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17C-150 Client#: 1553 DOUGL1 DATE(MM/D ACORD,. CERTIFICATE OF LIABILITY INSURANCE 09/14/07DiYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION King&Cushman,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Kin &Finn Streets HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 447 Northampton,MA 01061 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Peerless Insurance Douglas P Ferrante/Skyline Design INSURER B: P0 Box 60142 INSURER C: Florence,MA 01062 INSURER D: 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 TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1 POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY LIMITS A GENERAL LIABILITY CCP8251649 04/07/07 04/07/08 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $50,000 CLAIMS MADE D OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FI CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND WC8304684 0]/30/0] 07/30/0$ WC LIMIT OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100 000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS **Workers Comp Information** Voluntary Compensation Prem-568.00 Lmt-1 Prem- (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Michael Kasper DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _10 DAYS WRITTEN 106 High Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Florence, MA 01062 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. RUTH RIZED REPRESE T ACORD 25(2001108)1 of 3 #7014 LMB © ACORD CORPORATION 1988 g�t1AMP�. , O O LrZ �1 of QZ �Il1t�JIIIi Z = $ � �J lasaRCf�usetfs , DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 s ` HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as i:is/her construction sups::.-i or. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backlill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 M =� www.mass.gov/dia Workers' Compensation InsuranF e Affidavit: Builder /Contractors/Electricians/Plumbers Applicant Information o J l U �t�r� O� Please Print Le ibly Name(Business/Organization/Individual): ` 1 1 I Address: l a y o S 0I Y Z City/State/Zip: Rdf PPACp Phone.#: L/6 L/ 7 Ar you an employer?Check the appropriate box: Type of project(required): I am a employer with 2 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g. F_�Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp,insurance.$ 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 1 Roof repairs . 152, 1(4),and we have no ----___-_--- - - _ insurance recLuired]_t c §_ — __-- employees. [No workers' 13. Other comp.insurance required.] Ectiy app tcan a c ec ox ms a so t out a sect a ow s owing etr 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. j 1,0ss Insurance Company Name:_ 'P r rV,S,J r e", l ,p Policy#or Self-ins.Lic.#: l��l 2 14 ( � / Expiration Date: — O~f 0 Job Site Address: G � l S �`(O�f tl Ce 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 file 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 Gerd under the pains and gnaldes of perjury that the information provided above is true and correct Si afore: Date: _ % �� 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.Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ �A Name of License Holder: ��C/�1 �� ` � C 0(9 2'72-2 License Number C,0 /4a Vdo 4 JJ 0 "1 qg ' /d - Z — 0 Address Expiration Date Si r / L elephone 7 9:Reiiislei'eil e" ­K-Fovement ConEractor y­, , a � m Ja ... Not Applicable ❑ �v S ; l00 o Companv Na ft Registration Number Address Expiration Date +n^ / c Telephone �C 7 �j — 2 (' 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. Signed Affidavit Attached Yes....... ❑ No...... ❑ 11-2 et(l WWA6 r xeinpt�o 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-vear 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 Jed ac o d i"J et,t 1 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors F-1 Accessory Bldg. ❑ Demolition ❑ New Signs [E:3] Decks Siding[0] Other[❑] Brief Description of Proposed �� ©� ��u Work: R Alteration of existing bedroom Yes No Adding newbedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa 1ftNew-hoiaseandor�addttiori=#a:existin4=�ousma�complete.thr~�foflov�r�nc: 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. Masscheck Energy Compliance form attached? h. Type of construction I. Is construction within 100 ft.of wetlands? Yes o. s construction w i 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 rn c/(TES as Owner of the subject property hereby authorize to ton my behalf,in all matters lative to work authorized by this building permit application. Signature oftOvmek Date as Owner/Authorized Agent h reby decla tat 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. I oc, Print N e // — Signature f n Date Dole> Net A pp)y — of Odl L ' I Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side R:- R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Hasa pedal Permit/Variance/Finding ever been issued for/on the site? NO DONEF KNOW 0 YES ----- (D IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON-r KNOW 0 YES 0 IF YES: enter Book Pages and/or Document B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Date Issued: 0 0 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,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over I acre? YES 0 NO ?'Di 116, IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Northampton I u�ding Department r � � 212 Main Streete Room 100 a k Northampton, MA 01060eo- � Pan - fix phone 413-587-1240 Fax 413-587-1272 r APPLICATION-TO C4�UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY,DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: Th►s section to tse completed"Y9, ice 0 6P j-�-�(A� Map Lot Urut f(;) �C. one Overlay DistK�ct sElm St District CB Il'stnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �Mnrf,i yc�5 LAO I is Name Print) —I Current Mailing Telephone Signat e 2.2 Authorized Agent: DVQ i —1 ` \ C / Name(Print) —�j Current Mailing Address: 6-0 6j (0 t %I&(,vire aia,�S 2 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 0� (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=(1 +2+3+4+5) Check Number This Section For OfficialUse'Onl Building ermit Number. Date g Issued: Signature: Building Commissionerllnspectorof Buildings Date I w o. BP-2008-0272 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: BUILDING PERMIT Permit# BP-2008-0272 Project# JS-2008-000395 Est. Cost: $2000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Skyline Design 100705 Lot Size(sa. ft.): 4704.48 Owner: KASPER MICHAEL F&MARY LUCE Zoning: URB Applicant: Skyline Design AT. 106 HIGH ST Applicant Address: Phone: Insurance: P O Box 60142 (413) 586-8491 Workers Compensation FLORENCEMA01062 ISSUED ON.911412007 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE ROOF & REPAIR SIDING 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 9/14/2007 0:00:00 $25.0010489 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo ow