23B-079 (6) v LIIA► ,
ace group WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S62UB- 4598P38 -1 -12 )
RENEWAL OF (6S62UB - 4598P38 -1 -11
INSURER: ACE AMERICAN INSURANCE COMPANY
1.
NCCI CO CODE: 80500
INSURED: PRODUCER:
AXIOM LANDSCAPE AND HOME FINCK & PERRAS INS AGCY
IMPROVEMENT LLC 6 CAMPUS LANE
40 PINE VALLEY RD EASTHAMPTON MA 01027 -1430
FLORENCE MA 01062
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 04 -17 -12 to 04 - 17 - 13 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) 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: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
0.
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
ate_
asp
D. This policy includes these endorsements and schedules:
o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
0=
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY .
DATE OF ISSUE: 03 -20 -12 CB ST ASSIGN: MA
OFFICE: ORLANDO DA ACE 24M
PRODUCER: FINCK & PERRAS INS AGCY 28NJK
005355
City of Northampton
Mass achusetts` ►. = 3r'
t' DEPARTMENT OF BUILDING INSPECTIONS ,,. to
f 212 Main Street • Municipal Building � � y . n �"
Northampton, MA 01060 �'yy � ',
INSPECTOR
Louis Hasbrouck Chuck Miller
Budding 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, 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
— —
Office of Investigations
a- 600 Washington Street
''" Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): Ay t a m 1. elifc 4/c /7,7c/ NCse e • ru..f'47 (4 f LLB,
Address: /� 14 l'�t
' P'/► ,; E4 l /
City /State /Zip: PU!Pn cP t /47 00 t z Phone #: 11 /3 5 5 - 9 C
Are you an employer? Check the appropriate box: Type of project (required):
1I am a employer with Li 4. ❑ I am a general contractor and I
ff * have hired the sub - contractors 6. ❑ New construction
employees (full and/or part- time).
2. ❑ I am a sole proprietor or partner- tt listed on the attached sheet, 7Remodeling
ship and have no employees These sub - contractors h ave
p 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.
$ 9. n Building addition
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
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
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.
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.
r
Insurance Company Name: / k r / s
Policy # or Self - ins. Lic. #: C+ S 6 2 X1 - 1 IS9g P35 - / - / Z Expiration Date: `//17/ /3
Job Site Address: 6 2 Se 4 ri, Mi ►'n Str, r f ficn-te t fr/4 c /r,C,L 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 under the pains and penalties of perjuty that the information provided above is true and correct.
Si &Zature: , - - - Date: i /.3
Phone #: L 1 /3 - S4 _ G-- S'�g' c,
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : , 41i S 1 Pit `/, f C s — /o ' 373
License Number
II 6) P /// £ w , / / < 'r'lce /4 G /r.' ( 2 / 2 6/20/6
Address / Expiration Date
( �'
7/3— roc
Signature Telephone
9 wRegisteed Horrie1mproverrient Contractor C 7:17ZZaZIMZESITSSZ.Z:_:1 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 jd No ❑
it z- fume Owner,L Exemption
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
•
J
SECTION 5- DESCRIPTION OF. PROPOSED WORK (check all applicable)
New House ❑ Addition n Replacement Windows Alteration(s) Roofing El
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [O] Other [O]
Brief Description of Proposed
Work: hs i;,,p nj . .'l rn sf - +, �/
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa If New house:and or addition to exist nq housing; M oc m 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 FOR BUILDING PERMIT
e 1
,1n , as Owner of the subject
property
hereby authorize f/ d / c, P4//, l-r
to act on my behalf, in all matters relative to work authorized by this building permit application.
II� LO 13
Signature f Owner D
, 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 the pains and penalties of perjury.
Print Name
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 --- ,
Setbacks Front
Side L: --- R:
Rear ,
Building Height
Bldg. Square Footage , %
i .
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 (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 Page' i and/or Document # i
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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
0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
t ,
IF YES, describe size, type and location: 1
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.
D "�SB eai Use orl - t it
City of Northa ' `w � � af I � x tN
. Building Depa rtment `
urb,2'u �rlu wa e0:.: #0i, t w - 4
212 Main Street � S :p c �'�ailabtltt t r
Room 100 ���9� ���������
r Il A ;adabil �- ��.�r�.� � � :��
Northampton, MA 01000 ®fi rat ura p �;
phone 413- 587 -1240 Fax 41 5871�P� z' e the a
p
Or;p ecify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMIL DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completetl by = office
Su Vi I'll I" [1 r/1 �f � ( t f'a x : , Lot a . r UT�It a k
' ,r fai -s t -' ' - , '! x ,A ;i „ a . z ~*.:: ka . r f
F(v, c f '114 0 /' c Zone s Overlay Dt �,. •
;_E St. . _District CB District
SECTION 2 - :PROP OWNERSHIP(AUTHORIZEDAGENT
2.1 Owner of Record: M
GFace Lirl Z St� l "I�o,� �firc � r I r ��� / t'
Name (Print)
, �� e - U
( ) Current Mailing Add
C___ Telephone
Sign re
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
S ignature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
,, : ,_,,,,,, , ‘ i ,,, , , ,
Item Estimated Cost (Dollars) to be Offi use , 061y
completed by permit applicant
1. Building Ch /5 ( a):Building "'PermitFee
)
( b
2. Electrical Estimated To
xs t al Costof,'�
��
Construct fr om (6) " -',, - ,
3. Plumbing B u ilding Permi Fe e
l Sv u
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ji / l) Check Nu ;. %.
- ` Section For Official Use Only -
Date
Building PermitNumber: . Issued
Signature:
13 uilding Commissioner /Inspector of Buildings `' Date
•
File # BP- 2013 -0698
APPLICANT /CONTACT PERSON ALISHA PHILLIPS
ADDRESS /PHONE 40 PINE VALLEY RD FLORENCE (413) 586 -5986
PROPERTY LOCATION 62 SOUTH MAIN ST
MAP 23B PARCEL 079 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out //% (X ,
Fee Paid
Tvpeof Construction: INSTALL GAS FIREPLACE INSERT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 106378
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOXVIATION 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.
62 SOUTH MAIN ST BP- 2013 -0698
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B - 079 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: FIREPLACE BUILDING PERMIT
Permit # BP- 2013 -0698
Project # JS- 2013- 001154
Est. Cost: $11150.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALISHA PHILLIPS 106378
Lot Size(sq. ft.): 10585.08 Owner: LIN GRACE
Zoning: URB(100)/ Applicant: ALISHA PHILLIPS
AT: 62 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
40 PINE VALLEY RD (413) 586 -5986 WC
FLORENCEMA01062 ISSUED ON:1/23/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL GAS FIREPLACE INSERT
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 1/23/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner