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36-101 (2) * � Office mer A airs Bdsiness egulafion .�6 HOME IMPROVEMENT CONTRACTOR Registration: 931848 j ExPiration: 9/26!2014 Type: Private Corporatiol KARR3OWSKI REMODELING LLC. CHRISTOPHER KARBOWSKI 6 LAMB ST. BROOKFIELD, MA 09506 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations andSbndams GmemtA„ s % �«n r L»erm: CS10 446 \ \ : JOHN«MCKEQ14 343 AUBURN S CHERRY MA Oag \ \ \ ;7"/.— , e» E«%zmon c_Gam . 1521 From:Ashiey M Paiva FaAD:VIVeiros Insurance A Page 2 of 4 UaTe:.Wz IlGU I•r uC,co rm raye.c v,, KARBREM-01 PAAS CERTIFICATE OF LIABILITY INSURANCE DATE ID/ Y11, 3127/2014 THIS CERTIFICATE 1S 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 INSURERSh AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 Neu of such endorsement(s). PRODUCER (508)676-0309 NAME: Ashle Paiva Vivelros Insurance Agency,Inc. PHONE 375 Airport Road c No -,ti: 508-676-0309 127 (ANC,No: 508-324-9147 Fall River,MA 02720 ADDRESS:APaiva@viveirosinsurance.com INSURER(Sy AFFORDING COVERAAE NAIC A INSURER A:State Auto Insurance INSURED Chris Karbowski Remodeling LLC INsuRERa:Utica Mutual Insurance Company 25976 6 Lamb Street INSURER C: Brookfield,MA 01506 INSURER D: INSURER F: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 BEEN REDUCED BY PAID CLAIMS. LT TYPE OF INSURANCE POLICY NUMBER D.�YY1r1 D LIMITS GENERALLIA84LFTY EACH OCCURRENCE $ 1,000,000 A X C"MAERC1AL GENERAL LIABILITY SOP2680427 7,14/2013 7/14/2014 PRMSES tea Ecunenr_eZ $ 50,00 CLAIMS a1ADE cuR I MED Exr JAW one person; $ 5,000 FERSONAL a ADV iNJuRY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-C'WP/OP AGG $ 2,000,000 FRC,. X POLICY � LOC $ AUTOMOBILE LIABILITY UL (Ea accident) $ ANY AUTO BODILY INJURY Per person) $ ~- ALL OVVIJED SCHEDULED _---—- ALITOS AUTOS BODILY INJURY(Per ercidbnt) $ _- NON-(NhIED Y At HIRED AUTOS AUTOS PER ACCIE)EPTf) $ UMBRELLALIAB OCCUR EACHOCCURR&KE $—T]EXCESSLLAB CLA44'�MADE AV GREGATE $ DED RETENTION $ $ WORMERS COMPENSATION I OTH. AND EMPLOYERS'LIABILITY Y r N T P.Y 1t f TS I EP B ANY PROPRIETMPARTIERExECUTIVE n 21 7/23/2013 712312014 EL EACH A.CC ANT $ 100,000 OFFICERAhEMSEREXCLUDED? 1 1 NIA _ (Mandatory in 1*4 E L.DISEASE-EA EMPLOYEE $ 100,000 pyes descs under UES�RIPTION OF OPERATIONS below, E .DSEASE-POLICY LIMIT $ 500,000 , DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,I more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Northampton Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 212 Main Street,Room 100 ACCORDANCE WITH THE POLICY PROVISIONS. Northampton,MA 01060- AUTHORIZED REPRESENTATIVE O 1988-2010 ACORD CORPORATION, All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the-affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pennit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 7/2013 The Commonwealth of Massachusetts Department of Industrial Accidents 1f Office of Investigations Tt ,c I Congress Street, Suite 100 :T Boston, MA 02114-2017 M www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: C�3 'Vl �� Address: (4 l_o M V�> 9+ City/State/Zip: P)V-Gc�K ;e 0 Q)60(0 Phone #: ;og D9 y_g,a Are you an employer? Check the appropriate box: Business Type(required): AI am a employer with 1 employees (full and/ 5. ❑ Retail or 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]" 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#l. I am an employer that is providing workers'compensation insurance.for my employees. Below is the policy information. Insurance Company Name: V sl vFcn_>51-2�t is.D) Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: 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, er the ains and penalties of rjury that the information provided above is true and correct. Signa ture: Date: Phone Li4a 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. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia `SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable 0 Name of License Holder: I j I y l (,�2U'i� 11) 3,- ' k, License Number -�113Chey Expiration D�t�J-3 SOL 335-7e,50 Address r Signature Telephone 9.Reallstered'Home;lmprove 'or: Not Applicable ❑ Company Name Registration Number (1 Address (f Expiration Date ��t Telephone �'� oq, ` 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 building permit. Signed Affidavit Attached Yes....... pf, 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [M Siding[0] Other[p] Brief Description oproposed j Work,M`C�C It r:N&Itt r--4 s4,x—)q1Q �1� 1 1 ICSe� ���� C� Q`-) Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. if Now house and or addition to existing housing,complete the foliowlna: 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? 2- i+ 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 . 1. 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, .5 r l w n C 2,d as Owner of the subject property i / c-� hereby authorize !�`� {�� 1�1A�jC�.'��1 to act on my behalf, in all matters re Live to work authorized by this building permit application. Signature o er Date I, ��� 11�� �'7i4 Fj® � ,as Owner/ Hzed 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 Vn 04 Signature of O er1A a 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 ark" #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 ® DON'T KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , 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 ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. D Department use only fCjiy of Northampton Status of Permit: APR yfl�ding Department Curb Cut/Driveway Permit 4 2� _ f4 ;.7x12 Main Street Sewer/Septic Availability I Room 100 Water/Well Availability 43,,> ampton, MA 01060 Two Sets of Structural Plans phone 4 -5 7-1240 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 9 J ol-6 kC—I /� Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Si nature 2.2 Authorized Aaent: �'/` ii Q `/ Q C�1-l�;S�)a�,�f l�tt i _ l Ck M �j(7cc,477i e'[yI Ef A - ©i Sc Name -Kin Current Mailing Address: Si ature 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) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 965 BURTS PIT RD BP-2014-1008 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 101 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-2014-1008 Project# JS-2014-001752 Est. Cost: $5600.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN MCKEON Lot Size(sq.ft.): 19994.04 Owner: CONNELL JOHN F&SHARON C MORRIER Zoning: Applicant. JOHN MCKEON AT. 965 BURTS PIT RD Applicant Address: Phone: Insurance: 343 AUBURN ST (508) 335-7050 WC CHERRYMA01611 ISSUED ON:41412014 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 Sijinature: FeeType: Date Paid: Amount: Building 4/4/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner