Loading...
31A-316 (7) AcGR° CERTIFICATE OF LIABILITY INSURANCE 11/5/2012 THIS kars ii 2O12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lynne Methot, Ext. 102 NAME: Foley Insurance Group Inc. PHONE (413)214-7474 (413)214 -7474 (A/C.NO):(413)214 -7447 37 Elm Street E -MAIL lmethot@fole insurancegrou ADDRESS: Y p . COm INSURER(S) AFFORDING COVERAGE NAIC # West Springfield MA 01089 -2703 INSURER A :Ohio Security Insurance Co. INSURED INSURERB:Safety Indemnity 33618 Safco Foam Insulation LLC INSURER C :Ohio Casualty Insurance Co. 126 Mountainview Road INSURERD: INSURER E : East Longmeadow MA 01028 INSURER F : COVERAGES CERTIFICATE NUMBER:CL12101606644 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS — LTR INSR WVD POLICY NUMBER (MM /DD /YYYY) (MM /DD /YYYV) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE EMI S(aEcurr 300,000 PREMISES (Ea occurrence) $ _ A CLAIMS -MADE X OCCUR BLS55295903 10/17/201210/17 /2013 MEDEXP(Anyoneperson) $ 15,000 X PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 X POLICY PRO- ri LOC $ .IFC.T AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 _ ANY AUTO BODILY INJURY (Per person) $ B ALL OWNED SCHEDULED 6218999 6/22/2012 6/22/2013 AUTOS X AUTOS BODILY INJURY (Per accident) $ X HIRED AUTOS X NON -OWNED PROPERTY DAMAGE $ AUTOS (Per accident) — Medical payments $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- C AND EMPLOYERS' LIABILITY X TORY LIMITS FR ANY YICEOPRIETOR /EXCLUDED? ECUTIVE N N N/A E.L. EACH ACCIDENT $ 1,000,000 (Mandatory in NH) WC55295903 11/10/2012 11 /10 /2013 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The certificate holder named below is included as an additional insured for general liability coverage for ongoing operations if required by written contract, permit, or agreement executed prior to a loss. CERTIFICATE HOLDER CANCELLATION j of f®greenspoons . COm SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Jeff Green ACCORDANCE WITH THE POLICY PROVISIONS. 45 Ward Ave Northampton, MA 01060 AUTHORIZED REPRESENTATIVE Brian Foley /LYNNE � � y°e-O � ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. INSn95 (9m ( - Inc) ni Thn ACARll nmmn nnrl Irwin aro ran icfororl mmrkc of At fPr1 EH F SAFCO Foam Insulation LLC SA Stuart Fearn President n 111 — A � — `�tisF • o� SPRAY FOAM INSULATION 126 Mountainview Rd Phone: 413 - 525 -3380 cell: 413- 265 -9029 East Longmeadow, MA 01028 Fax: 860 - 265 -3790 email: Stuart@SAFCOFoam.com QUOTATION To: Jeff Green Quotation date : August 27 , 2012 45 Ward Ave Northampton, MA SAFCO Foam is pleased to present this proposal for installation of the Icynene Insulation System for your home. The proposal included air sealing and insulating the areas listed below to the Icynene recommended performance levels and local building code approval. All dims are nominal. •+ Entire attic roof line of house, closed cell, 5.5" thick (R38) Gable end walls in attic where accessible, closed cell, 3" thick (R20) Investment for The Icynene Insulation System' : $ 7,224 Options: 15 minute thermal barrier coating over exposed spray foam insulation. Add: $ 2,600 Notes: Customer to remove sheetrock & insulation covereing roofline in utility room. Cutomer to remove stored items to make work area accessible Also included in this proposal are the following services: do All valuables and other items must be removed or otherwise protected in the spray area SAFCO is not responsible for overspray or foam on items left in areas to be sprayed •+ All preparation and clean up is included in the final price Quotation prepared by : Bob Podgurski Access must be available for a truck and spray rig within 20' of the building. All surfaces to be sprayed must be clean and free of dirt, grease, and oil. Work area must be free of construction debris and obstructions. To accept this quotation, sign here and return to SAFCO: Payment terms: 1/3 deposit to schedule, 1/3 due at start of job, balance due at completion. Hw City of Northampton - l -N Massachusetts .1 '; 5 = ,�' t >,, )) DEPARTMENT OF BUILDING INSPECTIONS .^ 6, 4. " 212 Main Street • Municipal Building �� `. a Northampton, MA 01060 i °"S't~ h 'O, INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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 permits in conjunction to the building permit issued, 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, - 14' re `.7 , 6-4-P C) .--, 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 ii / -.' / 71) / 7 Address of work location II S 0. aL bp-4 L1.... x , 4,1 M a (U 6 6 1 t • The Commonwealth of Massachusetts -`— Department of Industrial Accidents 54 gri- Office of Investigations a 600 Washington Street ma: " , Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): 6- n _ Address: L() c 4 City/State/Zip: \i , VA 01 1 ) 0 ) Phone #: 1 " 9 - 1 ' 1 3 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I 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. n We are a corporation and its 10.0 Electrical repairs or additions r I am a homeowner doing all work officers have exercised their 11. ❑ 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 4 4i employees. [No workers' 13 Other IA Sti I comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify t s and penalties of perjury that the information provided above is true and correct. Signature: Date: /l 7 t Z Phone #: Y�3 - 5 EN ` LO Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: A SECTION 8 - CONSTRUCTION SERVICES 6 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address - Expiration Date Signature Telephone `.':Registered .Home,Impcovement Contractor' y„ , .._ ,_ a� ; , ,. ; 7 , = , 1 , .._, Not Applicable ❑ SAFG'' Fe/ ^^ MA 4IC$ tout Company Name Registration Number 1 L(c M ovt-&+.„•^i ei-- ?" ° Address Expiration Date IZ. (-o ,Are - <c °lo.a 1 N\ / 0( O2' Telephone '4E3 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG 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 ❑ .,c. 'Home Owner.. Exemption 11 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 1083.5.1. 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 oca 'rig Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) PK1 Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [E] Siding ID] Other [D] Brief Description of Proposed Work: t el'* ek H'AL u i (i47 r-b0 aic q 1 I- IA 56( /a'F! vK v n4 140 d -ce.[l M Alteration of existing bedroom Yes (\ No Adding new bedroom Yes ){ No Attached Narrative Renovating unfinished basement Yes _ Plans Attached Roll - Sheet 6 1f New.;house and -or addition to existing housing,zamplete,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 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , 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 ..�. f t e ` ] T , as Owner /Authorized Agent hereby declare tI(at 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 perjury. re eo° Print Name Or I 7to /14 Si . er /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 - - Setbacks Front Side L: R: L R: �. Rear Building Height i Bldg. Square Footage I %^ Open Space Footage % (Lot area minus bldg & paved parking) t 3 # 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 DONT KNOW 0 YES 0 IF YES: enter Book i Page f 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 0 Obtained Q ,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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 'i OF BUILDING Departrn'r>at or11y City of Northampton Sta of I -e mi 3 { 4 4i V ` ��C ilding Department Curb�Cu nvew yPermlt �` F r 212 Main Street Sewert epticAya 5 "' J, il, E -z,'' iii - 3 its NOV 0 Room 100 Wateriwetl Av ,� N1[ No hampton, MA 01060 7w ofStructut I Plahs ; pho 413 87 -1240 Fax 413- 587 -1272 DEP Plot/Slte P ans T. IN Other Specify NORTHAMPTON, MA 010 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 1../ 5 GJ A �� A''.` M Lot Urnf 1 � r' i- Q . zone ` Overlay District :' (V EIm St. District " CB Distract SECTION 2 - PROPERTY OWNER /AUTHORIZED AGENT 2.1 Owner of Record: T AM 6e CTS y S 1,k) CA z A U f 0 Name (Print) Current Mailing Address: e-i t 3 =5`b if — I ( - 1 1 Telephone Si nat 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COST Item Estimated Cost (Dollars) to be Official Use Only a completed by permit applicant 1. Building l O C) 0a (a) Building 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) ( o �joO Check Number This Section For Official Use O nly " Building Permit Number: Date Issued:. Signature: " Building Commissioner /Inspector of Bu Date • File # BP- 2013 -0578 APPLICANT /CONTACT PERSON HASTINGS WILMOT R & JOAN L CIO JEFFREY GREEN ADDRESS/PHONE 45 WARD AVE NORTHAMPTON (413) 584 -1478 Q PROPERTY LOCATION 45 WARD AVE MAP 31A PARCEL 316 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filed out �'!�� Fee Paid j Tvoeof Construction: REMOVE UTILITY ROOM WALL, AIR SEAL & INSULATE ATTIC New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 169211 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION PRESENTED: pproved 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 7y,., r- ay 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. 45 WARD AVE BP- 2013 -0578 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 316 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2013 -0578 Project # JS- 2013- 000924 Est. Cost: $10000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SAFCO FOAM 169211 Lot Size(sq. ft.): 15115.32 Owner: HASTINGS WILMOT R & JOAN L C/O JEFFREY GREEN Zoning: URA(100)/ Applicant: HASTINGS WILMOT R & JOAN L C/O JEFFREY GREEN AT: 45 WARD AVE Applicant Address: Phone: Insurance: 45 WARD AVE (413) 584 -1478 () NORTHAM PTO N MA01 060 ISSUED ON:11/26/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE UTILITY ROOM WALL, AIR SEAL & INSULATE ATTIC 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 11/26/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner