The URL can be used to link to this page

28-051 (2) al p�?liLlL ('NI Wood/Vlnyl,Composlte Frame f?+ti Baal I -tx Mer Dual Arpon Low IF Double HUPO U Factor((I.S)/I-P Solar Heat Gain Coefficient 13, is %33 • L \fi�311:i1e Tian;mittence 101481. i N. hC25 100-0023131-9-001" Jan 02 2007 15: 26 JPUMcKeone4lns 734 662 8101 P• 2 wwv7w;fyy'A ACORD, CERTIFICATE OF LIABILITY INSURANCE osi PRODUCER THIS CERTIFICATE IS ISSUED AS A-MATTER OF INFORMATION, Joseph MCKeone ONLY AND CONFERS •NO RIGHTS UPON THE CERTIFICATE cKeone Insurance Agency, InC. HOLDER. THIS CERTIFICATE DOES -NOT AMEND, EXTEND OR JP M ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 333 Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC0 NIURED Renowel by Anderson MVRFR A: Haftrd In3urange J&L Wlndcws jnc. INSURER O! 104 Otis St MUKA C: Nathborough, MA 01532 INSURER 0. 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 TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAAA. P�LICYNIiMEER POUCY096cTNE CYEX►RAn10N UNIT! B 0E+IERALVA IWTY HER8858850 9/7106 9/7/07 EACH OCCURRENCE : COMMERCIAL GENISRAL ABILITY PR i 1DO CLAIMS MADe ®OCCUR LIED EXP onr on s 10000 PERSONAL&ADV14JURY f GENERALAGGREGAn S 2 OO GEN'L AGGREGATE LIMIT APPLIES PER= PRODUCTS•COMPAOP AGO f 2.000.000 POLICY PRO LOC ' A "mmetRJ&LL*ollm 35 MCC XD 6388 1011105 10/1/07 COIANINEDS.*4LELPAIT ; 1,000,000 ANYAUTO IEP0oe 0 X ALLOANEO AUTOS GO WJ R LY Y S SCHEDULFOAUTOS HIREDAUTOS BOOILYINJURY s NON.O%AM*IDAUTOS- (Pr�ede�nq PROPERTY bA AGE' s (PIT�wa�nq GAAAQELUUILnY AUTO ONLT-EA ACCIOENT f ANYAUTC, OTHER MAN GA AOC s AUTO ONLY: AGO i OLCRIMM IAMi LLUIltILITY EACHOOCURRENCE f' OCCUR C,WAS MIAOE AGGREGATE i f DEDUCTIBLE R s RETENTION i vrcS A wonnouoow "kYlonAND 35 VRGNC8861 1/1107 . '111/08 TORY LWITS E4PLo my LJAERJIY E-L.EACH ACCOEW S A�Y PROPRIETOWPARERICKEGUTNE CERMEamER EXC LOEDT E.L dgEABE-EA EMPLOYEE s Kozo- M EE L 6wbemVM ELOISEASE-POLICYLq,11T L /ROVSKWS Eder OiwER . DE3CA1PtIOI Cs OPt1U1T/4Ni 1 L.DC.AT1Qai IvEHICLEE/EJl0.l!¢IONf ADDED EY EMDORLEMIENT/SPECIAL PRONsoftl CERTIFICATE HOLDER CANCELLATION i11ouLD AM'or M A00VE DEiCR TKO FOLJCK!K CANCEILiD BEFOOXE 111E vo*ATKIN GTE UIEREbF,THE I5701No *MOEN WLL ENDEAVOR M L A14 1j—DAYi H -INSURED COPY NoTKe TD THE CEIITIRCAW NDLDlR NAYED To THk LEFT,EDT rAlwE=E TO Do go 6144", AI►!p o OEUOATION 04 UAYLIIY of ANY KIND WON THE M IUM9 P1,its AGENTS aw pp 0 re al BY ANDERSEN® window replacement Board of Building Regulations and Standards License or registration valid for indiYidul use only HOME,IMPROVEMENT CONTRACTOR before the expiration date, If found return to' j Board of Building Regulations and Standards RoplSt/�Ilof% .049601 One Ashburton Place Rm 1301. 24/2008 kpir�Eto n ,11; r Boston, Ma, 02108 rivate Corporation RENEWAL BY JOHN ESI.ER 78 TURNPIKE WESTBORO, MA 01581 Administrator Not valid without signature fie i�o�nirnoxu�ea.� o�,/�aaasacc/%u4e� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR NumbeF CS„ 074251 ate..�. Birt u 963 x _ 097 Tr.no: 8556.0 JOHN K ESLER ti` �z? j y 78 TURNPIKE R4t,� r G- WESTBORO, MA O ,t3 Commissioner Renewal by Andersen • 104 Otis Street • Northboro.N A 01512 •Tel: 1-966-987-�;(,AQ 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 therein, 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 shalt 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 with 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-contractors)name(s), address(es) and phone numbers)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 carry workers' compensation insurance. If an LLC or LLP does have crnployees, a policy is required. Be advised that this affidavit may 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 Iike 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 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE . The Commonwealth of Massachusetts Department of Industrial Accidents Ogee of Investigations 600 Washington Street' y` Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/�Organization/Individual): &Ilk c 5—e,P,n Address: lam! City/State/Zip: �Wo Phone#:(9F) (?n- 0c Are u an employer? Check the,appropriate box: Type of project(required): 1. I am a y to er with 4. ❑ I am a general contractor and I # have hired the sub-contractors 6, ❑Ne construction employees(full and/or part-time). 7. Remodelin 2.[] I am a sole proprietor or partner- listed on the attached sheet. t g ship and have no employees These sub-contractors have 8. Q Demolition working or me 'many capacity., workers' comp. insurance. g Y P ty 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.Q Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c: 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ 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 ate doing all work and them hire outside contractors must submit anew affidavit indicating such tconactors 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. D A Insurance Company Name: �!-, Policy#or Self-ins.Lic....#: �W6 Gn c)EK I Expiration Date: . Job Site Address; PLA 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 maybe.forwarded to the Office of . Investigations of the DIA for insurance coverage verification. 1 do hereby cent' r th pa s and penalties ofperjury that the information provided above is true and correct- S' ature: Dater Phone#: 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.Plumbine Inspector SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: J�o �. Not Applicable 0 Name of License Holder:---�L �1_r L— !�-f --------------- ------ -- ---- ------------------- License Number A s Expiration Date - --------------------- . r r-- � p l�Q------------------ Signature Telephone WW.� ` corfalir M '�� Not Applicable ❑ =w L----- - ----------------------- -�`�-D_ c j------------------- Company Name Registra�tion Number -�0 ---- �-- ------ �y-�' s`1�Q -------- - _ 2 f—0"---------------- Address r Expiration Date -----------------—------—----------– ----Telephone_ 4! SECTIQN 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.1,52,§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 buildi ermit. 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 buildine 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 ❑ ReplacemenYVIindows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ J Decks ( ) Siding Other[ ) Brief WorkDescriptUtEolvaN d (�00T)c 6 V0 Alteration l AQ1�1�P� Alteration of existing bedroom------Yes_-----'No Adding new bedroom—___Yes No / Attached Narrative Renovating unfinished basement __ Yes __/_No Plans Attached Roll -Sheet 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.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 ping regulations? -------Yes—----- No . I. Septic Tank_____ City Sewer_ _____ Private well_----__ City water Supply ; SECTION 7a•OWNER AUTHORIZATION-:TO BE COMPLETED WHEN _,01AiWERS`AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT. - - - - U !------------------------------------------ --------- as Owner of the subject - property r^ hereby authorize __ I r _ Q�!IVl --------- _ ------------------------------------------- _____-- ---------— to act on my behalf, in all matters relative to work authorized by this building permit application. ---- _40-ant---------------------------------" ?` -------------------------------- Sign re of Owner Date I.___�! V ► __ 1_Z_° ___—_ _ _ _ _ _ _ _ _ ________,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ---- -------------------------- ----------------------------------- ----------- Print me 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 tilled 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_ i' YES IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? r" 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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone,413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be aktmptet office A 1.1 Proaertv Address: *:- r Map' _ Lot_ Hitt;! 9t/`�."/ , �44�KJ1 7 V., ^ag ^..1'bay' 3t6 SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ------------------------- - --R - ----- � Name(Print) Current Mailing AAdress: ------------------- -- ---- ---------------------------- T frepqQqe\ 5 — -510^ Sig ure 2.2 Authorized Agent: -fah-- F '------------------------------ 1.0?---��-- ---- &A��94 Name t) Current Mailing Address: ----------------------------- -- ure---- ------------------------ --------------- Telephone hone SgCTIOtj 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars)to be Official Use Only completed by ermit applicant 1. Building �l (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 c 6. Total =0 + 2 + 3+4 +5) FT 5 Y Iq Check Number This Section For Official Use Only Date Building Permit Number:_—----—-------- —__—_-____ Issued—----------------------- Signature: ----------- Building Commissioner/Inspector of Buildings Date BP-2007-0807 GiS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Windows replaced BUILDING PERMIT Permit# BP-2007-0807 Project# JS-2007-001114 Est. Cost: $5914.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RENEWAL BY ANDERSEN 149601 Lot Size(sq. ft.): 12632.40 Owner: DOSTAL JAMES M&NANCY L Zoning: SR Applicant: RENEWAL BY ANDERSEN AT. 624 RYAN RD Applicant Address: Phone: Insurance: 104 OTIS ST (508) 919-0900 WC NORTHBOROMA01532 ISSUED ON:212312007 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 7 REPLACEMENT WINDOWS 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 2/23/2007 0:00:00 $25.003612 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo