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31B-087 (3) A n�l"1 C' Cz111111t?11CCIC'(/lll vsi 'll Office of Consumer Affairs and B ness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 174422 Type: Corporation Expiration: 2/7/2015 Tr# 236022 HOME IMPROVEMENT COMPANY OF VT I JAYSON DUNBAR 6 MORGAN ST BELLOWS FALLS, VT 05101 Update Address and return card.Mark reason for change. Address ❑ Renewal ❑ Employment ❑ Lost Card SCA 1 is 20M-05/11 v. �'��r rinr�ir:yueF�tf(�r/�11iJJri��u��/73 License or registration valid for individul use only Office of Consumer Affairs&Business Regulation g ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: "— Office of Consumer Affairs and Business Regulation ,� Registration: 174422 Type: t"- 10 Park Plaza-Suite 5170 —expiration: 2/7/2015 Corporation Boston,MA 02116 y HOME IMPROVEMENT COMPANY OF VT INC. JAYSON DUNBAR 6 MORGAN ST BELLOWS FALLS,VT 05101 Undersecretary of valid without signature /�r AC°® CERTIFICATE OF LIABILITY INSURANCE M/DDIYYYY) 5/88/201/201 3 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 endorsements. PRODUCER CONTACT NAME: Clark-Mortenson Insurance PHONE - 2- 1 1 AX N o. 1 P.O. Box 606 E-MAIL Keene NH 03431 ADDRESS: INSURERS AFFORDING COVERAGE NAIC A INSURER A Acadia InSUrgnCe INSURED JANCEWICZ1 INSURER 8: Jancewicz&Son INSURER C: Home Improvement Co of Vermont Inc dba INSURER D: 6 Morgan Street Bellows Falls VT 05101 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:976469248 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 SEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DL U R POLICY EFF POLICY EXP LTR IN WVD POLICY NUMBER MM/DD/YYYY M/DD/YYYY LIMITS A GENERAL LIABILITY CPA038529312 16/2013 16/2014 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMA E ENTEU- PREMISES E occurrence) $250,000 CLAIMS-MADE OCCUR SAM P MED EXP(Any one parson) $5,000 Copy PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMPIOP AGG $2,000,000 POLICY X PRO- LOC $ A AUTOMOBILE LIABILITY CAA038529412 /612013 16/2014 Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident A X UMBRELLA LIAB X OCCUR CUA038529512 /612013 1612014 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 DED RETENTION$ $ A WORKERS COMPENSATION CA038529612 /6/2013 /6!2014 WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N FR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMSER EXCLUDED? fN-1 N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Comp Insurance: Part one(3A)applies to Workers Compensation Law of the State of VT,MA amd NH. No officers are excluded. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SAMPLE ACCORDANCE WITH THE POLICY PROVISIONS. XXXXXX XXXXXX XX XXXXX AUTHORIZED REPRESENTATIVE (2-- e` . ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD 40 . The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual): . , Address:6- file, r a/0 c�% City/State/Zip: 6 Phone#: S Are you an employer?Check th 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 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' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t 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.❑ 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' 13VI Other { (,�T u C�bij'� comp. insurance required.] J 1 -4 *Any applicant that checks box#1 must also till 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: rj/ \CG Policy#or Self-ins. Lic. #: / (Q Expiration Date: Job Site Address:`_g a('�� City/State/Zip:A� cAdam ol/ i, A14 6J 16�p 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 erage ification. I do hereby certify d the pa* and alties o perj that the information provided abo a is true and correct. Sip,na ture: Date: -3 Phone#: 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: Y� ,V �V�Rl� �{ (r �SS� 'Q 9/ 2 5 License Number Add s Expiration D e S' at Telephone 9.Rettleft—nd Hoare InriorwyemoM Conntmetor: Not Applicable �7Cylp� C„ GZ -i SC?!ll /7 yya al, Company Name Registration Number Address Expiry ion ate Telephone9C'�'y�Q 3 3S 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...... an+e 11(*> r Elemption 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.Aperson 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 ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[0] Brief De iption 4f Proposed (�,, I Work: �b�� ���6 Me �J 3(Ds V E UtA4�e(- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _No Plans Attached Roll -Sheet 6a3 N New house and or addition to sxistino housinst,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 l �Gj �(� j as Owner of the subject property her y authorize �Jlh� to con my behalf, in all matters rel live to work auth rized by this building permit application. Sig atu a of Own Date I, �i.A� fly ( ] (�Z��) -�( �) � 'l1 ,as Owner/Authorized Agent her by 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. a 0.AJ Print N ture 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 Department 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 Permi /Varian /Findi ever been iss ed for/ the site? NO Q ON'T KNOW YS IF YES, date issued: IF YES: Was the permit recorded at the Registry of De s? NO Q DONT KNOW Q YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained Q , Date Issued: C. Do any signs exist on the property? YES O 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 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 Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only J I — City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit MR 2 7 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability E � _ uo,�I rthampton, MA 01060 Two Sets of Structural Plans -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 YW-e Map Lot Unit , M A �I Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: GEpK:q', Na (Print) p /7,57 Sig re 2 A thorized nt: D P3 00 N - i C 2 4 S6 A/ G�1!q ST �01,t�`���I S' V/1 051L l Name(P' ) Current Mailing Address: 3 gnatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �.1.)ing ► � oLJ S /� Q (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) Check Number 67 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 4 BARRETT PL BP-2014-0991 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B-087 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: window replaced BUILDING PERMIT Permit# BP-2014-0991 Project# JS-2014-001716 Est. Cost: $13827.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JANCEWICZ & SON 99725 Lot Size(sa ft.): 8668.44 Owner: BARWICK GEORGIA Zoning URC(100)/ Applicant: JANCEWICZ & SON AT. 4 BARRETT PL Applicant Address: Phone: Insurance: 6 Morgan St (802)463-3585 Workers Compensation BELLOWS FALLSVT05101 ISSUED ON:312712014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 9 BASEMENT REPLACEMENT WINDOWS/GUTTER 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 3/27/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner