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36-085 (2) The Commonwealth of Massachusetts Department of Industrial Accidents arm 600 Washington Street Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit:Buildin lumbin lectrical Contractors name: address: city state: zip: hone# work site location(full address): ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole ro etor and have no one workin man capacity. ❑Buildinn Addition //% %%//%%%%%%%%/�%%%�%%%%O//%%%%/%%%%// I am an employer providing workers' compensation for my employees working on this job. comtiany name '' ooiw address. br . ettV t i`�/ phone insurttnce.co • �+ t T./ Tic .#' . t; �' f IM70 ❑ I ant a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers'compensation polices: company name address s. city - phone'#f instuisnce'co. comliany`name -- address- city, nlione#. . insurance.co DO he Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under Pe pains and pen o er• that the information provided above is true andicoor rre q Signature f Date % / Print name��T v5CX0�2J ¢O/� /G ✓�'/�O /✓��� Phone# 'Idyl' /c��—C� �� official use only do not write in this area to be completed by city or town ofncisi city or town: permitilicense# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (--ed Sept 2003) 04/29/05 09:04 FAX 16177709683 AMERICAN FIRST INSURANCE Z 001 Acoj?D CERTIFICATE 4F LIABILITY INSURANCE CSR 1 DATE(MMRID YYYY) NEWPR-1 T 04/29/05 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE American First Ins Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 122 Quincy Shore Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Quincy MA 02171 Phone-617-770-9000 INSURERS AFFORDING COVERAGE !NAIC ft INSURED - INSURER A: Arbella Protection Ins. Co INSURER B: Newwppro Operating LLC INSURER c: Wobuurn MA 6901801 NSUH R D: INSURER E: COVERAGES 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 WHCH 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXPIRAT LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/VY DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A X COMMERCIAL GENERAL LIABILITY 1 850000010649 I 01/01/05 01/01/06 PREMISES(Eaodourenoe) $50,00 0 CLAIMS MADE 1 X:OCCUR MED EXP(Any one personI $$,0OO PERSONAL&ADV INJURY S1,000,000 l GENEPALAOOREGATE ls2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG I s 2,OOO,O 0 0 POLICY PE LOG AUTOMOBILE LIABILITY COMBINE. B ANY AUTO 1 81037400001 12/31/04 12/31/05 (E..ocident)SINGLE LIMIT '$11000,000 ALL OWNED AUTOS I i I BODILY _ X SCHEDULED AUTOS (f PBr�.On) ..$ X HIRED AUTOS I BODILY INJURY $ NON-OWNED AUTOS i I(Per B=idWt) :$ "PROPERTY DAMAGE (P.,—derv) GARAGE LIABILRY AUTO ONLY-EA ACCIDENT S ANY AUTO I OTHEn THAN EA ACC $ AUTO ONLY: AGG S EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $5,000,000 A X OCCUR CLAIMS MADE 4600010709 01/01/05 01/01/06 AGGREGATE S 5,000,000 is DEDUCTIBLE RETENTION S WORKERS COMPENSATION AND X TORY LIMITS ER EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE 90967005 05/01/05 05/01/06 E.L.EACH ACCIDENT !$500,000 OFFICER/MEMBER EXCLUDED? I E.L.DISEASE-CA EMPLOYEE1$SOD,000 N yes,descPb.under - SPECIALPROVISIONSbelow E.L.DISEASE-POLK:YLIMIT:$500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS OPERATIONS OF INSURED CERTIFICATE HOLDER CANCELLATION SPECIME SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN (7E'.1" CERTIFICATE HOL AMEO TO THE LEFT,BUT FAILURE TO DO SO SHALL SPECIMEN O BL. ATION OR LI ILITY F A D UPON THE INSURER,ITS AGENTS OR SENTATIV S. UTHORIIED R NT T Samoa Farren ACORD 25(2001/08) ®ACORD CORPORATION 1988 ;fin. �omznzaaeaww�l�o�_ ��.attrre,/nreClt .%Ere(;anzma-reruerztl�i,�'.,�z'`r�,:xif�i+nleda BOARD OF BUILDING REGULATIONS - Board of Building Regulations and Standards License: CONSTRUCTION SUPERVISOR HOME IMPROVEMENT CONTRACTOR Number: CS 029090 Registration: 100020 Birthdate: 11/19/1953 Expiration: 8!82006 Expires:11119/2005 Tr.no: 9396.0 Type: Private Corporation Restricted: 00 ' NEWPRO,INC. THOMASP FOXON THOMAS FOXON 230 WALNUT ST ( ,� 26 Cedar St _ --r—, r �; READING, MA 018B7 Administrator Woburn,MA 01801 Administrator 04/26/2006 12:07 5088429248 NEIAPRO PAGE 01 MA Reg.#1000211 CT Aug,#517262 T}IPREPLrCP_MENTWIND(NJPEp'PLE t edoral ID#04,2714773 rnrnnrare lhnnrnrnrinn 7rr.,14m:r,r,0 rtnx7nnrl wmm�n.nnn nlwt,r/IIrnr;ngi.a mn ,•nnnanyyt5 THIS CONTACT MADE THE. JV /!n day of 200 1- hPiween, i e. �rnhG ! � (HA a Owner /� (Homo I=nnnnf taus,elwnaL �n of. ..Z�1 . . lfl'hys�pni/ . . bi PsnCf /�IGt Ulb� Z . . . (AddmnA) {31Afi1 (zip Codn) the"Owner"and NEWPRO,INC.,"NEWPRO". NEWPRO hereby agrem,that It will for the considerati0h heroinafrr;.r mentioned,furnish 111 labor and material necessary t0 Insr111 the folfowinq tlescrilm work at the promisor locar0d at TOTAL. NEWFRO Additional TOTAL CASH Wlyddws Purchase tl �� Style Qty Work PRLCE 1 '1y3 Window Color S _. p nciL .�!,.•��� _ Sliding Glass Door DEPOSIT Capping Color specify yG— Steel Security Doory y,„ Z 2 WITH ORDER UA Double Hung � TS Loaded Glass - Picturo Window J �_ Obscure Glass -_ _ _ BALANCE StatiOna GBSerinent f Screens — HALF FULL DUE AT . _. opi> N -- - (N$TALLAT'ION 2 LLte 3 Lile SlfdPr NEWPRO" doca nr do nn y palnlinq or_- :1tf11N,% NEwvao• le not rA>lnnnslbiA fm conmijona H I 13•'1/ancr Paid to Ganien Window / or ctrr.I,m+Inncnw boyonel Ra corerol I.Fi,mlra la^allef AI i»SIAILIhon AW»In sondenent+on rnadUnp rrr,m nr d,m ro pm-jftrlN�PM4,CK�)bar*_.. Cnmpinrion Dind r 0ved Signed Ar hislallsuon S rY -.Lvwl��!"._/1.t�a 'a.!..r_��__t� _u'!Y1 (•� .�y�L�C�t _ •� I,,,` _ _ anCu ty dM+ts will hgvr 3!A"Ahhm1111.NT1 11 rr.+hnM inrtAgrtl nvnr nxlJi nrJ threzhnlr Qcrstomnr Ir+lirnlc Eau. art date zA IL ESt.Comp.Cite; 30A65— security Interest: Ycs tl No II rhAII Ma Ihn n»fynfinn of NEWf�RO to nnteln Any and all permlin nnrn3'ary unrior thlR ngrrrmRnt,In thn Ownar'A AQnnl,Thr Owners who BCcurr Ihnlr awn cnnStrUCllon•rs?IRfrd Pn rnvo,nr dapl With r+r1Tr. IrIrTW Crnlrpelorn will ,1 G 1ApA All Nmm�Imnrnv .l++contrncinr rninling t0 n rag ri 11 eJ t,411n„1 ,(.-,.t I'ri 1161 In^m 1301. n shit Ownnr p;nh SHARON 6E FRAT1CISCt '�irirr',I r !(r-I f c'Ir.�I; I marts urltlnr Enid � r 00014 in hr rhgN nn irmor Of+1 ..1O2p..4.FAR7 MAIN ST,'- r As nnnn�m Agronmrnl Ihr Inrn1!:nl ihv r< 'PURCEELWfEOE,WA 9n1IP i1 r,i, ���+ i r, / - 'lr4 nrrl hw,.in, r:rr•rlrl npolirnitryl r r ,nlnn!,I thn ntl Iingnrr rhgrpn. ”ociudirg tJ£WPRO mrrmpn. I'„rr, I}fh-Owner hell. r 1 n,no I. r�rl.I�r �- % whAlcnevCT rhplt C + 7f // __.. any fn1:nn k9ukinted nrxl ppc, �rrl,.} yl/.r.11[,Yir.t!" t._ rh r LY_ "---- .-y -,,,�,: .. d,13 hard, w-'wpnO:.hal1 nut J Owner wnrrAni3 Ih In Railer No INS ar (-J ifsVY Q IASf;'YANK ho Owner: Thip comirne repro Ihq Ownrr And NEWPRO. .117pA.'AIABYI AND nrnta �, You Are entitle �l{I�1_,l'1 fl-a. F ,..?:,1.c.a M Owners,certify T".1, LOLAt ��(,1,,..- Iforesaid You may cane t:2 5 SCI 7198 1e: 241,3 200 59 111' 11;1 to salter, which may be 'arch b ordinary mail p .-_. , o,r,r 1 rdW11 018th mronhgnt Of the third business day foNowing the signing of this agreement.(Saturday is a togal business day). See the attached notice of coneNt rtion form for an explanation of this right, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES, The Owner has soon"sampre"warrnnlies that will Ire provldgd by NFWPPO upon instellntinn. WSample warranties provided to Owner. IN WITNESS wHER Ihr. lale yve horn0nto si,ned thnir namr.. this /t! da of .. �� �' $-ill q— y — �r/ Signed Marke mg Re r9aentative Owner Accepted:NEWPRO,INC. BY —.., Signed—.�. Authorized Signatute Title _ - Owner WOBURN hnANCH orrice 91 RF IIDY BRANCH I)FRCE WARWICK nnANCH cmr,F M Cadar 3UAnr la r-rip klfl „lnr prlvn rt,wnnne Perk ay ellhenn"IT-1 WAMrrn,MA Birth 'kAh B.0 Wnnwrk.RI 07 nm tF.L?Rt•cv-mnniFXT:nrn Shlr vJN ry,MAn1,nF TEL 4Cn-733-PAA7 30r.747•11VJ(FnI NF) Trt,:Fn3.647.079 nn13511-11 q(FROM kE) FM 7p+.732-Mtn FOp.AAc.-111.55(Mm NE) FAR:AAta?3137t FAX:nnn.3APANr t wHlTe'.Omnch CApy YE L6WI Cuslomnr'r.Copy, PIN -In Copy npl_p:Fin-co Cony Is-15 1m"S.NO 4 � SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: © f D 1 � d f� License Number Address Expiration Date g / Telephone 9.Reaistered Home Improvement Contractor: Not Applicable ❑ M�o lace :z2� Company Name �1 Registration Number 6 xLo�itd , - Address Expiration Dat 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....... No...... ❑ 11. - Home 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 • w SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition Replacement wpdows Alteration(s) Roofing Or Doors IV Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [M Siding[O] Other[CI) Brief Description of Proposed Work: Alteration of existing bedroom Yes X No Adding new bedroom Yes 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 _X 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 )A_kJ9 t 6_r5 L as Owner of the subject property hereby authorize 648 /V� to act on my behalf,in all matters relative to work authorized by this building permit application. a ature of Owner Date zl&Lc � -, as C3 r/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 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 Deportment 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 DONT KNOW � YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW � YES a IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW t'0"' YES O 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 NO 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 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 Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability, nI % Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO-C8 TRUCT,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 J W e Sf �� � � Rck. Map Lot Unit F/O/-rn Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:-5///qA6 tt�7 �-L� --911 yyet :t Home ors kd , Name(Pr t) Current Mailing Address: W/3 59?-33"lu Telephone Signature 2.2 Authorized Ascent: j�7pgX X6 3-Ale- Name(Print) Current Mailing Address: �-�'9 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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= 0 +2+3+4+5) —T— 2+3+4+5) Check Number S This Section For Official Use Only Building Permit Number. Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 211 WESTHAMPTON RD BP-2005-1069 GIS#: COMMONWEALTH OF MASSACHUSETTS MV.Block:36-085 CITY OF NORTHAMPTON Lot:-001 Permit: Building Catego a-,windows replaced BUILDING PERMIT Permit# BP-2005-1069 Project# IS-2005-0732 Est. Cost: $15243.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: NEW PRO INC 100020 Lot Size(sq. ft.): 30796.92 Owner: FAGAN MARY&SHARON Zoning: SR Applicant: NEW PRO INC AT. 211 WESTHAMPTON RD Applicant Address: Phone: Insurance: 26 CEDAR ST (781) 933-4100 Workers Compensation WOBURNMA01801 ISSUED ON.513105 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS/DOORS 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 5/3/05 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo