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25C-246 ,.30!du NORAM3 ..I OFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) l; 1/08/2014 a,UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES .;ERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED _,-4 TATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. iRTANT: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 endorsement(s)- PRODUCER CONTACT NAME: Karen D1511710 People's United Ins.Agency CT PHONE 860 524-7600 860 722-7728 One Goodwin Square MA�° Ext: ac Nc Hartford,CT 06103 ADDRESS: KDisipio@rcknox.com 860 524-7600 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Employers Ins of Wausau INSURED INSURER 13:Liberty Mutual Insurance Group NAMCO LLC INSURER c:First Liberty Insurance Corp Manchester,100 hest err Drive INSURER D.Continental Casualty Company ,CT 06040 INSURER E:Wausau Underwriters Insurance 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 CONTRACTOR 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. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DD A GENERAL LIABILITY TBCZ91427578043 6/01/2013 06/01/201 EACHOECCURRENCE $1,000,000_ X COMMERCIAL GENERAL LIABILITY PREMISES EaoicE ante $1,000,000 CLAIMS-MADE R OCCUR MED EXP(Any one person) $10,000 ' PERSONAL&ADV INJURY $1,000,000 I GENERALAGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG $2000,000 POLICY PRO- JECT LOC $ E AUTOMOBILE LIABILITY ASJZ91427578033 6/01/2013 06/01/201 ('EO aBcNdEn,)'INGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ B X UMBRELLA LIAB X OCCUR TH7Z91427578053 6/01/2013 06/01/2014 EACH OCCURRENCE s20,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $20 OOO 000 DED I X RETENTION$10000 $ A WORKERS COMPENSATION WCJZ914275780213 9/30/2013 09/30/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L EACH ACCIDENT $1 OOO OOO OFFICER/MEMBER EXCLUDED? N N/A , (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 00O 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Direct Damage RMP5087052655 6/01/2613 06/01/2014 $94,969,100 per occ. Property DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) � j I � i ' I CERTIFICATE HOLDER CANCELLATION I Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S466377/M442533 KXDCT Hatch Mott Project Name /VOWAK -_5LJrMt1ING- POOL_ MacDonald Project# _ _ Page � of Subject PU14-Pr W-- f'E RNrr__ Sheet# Calculated by Date _ Checked by _ Date a 1 C, 1 3a C► �XisrrNG- u0US� H W cv ,1 ?(-)POSEt) FOOL � E I o c1 ZQ, l SCVLe - City of Northampton � . Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 1 , 212 Main Street • Municipal Building Jib Northampton, MA 01060 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 he/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 m �� understand the above. \/ (Home owner/resident's signature requesting exemption) 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 Office of Investigations s 600 Washington Street Boston, MA 02111 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 you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.F-1 I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g, ❑ 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.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.� Other PGA, comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners 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 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 the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone M 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#: 4 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: License Number Address Expiration Date Signature Telephone 9."Registered Home Improvement Contractor: Not Applicable £ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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 Owrier Exemption` The current exemption for"homeowners"was extended to include Owner-occupied DwelIines 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" •�_ T SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors I I Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[A Brief Descriptio of Prgqppo d Work: ✓1 STU�kq fi-oA J C( St.),MIA K Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ss If.New,house an or addition"to ekisfingµhousinq complete the following' �JIA 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, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 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. Print Nam,e Signature of Owner/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information UICB Existing Proposed Required by Zoni'n This column to be fifled in by Building Department Lot Size Frontage -------------•--- --- - Setbacks Front F-71 [� Side L:= R:r J' L:�lI R:=�_ Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved 'r � parking) #of Parking Spaces " Fill: _ (volume&Location) t! A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW O YES Q IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book ����~��� Page and/or Document#i i B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO lot IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. s 1 _lam___.__--•. —_°-� � City of Northampton ;' i •-+�..E v . �Fa, `` ,, �� r � F�,}''c t t'��of i i Building Department Ctrrla Cut/DrlrceurayPetrrst# � ■ 2414 i MAY 7 212 Mom— �--J Street SeyverlSepticAvallablllty Room 100 WatertUktellAva31a5{Ilty a inspect��Qb hampton, MA 01060 Tvr�aSetsofStructuialPra�s Elec.r 0 0 -587-1240 Fax 413-587-1272 Plof/Ste Plans r r 5 k APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION ted by office 1.1 Property Address: Thls section to be comple MA Overlay Distract EIm St District :0a;Distract SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: dc4Aeci A Name(Print) Current f ailing Add ens: 3 — .S— 'ff Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATE I CONSTRUCTION COSTS ftem Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building l pa"i 414 Zvv.v0 (a) Building Permit Feb 2. Electrical (b) Estimated Total Cost of Construction from 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number Q J This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/lnspector'of Buildings Date File#BP-2014-1164 APPLICANT/CONTACT PERSON NOWAK MATTHEW A C(Zl16R ADDRESS/PHONE NORTHAMPTON (413)584-5963 Q _. PROPERTY LOCATION 259 BRIDGE ST 1✓ MAP 25C PARCEL 246 001 ZONE URB(116)/SC(4)/ ! THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out i w2 04 4K:a 00 Fee Paid Typeof Construction: INSTALL ABOVE GROUND POOL CA7 fro_ -N C.t, • xI New Construction (0 o& 26 Mcwzs Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO�tMATION 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 Demolition Delay l9—If 20 `It 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. 259 BRIDGE ST BP-2014-1164 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma :Block:25C-246 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: electrial BUILDING PERMIT Permit# BP-2014-1164 Project# JS-2014-001972 Est. Cost: $4200.00 Fee: $30.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 5793.48 Owner: NOWAK MATTHEW A Zoning: URB(116)/SC(4)/ Applicant. NOWAK MATTHEW A AT. 259 BRIDGE ST Applicant Address: Phone: Insurance: (413) 584-5963 () NORTHAMPTONMA01060 ISSUED ON.•511212014 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 24' ABOVE GROUND POOL - pool enclosure must meet all code requirements 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 5/12/2014 0:00:00 $30.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner