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31A-147 (4) Paychex, Inc. RF 10/23/2014 9: 26: 513 AM PAGE 3/003 Fax Server CERTIFICATE OF LIABILITY INSURANCE 110/23/2014DIYYYY) 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 Paychex insurance Agency Inc PAYCHEX INSURANCE AGENCY,INC. IN 150 SAWGRASS DRIVE PA CNNO.EXT: 877-266-6850 A/c No): 585-389-7426 ROCHESTER, NY 14620 E-IMAIL Certs @paychex.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: NorGUARD Insurance Company 31470 KEITH GUYER INSURER B: 60 RIVER ST BERNARDSTON,MA 01337 INSURER C: INSURER D: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MMIDDIYYYY) (MMIDDIYYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PR MISES Ea occurrence $ =�LAIMS-MADE[�CCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY =PRCJECT=LO( $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY ALL OWNED O SCHEDULED (Per person) $ AUTOS AUTOS NON OWNED BODILY INJURY $ HIREDAUTOS AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB O OCCUR EACH OCCURRE NCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ FED RETENTION$ $ WORKERS COMPENSATION AND X WC STATU- OB A EMPLOYERS'LIABILITY KEWC527899 05/22/2014 05/22/2015 - ----- I E.L.EACH ACCIDENT $ 100,000.00 ANY PROPRIETOR/PARTNER/EXECLT IVE OFFICER/MEMBER EXCLUDED? Y/N E.L.DISEASE-EA EMPLOYEE $ 100,000.00 (Mandatory In NH) FY N/A E.L.DISEASE-POLICY OMIT $ 500,000.00 If yes,describe under DESCRIPTION OF OPERATIONS helaw DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF NORTHAMPTON S 10ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 212 MAIN ST DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY NORTHAMPTON,MA 01060 PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORISED REPRESENTATIV I 1 �, ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership.,association,corporation or other legal entity,or any two or more of the.foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides thereL-i,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance rAjth the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to cant'workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts Department of bidustrial Accidents Office of Investigations 1 Congress Street, Suite 100 G Boston, MA 02114-2017 www.mtrss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Ji' -1 Phone #: l�j "��� -No U-7 Are you an employer? Check the appropriate box: Type of project(required): 1.4 I am a employer with C 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hued the sub-contractors 6. ❑New construction 2.El I 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.insm-ance.1 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.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4), and we have no employees. [No workers' 131-1 Other comp. insurance required.] *Any applicant that checks box#1 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 mid job site information. Insurance Company Name: 7PAYJ- ]V-\jyy'gn' A _ 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 certi y under the pains and penalties of erjury that the information provided above is true and correct. Signature: Date:' /2Z _3Z11 Phone#: C) 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#: !,lassacl., usetts - -Depar-me'l-c-f Boarci of Fiji'.dm-q Rgui anc-G and RL Office ofConsunstr Affairs&Sumuess tftgu"On n,,ruct turn i,n Su p,e:-A i,o 5z, Mi-*061t IMPROVEMENT CONTRACTOR ADCIISV~�. -171657 Type, _�cense: CS4Mi43 �4 -12 Ole individual I . KeithEGUYcr KEITH GUYER street 60 River Dernardston MA-41337 KEITH GUYER 60 RIVER ST BERNARDSTON,MA 0131 Understcretary unrestrm_­_�_- �_�zr wtv we ZMD WJUCD Lkeme or reektratmi vafid for indiwidul we only can Im ffim 35-000 cubie fed MIMI Of be%re the ex0bration date. U found return to- ~1^404 Ofte of Consumer A110n and Susibm SeguiRl" to Park rhm-Soft Sm ftston.MA Wift Falture to pomm a arrent miften of the MmwhweUs Stift Sue&ng Code is cause for revocagon of"Boers. mg"ad woad For DIPS Umnift NOW-NOW www I I Gov/am SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ i Name of License Holder: e, C f-) License Number �'S� 1r t� � cr 5 (➢'� /Y b133 7 ?—P l6 Z-C)j(c, AZ�= Expiration Date C.. 0 Signature Telephone 9. Registered Home Improvement Co Not Applicable ❑ ntractor: i _ Company Name Registration Number Address °' �/ a Expiration Date ( �`� ' kA gr �Iz Telephone UAW 0107 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. e 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 ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 17 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other[CQ Brief Des of Proposed ? Work: ¢ � — T(7tf � ��a"1 — vex Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing. <;omplete the following: a. Use of building : One Family Two Family -Other b. Number of rooms in each family unit: Number cf 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 1 i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No t. Depth of basement or cellar floor below finished grade I 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 I, AqO( �/1)" "/ CX as Owner of the subject property f hereby authorize to act on my behalf, in All matters relative t work authorized by this building permit application. 41 4-//:1 Signature of Owner Date I, f^ J27Z 6 U as Owner/Authorized Agent hereby dec are that the statemehts and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed nder the pains and penalties of perjury. Vv Print ame � d��3�� Signature of Owner/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 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES I 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 0 NO 0 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. �..��r _.,......�...,..� � , pia I Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 0 212 Main Street Sewer/Septic Availability "' Room 100 Water/Well Availability " Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans rd 6 Other Specify t ATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 4 SECTION 1 -SITE INFORMATION 1.1 Property Address: 11 This section to be completed by office O� �1�(-bea f II VC_ , Map Lot Unit Zone Overlay District t" Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print).) Cua: r�nt Mai g Address: Telephone Signature 2.2 Authorized Agent: 61711 GVVEZ Name(Pr n Current Mailing Address: Nib 9 06o 7- Signatur Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (.. ( ya (a) Building Permit Fee 2. Electrical !v (b) Estimated Total Cost of Construction from 6 3, Plumbing Building Permit Fee i 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 +2+3+4 +5) Check Number 5 This Section For Official Use Only Building Permit Number: Date i Issued: Signature: Building Commissioner/Inspector of Buildings Date 16 FORBES AVE BP-2015-0478 GIs#: COMMONWEALTH OF MASSACHUSETTS MV: 31A- 147 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-2015-0478 Project# JS-2015-000910 Est. Cost: $4800.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEITH GUYER 095143 Lot Size(sq. ft.): 7840.80 Owner: FOGEL PAULINE GOLDWATER&BRUCE M FOGEL Zoning: URB(100) Applicant: KEITH GUYER AT: 16 FORBES AVE Applicant Address: Phone: Insurance: 60 RIVER ST (413) 768-0607 BERNARDSTONMA01337 ISSUED ON.1012712G�14 0:00:00 TO PERFORM THE FOLLOWING WORK.[REPLACE FLAT ROOF & 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 it 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 sismature: FeeType: Date Paid: Amount: Building 10/27/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner