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17D-084 (2) ACC>R" CERTIFICATE OF LIABILITY INSURANCE 05�06�20�4 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 POLICIE 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 endorsement(s). PRODUCER CONTACT -NAME: __ Lockton Affinity, LLC PHONE 888-553-9002 FA/C No): at) PO Box 873401 E-MAIL ADDRESS: Kansas City MO 64187-3401 INSURER(S) AFFORDING COVERAGE NAICN INSURERA: ACE Property 6 Casualty Insurance Co. 20699 INSURED INSURER B Pioneer Valley Habitat for Humanity, Inc — INSURER C PO Box 60642 INSURER D Florence, MA 01062-0642 INSURER E 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 PERIO 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 TERM 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 POLICY NUMBER MMIDD/YYYY MM/DDlYYYY GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence _$ CLAIMS-MADE OCCUR MED EXP(Any one person) $ _ _PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEML AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AG $ _ _ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea_accident)_ $ ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS TOS BODILY INJURY(Per accident) $ AU NON-OWNED ! PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DELI RETENTION$ $ A WORKERS COMPENSATION C45426592 04/01/2014 04/01/2015 X WCYTATU- OTH- AND EMPLOYERS'LIABILITY II _FR -- ANY PROPRIETOR/PARTNER/EXECUTIVY4 �E L.EACH ACCIDENT $ 11000 000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) EL DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Proof of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ REPRESENTATIVE 198 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 13589493 1064964 City of Northampton 'r' Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Buildingilj� b i 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 made I, understand the above. (Home owner/resident's signature requesting exemption) I 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 IM 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): � r UVIA Address: YO box (00Coy 2 City/State/Zip: O,-ean C2 I M A- 01062— Phone #: q l_2:� s� • 5 3 Are you an employer? Check the appropriate box: Type of project(required): 1.ZI am a employer with ? 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. lew construction 2.F_1 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ 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 area corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] 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 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. r� Insurance Company Name: Lock- -x PA-vt.i UC SCE V" k Policy#or Self-ins. Lie. #--: rr ll� nn p Expiration Date: Job Site Address: 5 G5&�_teJd k\je J y-kc � �M1�O 1D�Z C ity/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 cer fy under the pains and penalties ofperjury that the information provided above is true and correct. Si ature: Date: Phone# q(�)— 15�BG" 624 3d 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: 0Yin 7) (-:� License Number Address (�,kA U I v`;;,a Expiration Date Signature Telephone 7� do 9 Registered H6me Imp rovement Con ractor., � „, .�� Not Applicable £ Company Name Registration Number Address Expiration Date 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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑r Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding [E-3] Other[0] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa:If>New'6'oiase and or'addit'on to existing h`otasitiq, compiete the'following!: ` a. Use of building:One Family Two Family Other O G 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 as Owner of the subject property hereby authorize to act on my behalf, in a matters relative to work authorized by this building ermit application. A�A tT 1 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 Name Signature of Owner/Agent Date ' Section 4. ZONING Atl.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 Rear Building Height Bldg.Square Footage 0/0 Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? �� NO �_��/ DONT KNOW x�� YES �~� |F YES, date issued:| � IF YES: Was the permit recorded at the Registry ofDeeds? NO K ) D �" KNOW _ IF YES: enter Book Page= and/or Document# B. Does the site contain a brook, body of water urwetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has permit been or need to be obtained from the Conservation Commission? Needs to be obtained v~� Obtained x—� Date Issued: �~� �~� ' � C. Do any signs exist on the property? YES NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES v��-� NO x«_�� IF YES, describe size' type and location: ! ( .... ..............................___-_____- ..._.� E. Will the construction activity disturb(clearing,gradingexcavation,orfi|Ung)over 1 acre orish part ofu common plan , that will disturb over 1acre? YES NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. - ity-of Northampton Status ofParmtt,ry k �. i. i ` r fit'.,7 ' fi+' I s r'{'Mf I — k f _Eldildlty Department Ctrr6 Cut/Drivevuay Perrrii# � MAY 2 212 IVY In Street Seyrer/SepttcfjvalCabl(Ity „� f M 222014 Rogm 100 VltatertUMteitRva(lablllty f 2 ' a E)ecfric, North 17f}� n, MA 01060 Two Sefs of S#rtrctriral Plans` I I' v s j ti Ptuf'P9rd -1 0 Fax 413-587-1272 PIoflSite Plans ��'' ' I Nort h- Pt on. ft1 spections A 07060 QtfleYzS�SECif 4{ .E4 a'lij ,:: ' APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE.INFORMATION This section to be completed by office 1.1 Property Address: / Map Lot. Unit ` YlilO�Lc T/C.' Zone Overlay Distrtct Or tJ� Elm St District B:District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: i o n a te Ic vtnnarit I VI c. PU 90 x Cob CP y Z El r e.►1 ce d 10(v 2- Name Prio.0 Current Mailing Address: ,r 413 58ta 5430 r Telephone Signature Z1,641 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. No 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=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissionedlnspector'of Buildings Date 5 GARFIELD AVE BP-2014-0588 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-084 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:New Single Family House BUILDING PERMIT Permit# BP-2014-0588 Project# JS-2014-000988 Est.Cost: $137518.00 Fee: $593.60 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group MICHAEL BROAD 046013 Lot Size(sq.ft.): 11412.72 Owner: PIONEER VALLEY HABITAT FOR HUMANITY zonine: Applicant: PIONEER VALLEY HABITAT FOR HUMANITY AT. 5 GARFIELD AVE Applicant Address: Phone: Insurance: P O BOX 60642 (413) 586-5430 (� FLORENCEMA01062 ISSUED ON:11/18/2013 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2 STORY SINGLE FAMILY HOUSE/PORCH 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: FeeTyDe: Date Paid: Amount: Building 11/18/2013 0:00:00 $593.60 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner