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25C-205 (2)
IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DATE(MM/DD/YYYY) WILL-12 06/22/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Kinney Pike/Brattleboro ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 225 Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P. O. Box 430 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Brattleboro VT 05302-0430 Phone: 802-254-2366 Fax:802-254-6132 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Acadia Insurance 31325 INSURER B: William G. Walker & Co, Inc. 759 Brattleboro Road INSURER C: PO BOX 47 INSURER D: Hinsdale NH 03451-0047 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1145R AL)U' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE DATE MMIDD/YY DATE MM/DD/YY GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY CPA180057211 07/15/03 07/15/04 PREMIsES(Eaoccurence) $250000 CLAIMS MADE X] OCCUR MED EXP(Any one person) $5000 PERSONAL BADVINJURY $ 1000000 GENERAL AGGREGATE $2000000 GLAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $2000000 PRO- AUTOMOBILE JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 A ANY AUTO CAA180057311 07/15/03 07/15/04 (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE x (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 71 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $TATU WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER A Property Section CPA180057211 07/15/03 07/15/04 Leased A Equipment Floater CPA180057211 07/15/03 07/15/04 Equipment 5000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLE$/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ROOFING CERTIFICATE HOLDER CANCELLATION TIMOMCN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Tim 0 McNerney IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 20 Linden Street Northampton MA 01060 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Rock River Consultin CO ACORD 25(2001/08) ACORD CORPORATION 1988 `- o � = Board of Building Regul bons and Standards =tl One Ashburton Place - _ - \� Room 1301 M Boston. Massachusetts 02108 Home Improvement Contractor Registration ��o Reqistration: 130327 Type: Private Corporation Expiration: 2118/2006 WILLIAM G. WALKER & COMPANY INC WILLIAM WALKER POBOX 47 HINSDALE, NH 03451 Update Address and return card.Mark reason for chang (-] Address n Renewal F7 Employment n Lost Card A`CORO CERTIFICATE OF LIABILITY INSURANCE OP ID DE DATE(MM/DD/YYYY) WILL-12 12/11/03 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Kinney Pike/Brattleboro ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 225 Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P. 0. Box 430 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Brattleboro VT 05302-0430 Phone: 802-254-2366 Fax:802-254-6132 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Acadia Insurance INSURER B: William G. Walker & Co, Inc. 759 Brattleboro Road INSURER C: PO BOX 47 INSURER D: Hinsdale NH 03451-0047 - INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'C - - POLICY EFFECTIVE-POLICY EXPIRATION LTR IN RD TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MM/DDIYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000000 - A X COMMERCIAL GENERAL LIABILITY CPA180057211 07/15/03 07/15/04 DAMAGE TO RENTED PREMISES(Eaoccurence) $250000 CLAIMS MADE X OCCUR MED EXP(Any one person) $5000 _ PERSONAL&ADV INJURY $ 1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $20 0000 0 POLICY, PRO- - JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 A -.-. ANY AUTO CAA180057311 07/15/03 07/15/04 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ ' OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- CTH-' TORY LIMITS ER EMPLOYERS'LIABILITY -_ _ ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? I E.L.DISEASE-EA EMPLOYEE $ If yes,describe under ---- -- -- ----- SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER A Property Section CPA180057211 07/15/03 ' 07/15/04 Leased A Equipment Floater CPA180057211 07/15/03 ' 07/15/04 Equipment 5000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION cob2d�Lkl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION The Commonwealth of DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Massachusetts - Dept of NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Industrial Accidents IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 600 Washington Street Boston MA 02111 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Diane B. Lon e ACORD 25(2001/08) fACARDRL-PIION 8 .► . Client#: 3334 WILGWA ACORD. CERTIFICATE OF LIABILITY INSURANCE 08/O1103D/YYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Sheppard Riley Coughlin ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 99 High Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Boston, MA 02110-2320 617 348-1900 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Liberty Mutual Insurance Company William G. Walker&Company, Inc. INSURER B: 759 Brattleboro Road INSURER C: P. O. Box 47 INSURER D: Hinsdale, NH 03451 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MMlDD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence) CLAIMS MADE r_1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: _ AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND TBD 08101103 08/01104 X WC LIMIT O R EMPLOYERS'LIABILITY T RY LIMIT ANY PROP RIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS This certificate will be superseded by certificate issued directly by carrier CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Massachusetts Department of DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL - 1 n DAYS WRITTEN Labor NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 10 Park Plaza, Suite 5170 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Boston, MA 02116 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE l.+lvA,A. ltd, ACORD 25(2001108) 1 of 2 #S65180/M65177 JMM O ACORD CORPORATION 1988 r• Rte: `"_<� F The Commonwe.a-li1z of Massachusetts Department of Industrial Accidents office Vf1WTeSff92L(0fiS 600 Washington Street Boston, Afass. 02111 %Vorkers' Compensation Insurance Affidavit location- ciry I am a homeowner performing all wcr-c myself. I am a sole proprietor and have no on working in any capacity I am an employer providing worken':ampensation for my employees working on this job. company name: William _ Walker & Cc)mpan�z, Tnr._ address: P.O. BOX 47 city: Hinsdale, NH 03451 phone#: 603-336-5539 insurance Co. See Attached pglicv# F1 I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the conmcxn listed below who have the following workers' compensation_olices: company name., address: phone#` insurance co'. company name- address- city- phone#- insurance coot#' Failure to secure coverage as required underSecnon aA of:NIGL 152 can lead to the imposition of criminal penalties eta fte up to S1.500.00 and/or one ye3m, imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100A0 a day zpi=me. I understand that a COPY of this statement may be forwarded to the Office of Investigations of the D Lk for coverage verification. I do hereby certify wider th p-ns an ;a naias of perjury 1/tat the inforrnwion provided above is true and�rtT 1 t SI?na^are i l.'�j �-- Date Print name William G Walker & Company, Tnr _ Phoncr6 043-336-5539 off cial use only do not write in this am to be completed by city or town official .. city or town: permit/license# r73adiug Department -7Uansiog Board C check if immediate response is required `-ectmen's Office r Halth Department contact person: phone -Crier .c• s.aa;.95 PJA) (rzty of Nort4ampton L �ASSAChITBltt4 � � DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Mein Street • Municipal Building Northampton,MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sups:,•isor. The stale 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 roueh 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 -t ttl�N hT �,�fy1 of �NartljcillTpf(1II 6 fRI[S l R111 11f;C t 15 _ LiEf'fiRZ'A1EArI Of' LUILDI?�G INSPL'CTIONS 212 Mnin Street Municipal Building a Northampton, Mass. 01060 WORICLRrS CONITENSATTON ImumU -NCF f rFij). viT (l1CvP.S°_�i'I"r;IIll itC^) with a principal place of bus' C-SSJre:,dente t'. CIO llcreoy ccr'dfvZ unfit-1- UIC pa inS I'ii0 pC:il"'.itIC5 O; 7(:r31lr`V, am an empioye.r providing the follo..ing .:orr_crs colnpcnsation --ov for Iny ctxlployces `vorEng on this job- sSa a-Adlzed (Ins =c- Compam) (P0 C- Ntzmlxr) ("rte pir ion Date) I any a sole proprietor, genera± conk-.or tjorlco:veer (cycle one) and have hired, contractors listed below;t l]0 it 'Lilt iOLI ,P.? woritP,2S coC peIIS'_-Oil %O?Ic:cS, (Namc of Contmctor) (inS� ,1C Cvlr^::i7i�G�1Cf Nll1Il f) ?'; . ..iC'> ate) (Name of contnczo-) (I11SJ.MPcz C Z Da:i d i cy I um,ly--f) Dale) (Namc of Contractor)) (IaFurazc� Comb an.;�i'G1i�; t�tul)rr�r} - =.z,. -:eon Late) - (Name of C ontrlctor) — (hist r_nc Cetnr Y't),Policy Numb=*) (E::ri-aiG Date) ( 1 ani ?. ,;Olt; proprictJi c1i!'1 ha vC 110 OI: U?"�1ii`� for IIIc; I amI 1 home i;�;?1Cr 'tiC?:C"I?11I' all NOT plcaac Lac awz c d:a:.t Lilt 6c<r�o szm .�r..ap!c;Ir- :'. .e_:!an Cc,ar:_': m cr rcY.ait« ..- not tutee th_n U-Soc unit-in N�'--di ce a; cr ezn to utirs t}r_Baca:a's cc:r-_:nticn rx' GL!52-=-1 tl!, �;ic::by a h mco«-,cr`cr e Lc=tze Ce p-ra:i: P Y� � �- ate;:C-- lcgil ctatuc of nn axmployor uoder thn Worko,'.Ca2,-;>r bon:`.CL I uzndc_-itsad thi a copy of o-i,j clztci.st r_:ay bo faw,vcSoS to tt»D-j>art'—d of 1zdzisuinl A,,& z 'Ciricw of i:::t,ri.-r,a for t!x cover-&&C vcri6calioc and t11--t failure to c-ire mt r ut 3: ct.iC 25,4 of?.(GL.152 can It--d to the imposifia cf c-ice oomistin of a flm-Of up to S I.SQO.00 a:r1'cr it:nrirx� oft: In cr, 3 P ? )'=:r.:.j civil pcnzltia in d4 Ic;nn c(a f r�of S 10.0 QW s day t✓r-in-t ttr. ` For iq ut trstsl use oily j Pcrmit Numtx:r r Q : T F , Jtr �lturc tit i.ict;a-:cJi'crnriar.-; ' _ � S�014,8.=CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : � ) License Number Address Expiration Date Signature Telephone Re ere 'orne uemen" ContYacto Not Applicable ❑ I Company Name Registration Number ) Address Expiration Yate CkCL e �+t C ? es I Telephone C.FO'1 5:36 x,537 SECTION i0"WORKERS' COMPENSATION INSxURANCE-AFFIDAVIT(M Ga.-.c'. 152,>§ 25C(6))11 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...... ❑ 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 S R PTatO F PROPOSED WORK check 11 a' lica le W � New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ Other [ ) Brief Description of Proposed Work: 10 SIR C at GA © �- Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No Attached Narrative 0 Renovating unfinished basement Yes ✓ No Plans Attached Roll 0 . Sheet 0 6a . e , o d or dd:ition t-o7existn i o s u n"g comphe a HOf0-F1 : 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. Mascheck 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 SECTIO� NERt)TyORIZATION TO BE COMPLETED WHEN OWf�tEFtS�GEORCO�ITRACTORAPPLfES 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/he foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name i Signature of Owner/Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF 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 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 _ No IF-YES, describe size, type and location: 1' Northampton �$u I g Department Main Street I om100 AUG - 6 20lUort' 1 ton, MA 01060 $ phone 413.5 7-1 40 Fax 413-587.1272 : nal 0,6t1 :i 1"dSFECTIONS ei =. �. 1�1`r1a?gpTi : UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 3„This sectio ��tote comp ete`tib offtce' �; , 1.1 Property Address: ' �0 Zlocrl (A MaP } q Zoned Q� rlaD�strtct �� Elm 't District f � CB Des rict�, SECTION.2 - PROPERTY OWN ERSHIP%AUTHO,RIZED Ad.ENT 2.1 Owner of Record: / �/ �r/ �// �_",., r t 6 /\ /�� N e r', e. X2 0 LI✓l Crf e v1 c. �)r � atyl, )" 0,4 Name(Print) Current Mailing Address: 13 ` 1 5 r Z� Telephone Signature _ 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone _. SECTf.OK-', - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official'Use Qnly completed by ermit applic ant 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) 'J uo j Check Number This Section For Official Use Only Building Permit-Number: Date.Issued: Signature: Date Building CommissionerA spector of Buildings --T 0 LINDEN ST BP-2005-0175 GIS#: COMMONWEALTH OF MASSACHUSETTS MW:Block 25C-205 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit# BP-2005-0175 Project# JS-2005-0196 Est.Cost: $5465.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WILLIAM G WALKER & CO 130327 Lot Size(sa.ft.): 5052.96 Owner: MCNERNEY TIMOTHY H& Zoning:URC Applicant: WILLIAM G WALKER &CO AT. 20 LINDEN ST Applicant Address: Phone: Insurance: P O BOX 47 (603) 336-5539 Workers Compensation HINSDALENHO3451 ISSUED ON:8112104 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL METAL ROOFING & SLATE REPAIR 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 Occ pagy Signature: FeeTVpe• Receipt No: Date Paid: Check No: Amount: Building 8/12/04 0:00:00 1157 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo