. -` '`S t kEi6 T t , Not APPlioable ❑ i' t i4 3sve Company Name Registration Number t -1-1`4 Address Expiration Date Telephone sEC .O1 its 001 RS' CQMpENSA 1ON IH RNCE AF'EIDAViT (M4G L< 1$2,;€ 25 90 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 e No ❑ 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 Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning ' J / �.d � GJ'9' This column to be filled in by N�i O t✓�r ,( , o -� Building Department Lot Size , Frontage Setbacks Front 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 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO tV DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: , ECTION S ,gtESORIPngt4 OF f tROPIriSED WO1 K tcI ck all°applic ble) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] • Brief Description of Proposed Work: 4. CC ' - lJ ` • 1 2X & Ate e �} . o f r11, kg* (4 ` fl i U Alteration of existing bedroom Yes ✓No Adding new bedroom Yes ✓ No Attached Narrative ❑ Renovating unfinished basement Yes "�No Plans Attached Roll ❑ - Sheet ❑ a ue e - t ' .�° '1. 1. 1i! L'-,,,,,„i 1rii: r: 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. Mascheck Energy Compliance form attached? . 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 s d TIot4 l O VV R PA TH d ATIQ T BE C o m p D WHEN 1� OWNERS AAA OR C{NTRACY AP FOR Bin , G PERMIT / A '1*"- /44 c(� /d as Owner of the subject property hereby authorize 41v1,, 4 1"•• to act on my behalf in all matters relative to work authorized by this building permit application. G?. ----- 4 ,.,_,,L ,_.r. �-J /'o/ / 1 L— i n ature of Owner Date I, 41P. < J,14 , 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 th pains and penalties of perjury. Dal 2 Print Name ‘—'. /0/411 t--- Signature of ner /Agent Date • M , RECEIVED ity of Northampton OCT ti uilding Department OCT 212 Main Street �� ��_���, ����� Room 100 , , _ - �' � � 3 � x _ ,• , T ;,;,, QQrthampton, MA 0 p i1e 413 587 1 Fax 413 - 0106 587 1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING GcPT. OF BUILDING INSPECTIONS NORTHAMPTON, MA 01060 SECTION 1 -SITE 1NFORMAT O :air. ;}, { � 1.1 Property Address: R� �s g a dx ., } � 3,' e 9L r , Yyy z , , y a >,re�A nF x SECTION 2 PROPERTY: OWNERSHIP /AUTHORIZED AGENT s 2.1 Owner of Record: t i./16 »• ,1 Fc 00-‘4.14.t f a Na - Print) Current Mailing Address: ,.s—(,,r(7 , Z� ,,,, ""' Ao-uit,--..-J Telephone -ture 2.2 Authorized Agent: e -, , e .l e ,�6 f ' cam ,�v- C Nb t{ Name (Pant Current Mailing Address: 7/ A-'eti _ / ZL ‘f Signature Telephone SECTION =3 ,ESTIMATE CONSTRUCTION COSTS - Item Estimated Cost (Dollars) to be _ Official Use Only completed by permit applicant 1. Building �� (a) Bbi ti g.Permit Fee 2. Electrical (b) Est mated_ Total t Constr`uctiort fro (6) 3. Plumbing Budding Permit + e- r 4. Mechanical (HVAC) 5. Fire Protection - 1 + 2 + 3 + 4 + 5 ° Cheek: Number, 6. Total -c ) G . � � hIs S��io�t �'ar.Cf Use O ',T rly 3 � Bulidin milt Number` Date I ssued' I Signature: Building C.'?mrrttsstorter /Inspector of iaiidings Date'. File # BP- 2013 -0431 APPLICANT /CONTACT PERSON OLIVER ISELIN ADDRESS/PHONE 36 Service Center NORTHAMPTON (413) 584 -1224 PROPERTY LOCATION 42 FRANKLIN ST MAP 31A PARCEL 024 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Perm Filled out 9 Fee Paid Typeof Construction: REPLACE GLASS ROOF W/DECKING & SHINGLES New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 039073 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INRMATION 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 D o'••.n ► -I. y Si_ • e . Build' g 0 facial 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. 42 FRANKLIN ST BP- 2013 -0431 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 024 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2013 -0431 Project # JS- 2013- 000687 Est. Cost: $6000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: OLIVER ISELIN 039073 Lot Size(sq. ft.): 17903.16 Owner: SIMPSON MARIAN V H Zoning: URB(100)/ Applicant: OLIVER ISELIN AT: 42 FRANKLIN ST Applicant Address: Phone: Insurance: 36 Service Center (413) 584 -1224 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:10/17/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE GLASS ROOF W /DECKING & SHINGLES 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 10/17/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner