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29-601 05/10/2013 12:18 4135686708 ROGER BUTLERINS PAGE 01/01 .4om CERTIFICATE OF LIABILITY INSURANCE DAo�r,o 01 _ 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 pollcy(Ies) must be endorsed. It SUBROGATION IS WAIVED, subject to the terms end eonditlone of the policy,certain policies may require an endorsement. A star'ment on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Phone: (413)562-2304 Fen: (413)586$70B CONTACT Agency,Roger Butler Insurance A en Inc. �..-,. NnME:------- g g ROGER BUTLER INSURANCE AGENCY,INC_ PHONE (413)413 582-2304 IFAX.,Iu°):—(413)568-6708 5 COURT STREET!P O BOX 816 '— -- (nc I nfo@rbutiarl ns.com WESTFIELD MA 01086 nobREea;. ., ..._...--.-------------_-----...------,-,-- �IiP4UCER 10423 CUSTOMER io: — —...----- Agency Lice 17E0920 INSURERS)AFFORDING COVERAGE NAIL N INSURED IesURE�A_' A I M MUTUAL STATEWIDE HOME IMPROVEMENT,INC. C/O JOHN GORDNER . INSURER e : _ — P.O.BOX 888 INSURER c : WESTFIELD MA 01086 INSURER D: INSURER E INSVRER F doVglitAdli CERTIFICATE NUMBER: 18070 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, ,.. ' •� -,P •AP •1 • . "„ I■■ .• ■,- •. - , . I I : II - 1l INRR TYPE OF INSURANCE A001 BURR POLICY NUMBER POLICY EFF POLICY EXP LIMITS QTR ...._.._ INBR YWO . .. IMMmoYtry) _rMM/DDMNYJ- GENERAL, LIABILITY EACH OCCURRENCE $ AMAGE TO RENTED COMMERCIAL GENERAL LIABILITY $ ._, PREMISE/11ER amor°nac MED.EXP(Any one person) 8 CLAIMS-MADE OCCUR PERSONAL$AM/INJURY a GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PEP; PRODUCTS-COMP/OP AGO $ POLICY ,IECT ' LOG S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Es accident) • ANY AUTO— BODILY INJURY(Per person) $ ALL OWNED AU1 OS BODILY INJURY(Per accident) y SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) NON-DwNF.D AUTOS $ ,UMeaELLA Lino .00CUR EACH OCCURRENCE g IEXCEBB LIAB CLAIMS-MADE AGGREGATE DEDUCTIBLE 8 RETENTION $ 6 A INOeNERS cnnnn@unATIGN AWC4007020547 01/18/13 01/18/14 EACH i AND ISMPLOYF RS' LIABILITY YIN ANY PRDPHILIOHIPAR NER1EXF,CUTIVE E.L.EACHACCIOENT 100,000 °emcee/ EMBER EXCLUDED? 7,Nra E.L.DISEASE-EA EMPLOYEE g 100,000 IMmdet°ryIn RHl _,_._.._, .-........_ Ir Ma,doncrll>re nndnr E.L.DISEASE-POLICY LIMIT 500,000 DESCRIPTION OF OPERA reoNS brio. AS -_ $ DESCRIPTION OF OP ERA-rIONS/LOCATIONS,VEHICLES Attach ACORD 101,AdditI n■I Remadta Schedule,If more space le required) THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JOHN GORDNER CERTIFICATE HOLDER CANCELLATION- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 212 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. NOrthampinn MA 01060 ALITNOFIIZED REPRESENTATIVE Attention: Ate amen ACtM 26(2000E) ©1988-20Dg ACORD COf;;AORATION. All rights reserved,- The ACORD name and logo are registered marks of ACORD 4161.010•0110111110111111111EMIN iptiolpocat veristrimonewM1110111111MIle 1•1100.1101\ /1-------w---STATEWIDE HOME IMPROVEMENT INC. Since 1954 P.O. Box 888•23 Wintergreen Lane WESTFIELD, MA 01086 CSL 91979 (413) 568-7262 HIC 149510 P _rOPOSAL SUBMITTED TO TPHONE ---1-DATE t „„ ,7-- .,''''''' 1 4'f/..L....,..3;1(_,z'f.4Z) 1:6-,-W ( Ar3On. 0 ...:!=2--S 1 TREE''' A 4 JOB NAME -- ---- i te?')1? r e'''..YC /7 p i''" ,„, .7..... ;..) _...4 t_. „rr _ c STATEand ZIP CODE Tr 11 JOB LOCATION ARCHITECT DATE OF PLANS JOB iiiONE------ , ...---..„ ravage.............".1 We hereby submit , , andlestinvates for (--7,"///..) 1 -26 if-Y7itetzl- ,- . „ e.se, submit Y Lotto(4,_ e-- bt..14.1-17 c il:,;•6,t, la 4'ilk 17:74 - -/ „yip e'.,•:Asti:. .,.::-, 1:4_,A i (40 . , , / , . l, _Li. . _4/ ,2,„ „, ,- ,„,, Al ( -/i - ,....,ert-tf.„(t..., ......„ 26 de 40/7„,0,..1 e./..,..,) .,/ _(-6, - „i' .......: 7 , i „..., 1 (4)67/c.x..; c. 6/1., ,,,,..„4-7 it/ ‘,...„, // 1/7.„7,/9( ,.-,--) 7 —, -- / 1.. , , ,,./ /Le. . . y r nif L., , /, , ,„,, You may cancel this agreement if it has been consummated by a party thereto at a place other than an address of the seller which may be at his main or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. _ a............... ...... ..... .A0.. rrowastwawnesbe...1 to p o i ii p rf/I I e of: er,..) L ,,, ,....,,a 1-.7 c, . ..„,„, .„J.‘ ..' (1 i , _-1/ , ..... ,. cei 5:47,2\ . ..._ r (.., 1 ) c P .4 .. ,,...)......-„x,....,, 6-„i.-: „, ,,, (.e.-. dollars($...2_,'.1......... .1......,L--:_.........._........_). Payment to be made as follows: — --- — —- ,-,,- - — Al materislaoxli%aranteed to be as specified.Al work to be adapladia k a wariaaafake Authorized ‘,.--,. ..-- .."./.. to standent pictices.Any alteration or deviation wont above spodfications Signature ..- invohring extra coats MN be executed only upon written ostlers,and will beans an extra 7 — chime over and above the estimatejoAll agreements contizontiheuron strikes,insacucirtegs New .. 71 be gur workerabe"aireld:Jui rty covered by Worime:nrY's Cerapensation'neurones. ' withdrawn. . ' , --- .,.,'• days ... , 21tteptanct of Vr—all -The above prices,specifications and signa,...._ ,i '',,,,.,' " ,,,,/ ?''„p 'r ,' .,..,,',,:-.7 ) conditions are va„_z hereby!mod.You are authorized to do the work as spedlied. 2 i' ./7/914i'd '----- WM'IL Signature t„ ' . . / "" ., . Date of Acceptance: ...., ........,..... ....'.2___ __________ ,. / L ......, rya . City of Northampton „; r�, S15 °`a.` . liot Massachusetts J r . " , r,t ?1 DEPARTMENT OF BUILDING INSPECTIONS f sue• r 1' 212 Main Street • Municipal Building J r�C. .'� Northampton, MA 01060 °15sbjy , 1t(6 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 tie/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 =AM' :4. Office of Investigations 11ll= ,,, � #' 600 Washington Street .. .= TM' Boston,MA 02111 -4O www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ,____,_ Address: City/State/Zip: Phone#: Are ou an employer?Check the appropriate box: Type of project(required): I am a employer with 4. El am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 111 New construction 2.❑ I am a sole proprietor or partner- ors listed on the attached sheet. 7. ❑ Remodeling These sub-contractors have ship and have no employees 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ 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 12Roof repairs insurance required.] t c. 152,§1(4),and we have no r . j q ] employees. [No workers' 13.0 Other Tsai s-i-ef ESA iA (O 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: 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 elate). 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 here certify u r the p ins d penalties of perjury that the information provided above is ue and correct Signature: Date: 7-8 Phone#: 1-#?'��9's l2 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: C;L iO l r) (97? License y umber / iE 774 1 nfA /off /0/43 Address / / Expiration D to /—: S/1`—�Zc/f Si.nature Telephone .a �seredloaea is�:rovemen'Coritra o�.`=` _„ No Applicable ❑ ' 0-1 l o(we 1 m e- Yol► ov Ervt f /cR 70 man Name � /�� Registra' n Nurser Address Expiration Date Telephone--c7! /24// SECTION• 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M G L c.x152,§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 =� om• Owne.1 h.,:e pt on 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable) „ . New House n Addition ❑ Replacement Windows Alteration(s) [] Roofing X Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[0] e Brief Wok escri apO propose - I-p E c j_1 r `_ Alteration of existing bedroom Yes No 4(J Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet a e Quse-arndior iddit on:t `"xisu ilic Horrstn'•':iro p e e the:oll`owi g: 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 t OWNERS AGENTrOR CONTRACTOR APPLIES FOR,BUILDING PERMIT A.. I, ,as Owner of the subject property � ' hereby authorize S" fN[OE me ,0-eti nie-�l/� to act on my behalf, in all matters relative to work authorized by this building permit application. V9 i_g Signature of Owner Date I, .So1/4Nv■ 60P b)kre'G- , 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. _,..)dV\h 62hWE — rint Name „--— ez64-4_, -5- 9//,3 - Signa I re of Owner/Agent Date Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incorrplete Information „j-.,,_ t a if Existing Proposed Require;�l by Toning Thus col to be filled in by Building!Department 1 MN if Lot Size + i Frontage i i 1 Setbacks Front i ( = I— Side L: I ll.:i I L:1 I R:` 1 ____.__ t Rear Building Height = Bldg.Square Footage = % = 1 Open Space Footage _� % , (Lot area minus bldg&paved i i parking) #of Parking Spaces I - —_ _ _ W _ __ ______ Fill: i` (volume&Location) I A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT 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 Pages and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES l 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: l 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 I i i 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. • GEl\'r qty of Northampton stave S:, . :a -43 f, ��� � �' `Iding Department A� ® ,, �I t (i ' " _ ���� xT 12 Main Street � . Room 100 , ort ampton, MA 01060 • ` - o�Fo ,• :=' -- 87-1240 Fax 413-587-1272 ,a ��_ k APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING CI ,r b ° - a �3 O 1 SITE INFORMATION .E ection to be completed y offc . k ,4 1, Thrs s t� ,t �...STn g - a s O. ... k L�tItii:1,n . " -e :'�� '�, "y- t 1.1 Properh Address: µ � x' . '1 ttkt �a baS y � K r Q� * s '4, er"ay D stricti � ER����� ;: * 'w I m �� #' Distrc"t ::RSt Distr ct .. SECTION i,,PROPERTY OWNERSHIP/AUTHORIZED AGNT N. 2.1 Owner of cord: �, n� � • w (_.o�rSon S S-1o► �/ Name(Print) Current Mailing Address: Telephone Signature , 2.2 Authorized Agent: �0 Y\ 612 on, s- -b Ir7� r ..�, e. P o. R o�c w �iE,�P 1A 6u© Name(Print) Current Mailing Address.ci/g --'C-/9'--/2-41(Telephone -SECTION 3 ESTIMATED CONSTRUCTION COSTS _ Item Estimated Cost(Dollars)to be Official,Use Only completed by permit applicant l 1. Building 9.-X_c"---0 �- (a)Budding Permit Fee 2. Electrical (b)Estimated Total Cost of 'construe from(6) _a . =_ 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number �� -:This Section For Official Use Only Building Permit Number Issued:-,- Signature Building Commissioner/Inspector of Buildings Date • 58 STONE RIDGE DR BP-2013-1084 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-601 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-2013-1084 Project# JS-2013-001789 Est. Cost: $9850.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: STATEWIDE HOME IMPROVEMENT INC 91979 Lot Size(sq. ft.): 94089.60 Owner: CARSON KIMBERLY J&KENNETH E Zoning: Applicant: STATEWIDE HOME IMPROVEMENT INC AT: 58 STONE RIDGE DR Applicant Address: Phone: Insurance: P O BOX 888 (413) 568-7262 WC W ESTF I ELDMA01086 ISSUED ON:5/10/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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 5/10/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner