12C-086 (2) A`C,C3R►7fa CERTIFICATE OF LIABILITY INSURANCE_ °"Taowoe' '
THIS CERTIFICATE IS ISSUED AS A MATER 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: 0 the certificate holder is an ADDITIONAL INSURED,the policy0es)must oe endorsed. It SUBROGATION IS WAIVED,subject to
the wrma 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).
PRODUCER CONTACT
I Parodiso Financial&ins Siva,LLC ) 4 52 7 Pn IfE (860 680 —�7 FAX n 860)851-9564
Jic.JESS! I iKG�1 �
18 East Main Street gQpgEgy un ed so(�pa 7o smn5wdnce cow_..._ r
Stafford Springs,CT 06076 uasuRER�sLAEppROlnGgpytAAyE .. _..._f _KQ1�s-__
Phone }6$4.5$70 Fax 860 651 9564 INSURER A, NAUTILUS INSURANCE COMPANY 17370
INSURED N,@ugEg-e AiiSlale 15232
Now England Green Hanes LLC lsugEg,C: 1>'us Nal e,al 25486 .
IN•UAER 0... .. ..__.. ......
�59 East Main 31 � _. __ i
I INSURED,
Stafford Springs,CT 06076 I...-- _. ... ._..__._
_..__.___.....---...............-.—.___ .�_...�...._.._.— —.._..___.___-__-....__ .i.INSURERF
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 16 TO CERTIFY THAT 1'NE POLICIES OF WSURANCk.USTEO BELOW NAVE BEEN ISSuEO TO FHE INSURED NAMED ABOVE FOR THE POLICY PERIOD '
INDICATED NOTWITHSTANDING ANY REQUIREMENT,T ERM OR COND,I ION OF ANY CONTRACT OR OTHER DGCUMEW WITH RESPECT 10 WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,TILE INSURANCE AFFORDED BY THE POLICIES OE.SCfIfBFO HEREIN IS 51)dJtC[TO At 1.THE TERMS.
i EXCLUSIONS AND CONoiTIONS OF SUCH POLICIES.LIMIT-SHOWN MAY NAVE F)FEN REOUCEO NY PAID CLAIMS
t..� �.._-.. ...._....._. _ _.. ..___"._- _.
ilVatp UaRI POLL POLL YPl
TYPE OF iMtiURANCE ....._POLICY N4w;3E.B. i1MM :! J L_ _ i--_
OENFHAL U"&UTY J t EAGN OCCURR NCE _ 1000.000.00
J DAMAGE 7�ii NTFQ _ S 100,1x}0 00
COMMERCIAL GENERAL LIASILIYY
"l � Lil occvR MLO EXP!Any:na pa,eM s 5,000.00
. .
• CLAwS•MADE I NN386246 '
I i -1 I ,09;1 Qi2015 I PFASONAI S A ,N�JRY S 1 000 000.00
A Y 09i 182014
j GF NEntnt AGGAEGArF_�.S 2 000 000 00
I GENT AGGAEGATE LIMIT APPLIES PER I ! PRODIiC I S GOMP:DF AGG 15 Z 000 000 00
AUTOMOBILE LIABILITY u dti;[:4entJ ._...__i. .�'000,000.00 1
ANY AUTO SOD)I.Y INA;AY)pro Dosch) {F.5...
It- ALL OWNED SCNEOU:ED 648199456 0/44%-014 10'04/2015180�>l`'N'uk IPaaccaarys
11 __ ..
AUTOS I_. AUTOS ( ` S
�••7 NON•OWNED I OPERTY pAMAGE i
i 1j HIRED AUTOS L~r'� AUTOS I :.1.�!•46�ACti---...__._......._.._ -�
UMBRFILAUM NJ OCCUR I :.._—... ......j.._.. .. ..�.. __ .._ FA CH UC jNRLNGF.
I•^i 23585D 140AU .... ,–
'C EXCESS LIAO I GIAIMS-MApI:, f I 04;23 X01 4 44/13.'2015 AOC,r,c F _ -,.. I E 1 000.000-00
DEC)_l..U_?klliN.l+qN.i....__.._..__.--•-...-._!._. .. TS- .. ..
wOR%EaS%EMS COMPENSATION i TALY)JMiT5
1 AND EMPLOYEAS'LIABILITY Y'N
I ANYPROPRIETORIPARTNER/EXECUTIVE F �n%HA CIOF N_f __ 5
I OFPCER/MEMEIER EXCLUDED ...1�N'A j L L 7ioEA3c r�_ of: 5.........
. (Mendelaq in Nn) L I A E rI U _.t ..
(ties,de=iW under
1 O6CRIPYION Of OPERATIONS uelow
+OESGRFPTION Of OPRAA770NS i LOCATIONS;VEHICLES tAtuoM 4CORD 101 Agdlllgnal RamelMS ScmaYn,n mere�p.<r e Nquirid)
COLUMBIA GAS OF MASSACHUSETTS IS ADDITIONAL.INSUAED +
' I
CERTIF)CATE HOLDER CANCELLATION . . ...._.-.__..._....y
SHOULD'ANY Of THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE
COLUMBIA GAS OF MASSACHUSETTS i TiiE EXF'tFtATION DATE THEREOF,NOTICE wiLL 6E DELIVERED IN
i
ACCORDANCE WITH THE POLICY PROMWONS.
2 TECHNOLOGY DR SUITE 250
W ESTBOROU G H,MA 01581 AUrHORQEO REPRESENTATIVE j
t sba�2o10 ACORD CORPORATION. All rights received.
ACORO 26(2010/05)OF The ACORD name anO logo are registered marks of ACORD
.r', NEWENGL-20 JROBEDEE
AFRO- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DO/YYYY)
8!4!2014
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 terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not collar rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
AP Intego Insurance Group,LLC PHONE (g00)274.4532 FAX No
144 North Road
Suite 2050 -MAIL
Sudbury,MA 01776 ADDRESS:
INSURERS AFFORDING COVERAGE NAIC S
INSURER A:Guard Insurance Grou 25644
INSURED INSURER 8:
NEW ENGLAND GREEN HOMES LLC INSURER C:
59 E MAIN ST INSURER D:
Stafford Springs,CT 06078 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.
IN ADDLSUBR SR TYPE OF INSURANCE POLICY NUMBER MMIODIIYYYY) (MMIDDfYYYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS-MADE FI OCCUR PREMISES(Ea oacu n $
MED EXP Any one person $
PERSONAL 8 ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY❑JET LOC PRODUCTS_COMP/OP AGG $
OTHER: S
AUTOMOBILE LIABILITY CO $
Es accident _
ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Pefacddent) $
NON-OWNED PROPERTY DAMA S
HIRED AUTOS AUTOS Per accident
S
UMBRELLA LIAR OCCUR EACH OCCURRENCE 5
EXCESS LIAR HCLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION X I STATUTE R
AND EMPLOYERS'LIABIUTY
A ANY PROPRIETOWPARTNEW/EXECUTIVE Y� NIA NEWC529637 08/01/2014 08/01/2015 E.L.EACH ACCIDENT $ 600,00
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEd S 600,00
If s,describe under
DESCRIPTION OF OPERATIONS beiov, E.L.DISEASE-POLICY LIMIT I S 500,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101,Additional Remarks Schedule,may be attached if mom space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Thielseh Engineering,knc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
195 Frances Ave.
Cranston,RI 02910
AUTHORIZED REPRESENTATIVE
C 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
O
00 tkN��"Y�,Rti� License Number Expiration Date
Name of CSL Holder —' -
$.Q ��Sr M�4 � y�� List CSL Type(see below)
No.and Street — Type Description
r•.
� �� ' /;. U Unrestricted(Buildings u to 35,000 cu.ft.
� R`� s ��� �' C—.1 O R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
g3q)--q tr _JP241 4e tc —4&Wghtn424-4 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 14 OBI _
*4 HIC Registration Number B�xpi�on Date
HIC Company Name o HI Re ise Name o 0
�q +�.>� tai SM- ��e
No.and Street FmM alldress
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
1,as Owner of the subject property,hereby authorize NRxnIYI�S
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print 6`wner s Name( lectronic Signature) Date
SECTION 7b: OWNERS 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 true and accurate to the best of my knowledge and understanding. Ll
Print Owner's or Authorized 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.miMs, ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts RIttF.tmin
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston, ,VA 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
Ci /State/Zip:Stafford, CT 06076 _ Phone 4:860-930-7794
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4 4. ❑ I am a general contractor and I
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 $. ❑ Demolition
working for me in any capacity, employees and have workers'
comp. 9 ❑ Building addition
[No workers'comp. insurance
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 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 t 1
employees. [yo workers' 13,_T_
comp. insurance required.]
'Any applicant that Checks box H 1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they pre doing all wvrh and then hire vutsidc cvntractvrs must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing 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'camp policv number.
i»®i G 9111 -
1 ate an employer that Is providing workers'compensation insurance for my employees. Below is the policy and jab site
Information.
Insurance Company Name:Intego
r
Policy#Or Self-ins.Lic.il:NewC424991 ___.._ Expiration Date: _,_.
Job Site Address:All Steets in City/State/Zip: iv ��
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 MOL 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 yavcragc verificsti-n.
o s+ -�sr�ratrac
l do hereb eerie under the gains and penalties o er'urt•that the information provided above is true and correct
i Date -
L9t � }�
Pone#:
-
Of)`lclal use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License ti
Issuing Authority(circle one):
I.Board of Health 2. Building Department 3. City/Tuwu Clerk 4. Flectrical inspector 5. Plumbing inspector
61 Other
Contact Person: Phone#:
The Commonwealth of Massachusetts
Q Board of Building Regulations and Standards FOR
W c Massachusetts State Building Code, 780 CMR MUNICIPALITY LITY
�' �' E p� Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
i One-or Two-Family Dwelling
This Section For Official Use Only
IL I-
(� B, ilding Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Propert y address: , 1.2 Assessors Map& Parcel Numbers
�J) CA i L I L ;4.�1_
1.1a Is this an accepted street?yes no h4zN 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.L c.40,J54) 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) Ci State,ZIP
0 V*No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2:
0 "% Lk &E LIA,
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 $
Suppression) Total All Fees:$
Check No. (%_Check Amount: �j�Cash Amount:
6.Total Project Cost: 1 00 0 ❑Paid in Full ❑ Outstanding Balance Due:
File#BP-2015-0616
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794
PROPERTY LOCATION 20 RICK DR
MAP 12C PARCEL 086 001 ZONE RI(100)/URA(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid Cvr-O 65G -40;5T
Building Permit Filled out
Fee Paid
Typeof Construction: INSULATE ATTIC TO R38 INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 173021
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
e Delay
Sign of BuildfinjrOff cial Date J
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.
20 RICK DR BP-2015-0616
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-086 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-2015-0616
Project# JS-2015-001188
Est.Cost: $1990.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 173021
Lot Size(sq.ft.): 10018.80 Owner: MYRES ETHAN
zoning: RI(100)/URA(100)/WSP(100)/ Applicant. JOHN PERRIER
AT. 20 RICK DR
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:121412014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC IINSULATION
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 12/4/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner