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07-013 JASME-1 OP ID:JT ACORO" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07128/2014 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 POLICIES 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). NT PRODUCER NAME:CT Raymond Lukas Chase Clarke Stewart&Fontana PHONE 413-788-4531 (A/C,Ne:415-214-6160 101 State Street,P.O Box 9031 AC No E# Springfield,MA 01102 aE AIIE Raymond Lukas SS:riukas@chasoins.com INSURERS AFFORDING COVERAGE NAIC N INSURER A:Northland Insurance Companies INSURED JASM Enterprises LLC INSURER B:Liberty Mutual Assig Risk Jeff Bradshaw INSURER C:Arbella Protection 41360 PO Box 1276 Chicopee,MA 01021 INSURER D:Arbella Mutual Insurance 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 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. INSR TYPE OF INSURANCE A DL BR POLICY LIMITS LTR POLICY NUMBER POLICY Y IDD/YYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE PCI OCCUR X WS201289 06/2012014 06/20/2015 PREMISES Ea occurrence $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY❑ J PRO ECT ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 Ea accident)_ C ANY AUTO 1020008523 10/05/2013 1010512014 BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS AUTOS Per accident X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,00 D EXCESS LIAB HCLAIMS-MADE 4600052470 09/01/2013 09/01/2014 AGGREGATE $ DED I X I RETENTION$ 10000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA C2.31 S-372772-014 05/02/2014 05/0212015 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate Holder is listed as additional insured on a primary and non- contributory basis in respect to General Liability CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE Raymond Lukas ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety Board of Building Regulations and Standards ('onstruction Supers isor License: CS-094734 JEREY ' POBOXM '1276 A BR*D MCOREE KA 41 0; 'j Iq Expiration Commissioner 11011I3!2015 Unrestricted - Buildings of an% use group ivhich contain less than 3>.000 cubic feet (991 rin )of enclosed space. AV Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. for DPS Licensing information visit www.Mass.Gov/DF`S "7"L(f'(:/fif,/ ol"-C—?�.J4J'C�f�C//G�Si✓��' N Office of Consumer Affairs and Business Regulation 10 Park Plaza L Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 166074 Type: LLC Expiration: 4/21/2016 Tr# 249390 JASM ENTERPRISES LLC JEFFEREY BRADSHAW P.O. BOX 1276 - CHICOPEE, MA 01201 -- ----- - Update Address and return card.Mark reason for change. SCA 1 w 20M-05/11 Address F Renewal Employment F Lost Card �J�e (!eJrt JSU�tttveCtt�ft t�C�l'��oir'CLC�ttt,:r�fG Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: `1,68074 Type: Office of Consumer Affairs and Business Regulation xpiration: 4f2V2016 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 JASM ENTERPRISES LLC JEFFEREY BRADSHAW 805 NEWBURY ST SPRINGFIELD,MA 01104 Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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): �I l I t , C n le P r i J C-� L L Address: P6 8C) X 2 7 CD City/State/Zip: �-A ( C Cpe k)- �r 01 b-Z ( Phone #: q/3 '3G 1 S 0 1 6 Are you an employer?Check the appropriate box: Type of project(required): 1X I am a employer with 5 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs ff )) insurance required.] t employees. [No workers' 13.1Z Other L D Sv 1 c:z T 101? comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. , Insurance Company Name:_ L 1 Uty ��� U t U Ck P C> L� Policy#or Self-ins.Lie.#: VC -3 J J Z 3 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 ce un r the pains and penalties of perjury that the information provided above is true and correct Si mature: Phone#: / 2 } 5 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#: r► � C mass save CONTRACTOR SrAK&tnrngio eftni r esSid*VK r �► PERMIT AUTHORIZATION FORM 1, Dana Pasquale ,owner of the property located at: (Owner's Name,printed) 390 N Farms Rd Florence (Property street Address) (city) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. pp X U aJ�s Owner's Signature Date FOR CSG OFFICE USE ONLY 'Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: X5171 CnIer rises 21c 8-/81y Participating Contractor Date o�Ja M For OfFtce Use only Rev.12132011 r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) J r f ( ('"lit-,A(A(t_? License Number Expiration Date Name of CSL Holder List CSL Type(see below) PC) roc-?x /J 7C _ No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwellin City/Town,State,ZIP M Masonry RC Roofing Covering -- WS Window and Siding -e7113 y�y`, SF Solid Fuel Burning Appliances e, I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) l6 6 0 1 y. y_2� � y 7J 5, ) �f e rp(" Vic°j L L L HIC Registration Number Expiration Date HIC Comp any Name or HIC Registrant Name 7 'JoX iZ,G Jf�`�, G�C1 .CGrVI No.and Street Email address City/Town,State,ZIP Telephone SECTION 6: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...........0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT � r 1,as Owner of the subject property,hereby authorize � 2�,f ; f G1L(5�l l --- to act on my behalf,in all matters relative to work authorized by this building permit application. L7 f : Print Owner's Name(Electronic Signature) Datc SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Jeri Print Owner's or Authorized Agent'S Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/ s 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces _ Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Otherrj Brief Description of Proposed —7' b e F�d U r O P�?n yJ low CeAulose- y`, over /d 75 irf Z Work: /—� Alteration of existing bedroom Yes X No Adding new bedroom Yes �_No Attached Narrative Renovating unfinished basement Yes AC No Plans Attached Roll -Sheet 6a. If.New house and or addition to existing housing, complete the'following: a. Use of building : One Family X 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 l e- k lLr�ze {nrm as Owner of the subject property (�r J hereby authorize �LC r ad to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I Ta-a 6Jaol5/f &J as Owne u�thorizeld Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best o mge 9 Y and belief. Signed under the pains and penalties of perju � l3 r�ads�aw` Print Name Signature of 0 ge Date Section 4. ZONING Alt 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 7 Side L:l R:, - f L: _ R: Rear ..., Building Height Bldg. Square Footage ° a/o Open Space Footage _ % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: n volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO lop% DON'T KNOW 0 YES Q IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q IF YES: enter Book Page! and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained ® , Date Issued:w C. Do any signs exist on the property? YES 0 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: . E. Will the construction activity disturb(clearing,gradirq,e cavation, 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 Managem nt Permit from the DPW is required. ✓1 _ �. City of Northampton Building Departments �Ert ���� � � �i 212 Main Street See + ts1�fy' Room 100 Wat�r? eU$/ l( Vltabilt5 rX AUG 1 9 2014 --4 rthampton, MA 01060 ' t fS rt air ns ° phon$41 -587-1240 Fax 413-587-1272 Plotlifr3 Puns Electric, PiumLing&Gac i -peotions - t r. t RF u,u60 Othrf,Sp'G►fy _- ^^.,., � p :' 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 90 !V F0 r.m S /(0, / Map Lot Unit F—l®ren ee- , M h 01062- " /C) 78 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Dana va/e- 3YO Al ral'ins 16 Name(Print) Current Mailing Address: 6'e- A��o�Sze- �I-In Telephone Z Signature --113 �� 2.2 Authorized Agent: �� f3�ads aw 14 -JY1621a �<�eelee Name(Pr i Current Mailing Address: 4113 256 Sr f y16 Si re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building f Cl j (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) 410. ',�a Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0202 APPLICANT/CONTACT PERSON JEFFREY BRADSHAW ADDRESS/PHONE P O BOX 1276 CHICOPEE (413)427-5481 PROPERTY LOCATION 390 NORTH FARMS RD MAP 07 PARCEL 013 001 ZONE RR(100)/WSP(100)/WP(19)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 094734 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORM TION PRESENTED: 4,--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 o ' ' n la 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. 390 NORTH FARMS RD BP-2015-0202 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 07-013 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-0202 Project# JS-2015-000386 Est. Cost: $1440.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEFFREY BRADSHAW 094734 Lot Size(sg. 1): 37418.04 Owner: PASQUALE DANA C Zoning: RR(100)/WSP(100)/WP(19)/ Applicant: JEFFREY BRADSHAW AT. 390 NORTH FARMS RD Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427-5481 WC CHICOPEEMA01201 ISSUED ON.•812112014 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION 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 Si¢nature: FeeType: Date Paid: Amount: Building 8/21/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner