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31B-151 (6) CERTIFICATE OF LIABILITY INSURANCE °"TED 9106/1'4 THl8 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 1 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:: Hthe ceYtificett holder is an ADDITIONAL INSURED,the policy(iea)must be endorsed. if SU&ROGATION!S 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 endoreement(s). CONTACT- PRODUCER _____...._.__.....�; NAMeE�- .._............... _.._ _.�...__ ..._.. { Parodiso Financial&Ins Sfvs.t_LC P H 1860}684 5270 Favc 880)851.8564 o r:01 1__�S1 8 East Main Street AQGHE55_ pnlstlisoC�parTOisnlnsurance rom Stafford Pftone S(8r 60)s 6.8C4T.5026078 7 Fax (860)851 9564 A Nnuraus INSURANCE COMPANY 17370 (INSURED :i IRSUNER 0__Atictdlf. 19232 Now England Green Homes LLC I IN fiEq c I owb No o,al 25496 159 East Main St INSURER O 114SUR£FI E,. .__._._. Stafford Springs,CT 06076 C_OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: �..__....,_. ___ __.._.. .._�_....... THIS ISTO 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 CONEY!ION OF ANY CONTRACT OH OTHER DOCUMEN"WITH RESPECT 70 WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POI 10175 DESCRIBED HEREIN IS SUBJf;Cr TO At I.THE'.TERMS. i EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BF EN f1F OUCEO LAY PAID CIAI_MS, rIN N - UBRI�_...... .__f`SZ... .�fl.EA.. .. 'j ll v E f1 i POI Y ML- - 1 .__. _ vYY Y1YY TYPEOFINISURANtiE LI¢Y NIM N Lwrrs .. __—. _.._ ... t !GENERAL UAINUTY —..._.~.., EACH OCCURRENCE -{r-,S��000'()X It I! I I , DAMAGE TI)'�fi�N�E�--�!s 100,00000 COMMERCIAL GENERAL tNBILITV , !Pgf<MIyES_Fj,,�•yC.G149f1fi9...t........_...___ ..._� Irk � CUIMS•MADS W) OCGVR VtJ EXPIAy e11-0 S 500000 I NN386246 A Y osn&2D1a ;09;1Br2Ut51 I .. i I RFRSONAI s AUV Ndvar ! g i 000 000,00 j GF NERAL AGGREGATE , S 2.000 OOO 00 '^ ........_.._. .. ...... _ .. Of PROOI, GENT AGGRECu1TE LIMIT APPLIES PER c I S COMP AGG 1 5 2 000 OLIO 00 s _._..__. .._.� �. .R.._ I AUTOMOWLE LIABIUTY _.... _ 4(a dg[j nUS NCLE..MI._._.I..1../000 0()0.00 ! ANY AUTO BOJ4 v INJ RY IPM oarSJnl_I 5 .. _ -._..� ....: ALLpwNED SCHEOU:.ED .648199456 BOUIL•IN,,UR SPe accde u S I 13 I � Os AUTOS 10104,12014 10.,10412015 _.._.. NON OWNED t f P�iOPERTY DAMAGE S i HIREOAUTOS K7 AUTOS ) ( ', I I .l._114A�An1L_........._.._.._..._ s _,_...._.....-I 1 l UMORELLA OCCUR FA,'"UL ✓NHENGt _ _S. 1 000�OOO,tll7 G EXCESS UA8 �,_-_ �/ 235650140ALI CuUM5�MA0k. 1 �04i23i1014 -0403.'2015 AUC na On c 15 1,000.000 00 }i,L�_lr _ LN. P f ..... woRXERacoMPENSanoi+ '-_ _!_.�._._..._._. __-- _ _.__. we s'iAe✓ _:oTl,!� I AND EMPLOYERS'LIA6eJTY Y;N ANY PROPRIETORIPARTNERIEXECIJYIVE ! OPRCERIMEMBER EXCWOEO' N A o r ct- I ' cry In NHJ Ry9as d4svibe 0 FJPT10_4 OF OPERATIONS 4,10 _......_ I I i I I1...--. ... 1 DESCRIPTION OP OPaRAYION9 I LOCAYIOMS i VEHICLES JAtOah ACORD 101.Addibanal R-k&Scneaule,IT more VP�ee is required) I COLUMBIA GAS OF MASSACHUSETTS IS ADDITIONAL.INSURED i ' I CERTIFtCATEHOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I I COLUMBIA GAS OF MASSACHUSETTS i THE EXPIRATION DATE THEREOF,NOVIC6 WILL BE DELIVERED IN ) ACCORDANCE WITH THE POLICY PPOVIS10NS, 2 TECHNOLOGY DR SUITE 250 , WESTBOROUGH,MA 015Bt AU THORIYEO REPRESENTATIVE � ..- _�—__- ._.......... _....__._.. ...-. _ �!t9r1&•2010 ACORD CORPORATION. All rights resbrved. ACORD 25(2010/05)OF The ACORD name and logo are rogistersd marks of ACORD NEWENGL-20 JROBEDEE CERTIFICATE OF LIABILITY INSURANCE DATE 1 8/4/2 0714 4 8!4!2 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(les)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 endorsements). PRODUCER CONTACT NAME: AP Intego Insurance Group,LLC PHONE (800)2744532 ac No 144 North Road Suite 2450 E-MAIL Sudbury,MA 01776 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Guard Insurance Group 25844 INSURED INSURER 0: _ NEW ENGLAND GREEN HOMES LLC 39 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 CONTRACTOR 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. ILTR TYPE OF INSURANCE POLICY NUMBER MM1001YYYY MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE FI OCCUR I'PREMISES iEs occu $ MED EXP(Any one person) $ _ PERSONAL&ADV INJURY $ GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E POLICY❑ PRO- JECT El LOC PRODUCTS-COMMOP AGO S OTHER: S AUTOMOBILE LIABILITY Ee accident)I li ANY AUTO BODI LY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per aCCldenl) S AUTOS AUTOS HIRED NON•OVJNED PROPERTY DAMAGE S AUTOS Peraccident S UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESSLIAe CLAIMS-MADE AGGREGATE S DED I I RETENTIONS $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY S ATUTE R A ANY PROPRIETOPJPARTNERIEXECUTIVE YIN NEWC629637 08101/2014 08101/2015 E.L.EACH ACGDENT $ 600,E OFFICERMIEMBER EXCLUDED4 N!A (ARandatcry In NH) E.L.DISEASE-EA EMPLOYE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORO 101,Additional Remarks Schedule,maybe attached if more space!*mcpAred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielseh Engineering,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave. Cranston,RI 02910 AUTHORIZED REPRESENTATIVE / ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts ❑�,� ' Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 IF Boston, 41A 02114-2017 www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/tndividual):New England Green homes Address:59 East Main Street City/State/Zip:Stafford, CT 06076 Phone 060-930-7794 Are you as employer?Check the appropriate box: Type of project(required): 1.Z 1 am a employer with 4 4. ❑ 1 am a general contractor and i Cmployces(full and/or part-time).* have hired the sub-contactors 6. ❑New construction 2.El am a sole proprietor or partner- listed on the attached sheet, 7. ❑ Remodeling ship and have no employees These sub-contractors have $. ❑ Demolition working forme in any capacity, employees and have workers' cote insurance.' 9• ❑Building addition [No workers'comp. insurance p required.] 5. ❑ We are a corpvratiun and its 10.❑ Electrical repairs or additions 3.❑ I am s homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself.[No workers'comp. right of exemption per MOL 12.❑ Roof repairs insurance required.]' c. 2 §I(4[,and we have;no em P to y ces. [No workers (3,❑Other\ C � comp. insurance required.] *Any applicant that cheeks box N I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this uPPidavit indicating they arc doing all wurh and then huv vutside contractors must submit a new affidavit indicating such. 1Contraetom that check this box must attached an additional sheet show~ing the name of the subcontractors 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 informealon. Insurance Company Name:Intego Policy#or Self-ins. Lic. #:NewC424999 Expiration Date: 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 cuveragc vorin,.;atiQn. 1 do hereb certify u der the pains acrd enalties pf perjuiy that the in brmatlon provided above is true and correct Dater-77, /" Phone#: <DvD OJf1cl4l use only. Do not write in this area,to be completed by city or town ofj'Icia[ City or Town: Permit/License N Issuing Authority(circle one): I.Board ofHeallb 2. Building Department 3. Cityf vwn Clerk 4. Flectrical inspector s. Plumbing inspector 6,Other Contgct Person; Phone#: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 10G319 12. 121 13' m t-'p}�(V -1�,R,1 License Number Expiration Date Name of CSL Holder — $. List CSL Type(see below) No.and Street Type Description r. U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted l&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 I�mprovement Contractor(HIC) I'R OZ( Ile =&A PI eIIe~lz, HIC Registration Number E-Xpiration Date HI CC ompany Name o Hlt Re is rant Name O c No.and Street p Email a dress Ci /Town,State,ZIP Tete hone 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........... ❑ 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 NW ENC 1fi_C to act on my behalf, in a]]matters relative to work authorized by this building permit application. ,- -)I)h V1 Oe"n, M , 11, Print net's Name(Electronic Signature) Date 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 contained in this application is trug and accurate to the best of my knowledge and understanding. J i V1 ki f;VJ fir, h3 Print bwne�rPs or Authoriz d Agent's Name(Electronic Signature) Date NOTES: I. 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.eov/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" si NOV T e Commonwealth of Massachusetts Board of Building Regulations and Standards FOR g&Uas�nsF:eeti� IMassachusetts State Building Code, 780 CMR MUNICIPALITY LITY tin, M.A.01 DSO Building Permit 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: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers y �\ r-C\ L la Is this an accepted street?yes n0 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) J City,State,ZIP No.and Street Telephone Em `il Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) O Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units _ Other ® Specify: Brief Description of Proposed Work2: 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: S 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: Suppression) Check Wo Check Amount:��Cash Amount: 6.Total Project Cost: $ + '� ❑Paid in Full ❑Outstanding Balance Due: File#BP-2015-0527 APPLICANT/CONTACT PERSON JOHN PERRIER ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794 PROPERTY LOCATION 17 TRUMBULL RD MAP 31 B PARCEL 151 000 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building_Permit Filled out 2 2 Fee Paid lypeof 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 INFOPMATION PRESENTED: 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 lay 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. 17 TRUMBULL RD BP-2015-0527 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 B- 151 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-0527 Project# JS-2015-000991 Est.Cost: $2350.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin: JOHN PERRIER 105319 Lot Size sic. ft.): Owner: VOLLINGER CATHERINE Zoning: Applicant: JOHN PERRIER AT. 17 TRUMBULL RD Applicant Address: Phone: Insurance: 59 EAST MAIN ST (860) 930-7794 WC STAFFORD SPRINGSCT06076 ISSUED ON.111712014 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 Signature: FeeType: Date Paid: Amount: Building 11/7/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner