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23A-127 (8) BUSINESSOWNER'S POLICY DECLARATIONS Issued: 02/07/2014 Policy No.: WIBP503715 Effective Date: 02/25/2014 POLICY WIDE COVERAGES AND LIMITS OF INSURANCE Appurtenant Structures Lrrtit .. .. Business Income & Extra Expense Limit ; :. AtS UP 1 11IQI11Tv Contractors' Installation, Tools and Equipment Coverage Limit .. .,.. `Refertol=drmP t7 1 , Any One Tool Sublimit $500 Damage To Premises Rented To You Limit : Electronic Data R Ltmit Employee Dishonesty Limit Fire Department Service Charge Limit $25,000 Fire Extinguisher Systems Recharge Expense Limit, Y $5 000 , ,. -yam' Forgery or Alteration Limit $10,00 ; r Fungi, Wet Rot, Dry Rot& Bacteria (Mold) Property Limit $15,�10t} " Business Income/EE Number of Days 30 Liability Coverage Optiion r,.. ..:" y":Excel "CQUrac� , ;: : Glass Expense Limit Aal La Sustained ` T >� Interruption of Computer Operations Li;fhit liq Loss by Theft of furs, fur garments, garments trimmed with fur Limit ... woo Loss by Theft of jewelry, watches, watch movements,jewels, pearls, precious and semi-precious stones, bullion, gold, silver, platinum and other precious alloys or metals 15, Limit 00 Loss by Theft of patterns, dies, molds and forms ....................... Limit }�y •F-F.• <ti $21500 Money Orders and "Counterfeit Money" Limit $C;1100 ' Newly Acquired Or Constructed Property- Buildings Limit 25%ref Bigildincg Limit/Not more than, sie i000rd1i . Newly Acquired Or Constructed Property - Business Personal Property Limit $25t1,000 Ordinance or Law- Increased Cost Of Construction Limit $10,000 Personal Effects Limit $5;000 Personal Property Off Premises Limit $10110Q: Pollutant Clean Up and Removal Limit $10100 '" Preservation of Property Limit Within 30 Days- Terrorism IIT DS 01 05 Page 4 of 5 BUSINESSOWNER'S POLICY DECLARATIONS Issued: 02/07/2014 Policy No.: WIBP503715 Effective Date: 02/25/2014 SECTION II — LIABILITY COVERAGES AND LIMITS OF INSURANCE Each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Please refer to Section II — Liability in the Businessowners Coverage form and any attached endorsements. Coverage Limits of Insurance Liability and Medical Expenses- Each Occurrence $300,000 General Aggregate (Other than Products and Completed Operations) $600,000 Products & Completed Operations Aggregate $600,000 Medical Expenses (Each Person) $10,000 Liability Property Damage Deductible None Liability Deductible - Bodily Injury None IIT DS 01 05 Page 3 of 5 BUSINESSOWNER'S POLICY DECLARATIONS Issued: 02/07/2014 Policy No.: WIBP503715 Effective Date: 02/25/2014 SECTION I—PROPERTY COVERAGES AND LIMITS OF INSURANCE In case of fire, notify the company or its local agent at once in writing LOCATION: 001 BUILDING: 001 100 Cardinal Way Florence, MA 01062 Hampshire County Property Deductible: $500 Wind/Hail Deductible: N/A Optional Coverages/Glass Deductible: $500 Classification: 74171 -Carpentry-Construction of Residential Property-Not exceeding 3 stories in height(Shop) (1) MANDATORY COVERAGES: Business Personal Property Limit of Insurance $2,000 Valuation Replacement Cost OPTIONAL COVERAGES: BOP Location Level Information Awnings Coverage ",. � K����y C kfi?' ^-ryr�,.YZS'?,� -. _- .. _,..� �2,5•� �� .4' .. Business Personal Property Coverage Seasonal Increase Percent 25 Liability ... . Includ d Accounts Receivable r 254,000 Off-Premises Limit $25,000 Debris Removal 25%/$14,90 Outdoor Property Lt $10„000 Outdoor Signs -Optional Coverage Limit $ 0 Valuable Papers and Records y 3 :Prer�tises Limit $25,b00 Off-Premises Limit $25,000 IIT DS 01 05 Page 2 of 5 Eg BUSINESSOWNER'S POLICY 23ZzGU DECLARATIONS Comp•BuMnessownw's•Auto•umbrella AmGUARD Insurance Company Issued: 02/07/2014 A Stock Company Policy No.: WIBP503715 Renewal of: WIBP402595 POLICY INFORMATION PAGE [1] Narhed Insured and Mailing Address William Gemmell 100 Cardinal Way Florence, MA 01062 [2] Agency KING & CUSHMAN, INC. 176 King Street P.O. Box 447 Northampton, MA 01061 [3] Policy Period From February 25, 2014 to February 25, 2015, 12:01 AM, standard time at the insured's mailing address. [4] Description of Business Carpentry-Home remodeling [5] Coverage This policy consists of the Coverage Forms listed on the Schedule of Forms and Endorsements (IIT SF 01 05). [6] Premium The premium shown below may be subject to adjustment. Terrorism -Certified Acts Excluded TOTAL POLICY PREMIUM $876.00 TOTAL PAYABLE $876.00 [7] Payment of Premium In return for your payment of premium, and subject to all terms of this policy, we agree with you to provide insurance as stated in this policy. `GUARD INSURANCE GROUP a Berkshire Hathaway company IIT DS 0105 16 South River Street • P.O. Box A-H • Wilkes-Barre, PA 18703-0020 •www.guard.com Page 1 of 5 - Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165392 Type: Individual Expiration: 2/8/2016 Tr# 247865 WILLIAM S. GEMMELL WILLIAM GEMMELL 100 CARDINAL WAY FLORENCE, MA 01062 Update Address and return card.Mark reason for change. (� Address []20M•OS/11 SCA 1 ca Renewal Fj Employment Lost Card I r'`/�r ��ouariin�rncvi�l�c��r'/��a.rtn��nJr/l -0.. Mee of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: 165392 Type: Office*of Consumer Affairs and Business Regulation xpiration: 2/8/2016 Individual 10 Park Plaza-Suite 5170 ,� *y Boston,MA 02116 WILLIAM S.GEMMELL f WILLIAM GEMMELL 100 CARDINAL WAY FLORENCE,MA 01062 ��i'i Undersecretary Not val without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 M s www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ��/ Name (Business/Organization/Individual): r i 6' A�o�lf�T7 zwy Address: !4 0 yKe" City/State/Zip: Phone #: J20 L. 2-7f_7 f b �-- Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. E] I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.10,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.1 required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.bl 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. I 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: _ 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 of perjury that the information provided above is true and correct. Si mature: ' Date: 7� Phone# d Z Z 11 Z g Z- 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: License Number Address Expiration Date Signature Telephone 9.Re istered Home Improvement Contractor: Not Applicable ❑ S6 f `7J0�14 n0W-. Company Name Registration Number 1017 1�� �'L�,� �c�r - -2-If- 1u�/ b Address Expirati n Dafe Telephone L Z 7J-2g bz 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....... NL 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 holgeoi%ger. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she skoLljbe 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,S d Local Zoning Law Sta of Massachusetts General Laws Annotated. Homeowner Signature !� SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing IR2, Or Doors E3 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[O] Other[d] Brief Des tion of Proposed Work: m6V>' /31,/ �' � �� �C41� i,� i �'r o SCI i,�Gj p!✓ Fa2Ar/� Alteration of existing bedroom Yes No Adding new bedroom Yes _L No Attached Narrative Renovating unfinished basement Yes vL No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building: One Family J�— 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 1, If/fiJr El- 0, CJ' as Owner of the subject property hereby a rize Vv S 0✓,7 r) 0>J f to act behalf, in all ma.Uerg"f§Tallmo work authorized by this building permit application. 710 T Signa re Cie- bwner Date I ����yf�i✓1&-5- 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. YL Print N A pt L o h y Signat 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 Permit/Variance/Finding ever been issued for/on the site? NO 44X DONT KNOW 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW ® YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW ® YES Q 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 © NO Q 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 t/ NO IF YES,then a Northampton$t4rm Water Management Permit from the DPW is required. I "0 Department use only City of Northampton Status of Permit: j Building Department Curb Cut/Driveway Permit JjUN 2 d 201 212 Main Street Sewer/Septic Availability Room 100 WaterNVell Availability, 2CtriC Pi rr D, ,g&G ir.spections Northampton, MA 01060 Two Sets of Structural Plans k'I'4,of o 13-587-1240 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 2— �i�t;�� .. Map Lot Unit rL d 12�e- yJ14 O t 0 b Z,- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pji Current Malin ddres : 01 Ob y Telephone Signa 2.2 Authorized Agent: Name(Print) Current Mailing Address: 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=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 32 MIDDLE ST BP-2014-1371 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A- 127 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-2014-1371 Project# JS-2014-002317 Est. Cost: $950.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WILLIAM GEMMELL 165392 Lot Size(sq. ft.): 14853.96 Owner: PICK STEPHANIE EMM Zoning URB(100)/ Applicant: PICK STEPHANIE EMM AT. 32 MIDDLE ST Applicant Address: Phone: Insurance: 32 MIDDLE ST (413) 586-5652 () FLORENCEMA01062 ISSUED ON.612312014 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE PORCH 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 Signature: FeeType• Date Paid: Amount: Building 6/23/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner