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'•-...,,.Ni ty j/"‘ \ / ..., WORKERS COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE POUCY—INFORMATION PAGE INSURER: POLICY NO: WCF5898Y NGM INSURANCE COMPANY 4601 TOUCHTON ROAD EAST SUITE 3400 NEW BUSINESS JACKSONVILLE, FL 32245-6000 NCCI Company No: 16322 Account No: CACF589SY ITEM 1.NAMED INSURED AND MAIUNG ADDRESS: AGENCY NAME AND ADDRESS: AXIOM LANDSCAPE & HOME FINCK & PERRAS INS AGCY INC#2 (SEE NAMED INSURED ENDT) 40 PINE VALLEY RD 6 CAMPUS LANE FLORENCE MA 01062-3600 EASTHAMPTON, MA 01027 AGENCY PHONE NO.:,(413) 527-5520 AGENCY NO.: 200294 LEGAL ENTITY: LIMITED LIABILITY COMPANY OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) ITEM 2. POUCY PERIOD: From: 04-17-2013 To: 04-17-2014 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM a COVERAGE: 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 liability under Part Two are: Bodily Injury by Accident: $ 100,000 each accident Bodily Injury by Disease: $ 500, 000 policy limit Bodily Injury by Disease: $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: all states except ND, OH, WA, WY and states designated in ITEM 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Please see Classification Schedule. Total Estimated Minimum Premium: $ 320 Annual Premium: $ 855 j 71 3 Audit Period: ANNUAL Date: 03-06-2013 Countersigned by WC 000001 A Copyright 1987 National Council on Compensation Insurance (41.)VV0 A‘.1-/` cdi41 l c AGENT COPY =Er The Commonwealth of Massachusetts print Firm Department of Industrial Accidents * ) Office of Investigations y�l 1 Congress Street, Suite 100 .ifit Boston, MA 02114-2017 tk -t www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A ric w, L,,tiaSCiPx f 14 0,4 1.1-,-,-(/NI N f /--/-6-Address: `/v P1■t U //r, If2G4 vl _ City/State/Zip: 'iuq,4,e" /4/4 0/(4,2_ Phone #: V/3 - $ - .5 4)-G; Are :u an employer? Check the appropriate box: Type of project(required): 1. A I am a employer with L1 4. ❑ I am a general contractor and I employees (full and/or.* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.,Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' g Y p tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.11 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. Insurance Company Name: 416/✓1 .J'i S.,M 1 c L Policy#or Self-ins. Lic. #: l,"'C.F 5551 b7 Expiration Date: "f--/7- l'I Job Site Address: t Z 5"c-1.4 /r1't,A Si ris,l„4f nd oluL 1 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 tlJ,pains and i enalties of perjury that the information provided above is true and correct. Signature: �`� .._ Dated c, ziI s3 Phone#: Ll13 C-S4 ` S-9`64 / 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: !71 i S L t PI , /J y s l..-J - /063 .1 . Q i / License Number Liv 0144_ ��1/ie gi�:,�> f !U,-(ticr n G/OG z Zf Z_-6/z '/ Address / Expiration Date `113 S-Csc Signature Telephone ti 13 _ 3 ZG _ 4c 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address / Expiration Date (f I. ( Vc /l7- /2bcc/ N4 v1Gf,LTelephone L1' 5—056 - $L 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 buildi g permit. Signed Affidavit Attached Yes No ❑ 11. — Howe Owner 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 _ SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing n Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [U Siding[0] Other[0] Brief Description of Proposed, �/ J Work: ¶� ri�L1 A. Mua/f�✓M E✓-° h g� �y ff<<�.t t,-GII rhaf C7,..h2 AlmOffe4" Alteration of existing bedroom Yes No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes > No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete 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 I, GrGC4 G,`rt ,as Owner of the subject property hereby authorize /4-1iSL., Ph //,0.' to act on my behalf, in all matters relative to work authorized by this building permit application. 2---: S/2 ,e(l/F Signa e of Owner Date Gcc l-,V,.t ,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. G:a c C. Print Name /f/ 2� a/ Signatur- .f 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 P f 45-1/ Sry Frontage Setbacks Front I f, Side L: ? - R: 1.1_ L: R: Rear (1' Building Height Bldg. Square Footage 2 '1 �I % 2 2 / srF� , Open Space Footage % y (Lot area minus bldg&paved ' 701 parking) #of Parking Spaces lotn Poi k.4 (1 , t c,• (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO t I DON'T KNOW 0 YES 0 IF YES, date issued:.. IF YES: Was the permit recorded at the Registry of Deeds? NO (3 DON'T KNOW ® YES 0 ...... ..._ IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ►4,4 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 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES NO per IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES i NO IF YES, describe size, type and location: 'i!! E. Will the construction activity disturb(clearing,gradin., exc ation,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. Dep&rtmnt use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit u 20[3 I 212 Main Street Sewer/Septic Availability Room 100 Water/Weil Availability DEPT OF BUT: orthampton, MA 01060 Two Sets of Structural Plans NcRTHnti;P3uv,w. o ne 4 3-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 1e� S`14r1) M�iin S1 Map Lot Unit /v/ro z t "1,1- 0/6 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: lJ/mact l_,', L, l S�fnrL /11tiin 3-/ F/v'rsrr lift/e 41/612- Name(Printl, Current Mailing Address: Telephone Signs e 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building /q.uc (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of 410U Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 4 Ivey 5. Fire Protection 6. Total=(1 +2+3+4+5) i► U1 Check Number lda /5 1 / a4 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2013-1186 dk APPLICANT/CONTACT PERSON ALISHA PHILLIPS 76dii` Vi ADDRESS/PHONE 40 PINE VALLEY RD FLORENCE (413) 586--f5986 / �evl PROPERTY LOCATION 62 SOUTH MAIN ST p `P p am MAP 23B PARCEL 079 001 ZONE URB(100)/ 1 THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ��� 6.47-Fee Paid Cv Typeof Construction: ADD MUDROOM DOORSTAIRS/OVERHANG TO CREATE MUDROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106378 3 sets of Pla• ' of Plan THE F• OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON i F' ' ATION 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 :-,.lon R-la -7 " /„.- Z(-7Z-- —7 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-2013-1186 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: renovation BUILDING PERMIT Permit# BP-2013-1186 Project# JS-2013-001948 Est.Cost: $21000.00 Fee: $126.00 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:6/19/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD MUDROOM DOORSTAIRS/OVERHANG TO CREATE MUDROOM 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 6/19/2013 0:00:00 $126.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner