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18D-023 NEWENGL-20 JROBEDEE .4`CO�RV' CERTIFICATE OF LIABILITY INSURANCE DATE 8 4/2 DYYYY) 8/412014 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). PRODUCER CONTACT NAME: AP Intego Insurance Group,LLC PHONE — PAx 144 North Road A/C No E:t: 800) 274-4532 _ A/C Nom____ _ Suite 2050 E-MAIL Sudbury,MA 01776 ADDRESS:_ -- -r------ INSURER(S)AFFORDING COVERAGE _ NAI_C_ # INSURERA:Guard Insurance Group 25844 INSURED ----- -_.--- -- — INSURER B: NEW ENGLAND GREEN HOMES LLC INSURER C: 59 E MAIN ST INSURER D Stafford Springs,CT 06076 -— --- 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 AD POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR i�AFiAZ'ET61'FEfJTE� PREMISES(Ea occurrence) _$ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE POLICY PRO LOC ! PRODUCTS-COMP/OP AGG $ E JECT -_---- — i OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ r—� AUTO PROPERTY DAMAGE NON-OWNED ( 'Per accident $ r HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCU , RRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE I $ FDED I RETENTION$ $ i WORKERS COMPENSATION X PER OTH- IAND EMPLOYERS'LIABILITY YIN STATUTE ER _ A !ANY PROPRIETOR/PARTNER/EXECUTIVE NEWC529637 08/01/2014 08/01/2015 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑ NIA -- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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. Thi Frances Ave. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Cranston,RI 02910 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Print F©rrn- Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): New England Green homes Address:59 East Main Street City/State/Zip:Stafford, CT 06076 Phone 9:860-930-7794 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer witl_ (20 4. ❑ I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ 1 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' [No workers' comp. insurance comp. insurance.+ 9. E] Building addition 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.7 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#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. 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:Intego Policy#or Self-ins. Lic.#:NewC424991 Expiration Date: oR I zQ1 3 Job Site Address:All Steets in 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 cepnXv under the pains and penalties ofperjury that the in ormation provided above is true and correct. Si nature: '- Date- Phone#: k�_O) Rq, �_fj 1 2��15 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 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1(653 f � iZ 12,1 15 O O t- 'N� { 0 License Number Expiration Date Name of CSL Holder a List CSL Type(see below) S 11 E�-t_' M 4+N _5 No.and Street Type Description Q U Unrestricted(Buildings u to 35,000 cu. ft.) K��gP � ��`'� z C'r �� R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1�3 �i � T� , �� HIC Registration Number Expiration Date HIC Company Name o HIC Reis rant Name O v 5q �s-r �i INI — f-i-r e No.and Street Emai a dress Vi c?C wo,130 �-7a94 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 ..........*0 No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property, hereby authorize_ rnt-s to act on my behalf, in all matters relative to work authorized by this building permit application. c*,i Wiz-, q 11 G1 Iq Print Owner's Name(Electronic Signature) Dat SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information con i e in this application is true and accurate to the best of my knowledge and understanding. Prin v er's or Auth rized ent s Name(Electronic Signature) Date NOTES: 1. An Owner who obtains ding 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.g.w/oca Information on the Construction Supervisor License can be found at www.niass.gov/dps 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" �►- `, , , � .. .. A ..�..� ,M EP 1 8 2014 The Commonwealth of Massachusetts FOR oard of Building Regulations and Standards assachusetts State Building Code, 780 CMR MUNICIPALITY 8��1nsP�MOnR USE am ermt Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One- or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Dat p 'ed: Building Official(Print Name) Signa re Date XV SE TION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 3 3 N�112c�bt 61 Ky� i 1.1a Is this an accepted Street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(fl) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owners of Record: E5C)K1 ODKMAM On A , Name(Print) City, State,ZIP 3-3 MA B 6 ite-4C MOO 55L--014 09 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 1:1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other X Specify:_ Brief Description of Proposed Work':_ - b VJ_ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Suppression) .�- Check No.qW Check Amount s' Cash Amount: 6.Total Project Cost: $ y q9, ❑ Paid in Full 11 Outstanding Balance Due: File#BP-2015-0325 APPLICANT/CONTACT PERSON JOHN PERRIER ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794 PROPERTY LOCATION 33 PINE BROOK CURVE MAP 18D PARCEL 023 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin E rmit 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 105319 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO jA4ATION PRESENTED: pproved 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 D molition Delay Sign re o uildi fficia 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. 33 PINE BROOK CURVE BP-2015-0325 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18D-023 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-0325 Project# JS-2015-000605 Est.Cost: $2449.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN PERRIER 105319 Lot Size(sq. ft.): 13634.28 Owner: LIMA FREDERICK P&EVELYN A TRUSTEES zoning: URB(100)/ Applicant: JOHN PERRIER AT. 33 PINE BROOK CURVE Applicant Address: Phone: Insurance: 59 EAST MAIN ST (860) 930-7794 WC STAFFORD SPRINGSCT06076 ISSUED ON:912212014 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 Shinature: FeeType: Date Paid: Amount: Building 9/22/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner