17B-027 LINNorthland COMMERCIAL GENERAL LIABILITY
INSURANCE COVERAGE PART DECLARATIONS
Policy No: CP523982
Effective Date: * 12/22/2 0 0 6 12:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS
El Supplemental Declarations is Attached
NAMED INSURED:MORGAN A & D, LLC.
LIMITS OF INSURANCE
General Aggregate Limit(Other Than Products-Completed Operations) $ 2,000,000
Products-Completed Operations Aggregate Limit $ 1.000,000
Personal and Advertising Injury Limit $ 1.000,000
Each Occurrence Limit $ 1.000.)00
Damage To Premises Rented To You Limit $ 100.000 Any One Premise
Medical Expense Limit $ 5.000 Any One Person
RETROACTIVE DATE CG 00 02 Only)
Coverage A of this insurance does not apply to"bodily injury"or"property damage"which occurs before the Retroactive Date,if any,
shown here:
(Enter Date or'None"if no Retroactive Date applies)
BUSINESS INFORMATION '
Form of Business: ❑ Individual ❑ Joint Venture ❑ Partnership ❑ Limited Liability Company
❑ Organization (Other than Partnership,Joint Venture or Limited Liability Company)
Location(s) (Including Zip Code)of All Premises you Own, Rent or Occupy(Enter"Same"if same location as your mailing address):
VARIOUS
Your Interest in Such Premises: ❑ Owner ❑ Lessee ❑ Tenant ❑ Other:
PREMIUM
Rate Advance Premium
Classification Code No. Premium Basis Pr/CO All Other Pr/CO All Other
CARPENTRY - DWELLING (EXCL. ROOFING) 91340 P 50,000 INCLUDED 48.220 $ INCLUDED $ 2,411.00
POLICY SUBJECT TO AUDIT Total Advance Premium $INCLUDED $ 2,411.00
FORMS AND ENDORSEMENTS other than applicable Forms and Endorsements shown elsewhere in this policy
Forms and endorsements applying to this Coverage Part and made a part of this policy at time of issue:
CG 00 01 (12/04), S2621-CG (4/06), S2612-CG (12102), CG 21 39 (10/93), S21-CG (10/05), S17-CG (6/99), S23-CG (11/03),
S46-CG (6/99), S49-CG (10/04), 5354-CG (6/99), 5117-CG (R6/94), S2577-CG (6/06), S32-CG (R6/94)
* Entry optional if shown in Common Policy Declarations
THESE DECLARATIONS AND THE COMMON POLICY DECLARATIONS,IF APPLICABLE,TOGETHER WITH THE COMMON POLICY CONDITIONS,
COVERAGE FORM(S)AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETE 1 HE ABOVE NUMBERED POLICY
Includes copyrighted material of Insurance Services Office,Inc.,with its permission.Copyright,Insurance Services Office,Inc.,1985
S3D-CG(7/02) Page 1 of 2
G,tANITE STATE INSURANCE COMPANY 74711-0000 WC 825-70-25
13102 ---------------------------------------------
013-66-11o6-oo
•• . . a PENNSYLVANIA
MORGAN A G D LLC
114 WILLIAMS ST. Member Companies of
LONGMEADOW, MA Ol 106-0000 04M American International Group
EXECUTIVE OFFICES:
70 PINE STREET, NEW YORK, N.Y. 10270
SEE NAME AND ADDRESS SCHEDULE - WC990610
I.D# MA I : 4,DDRESS
WORKERS COMPENSATION AND EMPLOYERS
LIABILITY POLICY INFORMATION PAGE
INSURED IS
LIMITED LIABILITY COMPANY
OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC 0610
ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insured's
mailing address FROM 11/29/o6 TO 11/29/07
ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A.
The limits of our liability under Part Two are:
Bodily Injury by Accident $_ 100,000 each accident
Bodily Injury by Disease $ i 500,000 policy limit
Bodily Injury by Disease $_ 100,000 each employee
C. Other States Insurance: Part,Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT - WC200306A
ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Estimated Total Rate Per Estimated
Classifications Code Number Remuneration $100 OF Re- Premium
Annual[1 3 Year muneration 0 Annual E]3 Year
SEE EXTENSION OF INFORMATION PAGE — WC7754
TAXES/ASSESSMENTS/SURCHARGES $95
EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $284 MA
MINIMUM PREMIUM $ 00 MA TOTAL ESTIMATED PREMIUM $2,550
If indicated below, interim adjustments of premium shall be made:
Semi-Annually El Quarterly 11 Monthly DEPOSIT PREMIUM
ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM SCHEDULE — WC990612
01/12/07 ASSIGNED RISK 66
Issue Date Issuing Office Authorized Representative WC 00 00 01
35967
INSURED'S COPY
The Commonwealth ofltilassachusetts
Department of In dustrial Accidents
n Office of Investigations
1 _ 600 Washington shinQton Street
j,
Boston,4 02111
www.maSS.,,, li a
-Workers' Compensation Insurance Affidavit: Builders/ContractorsM. ectricians/Plumbers
AmAicaut Information PIease Print Legibly
Name (Business/Organ=tiowandividuat)
Address: ` S,il�_
City/State/Zip: "- ���� hone.T: �/ �7 4r-1 Vic'
Are you an employer? Check the appropriate box: i
Tvpe of project(required):
4. I am a general contractor and I
1.❑ I am a e�Ioyer with ❑ 6. [�New construction
employees(fuIl and/or part-tune)_* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have.no eniploy ees These ssb-contractors have g eIIOliLLon
wonting for me in any capacity. employees and have workers'
Buildi
[No workers'comp.insurance comp. insurance_+` 9. [] °addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work 11.[J Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required..]t -c. 152, §1(4),and we have no
employees.[No workers' 13.[]Other
comp.insurance requited]
`Any applicant thatches box:I an, also fill out the section below showing thew workers'comDersation policy infcr;maLion.
t Homeowners who submit this affidavit indicazinL,they are doing all work and then hire outside contractors must submit a new affidavit indicatins 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 emnioyees,they must provide their'wcrkers'comp:policy number.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. :d(f— V21s—70 -0 5
Expiration Date...
Job Site Address: J!� /(J /t/ 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 ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year'imprsonment,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 DLA.for insurance coverage verification.
I do hereby certi n the pains enables of perjury that the information provided above s true and correct
Si _ Date: Ly
Official use only. Do not write in this area,to be completed by city or town ofriciaL
Cty or Town:._.._._ - Permrt/I2zcense
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. ChT/Tovm CIerk 4.Electrical Inspector 5.11'1=bing Inspector
6. Other
Contact Person: Phone T:
i 03/1.1.:20:71? 07: 7-! _--41--5 27 S6?.9 SLj 1 E -7Z—� ��-4�a_
mow.!c._ 06/0S
$.t Lieu GMtrgc'n•`,--- o� - - — Not Applimble Ci I
s
Warm_of.Ltanaa
Add . J Expiration Date
r�'ptrBU.re Tefeptmone
tl NotApp(icaybLe 0 --
Company Name Registration Number
Address Exp:rattio Jaate�
// _
� C- . i r�y✓�J�� U� • -i�� Telephone)
SECTION 94-WORKERS'COMPENSATION IN$UURA.NCE AFFIDAVIT(M.G.L,c.162,§250(d))
Workees Compansation Insurance affidavit must be eomple%d and submitted with this Fapplioation. Failure to provide this affidavit will result
in the denlal of the issuanoe of the building rmi-..
Signed Afflidavi:Attached Yes ..... 0 No__ 0
The current exemption for"homcovne was extended to include Queer-necupied Dwelftnaa of one(1) or two(2)families
and to al ltiiw ouch homoow.ttcr to cn�agc an individual for hire who dues not possess a Iioense,provided that the owner sets
as_snperyllsor.CIti4R 786, Sixth Ediftion Section 108.5.5.1.
De6nMan of 1.4 earwntr:Faison,(S v who awn a psrcx l of land o which iazlshe resides or inter'ds to reside,on which there
N,or is intended to be,a one or two?amity dwelling,attached or dclachad structures accessory to such use and/or farm
structures.A person who pat—home ir at two-year period shall not be considered a homeowner,
Such"homeowner"stall suhmit to the Dailding Official,on a form acceptable to the Building 0Ymial t the/.she..shad_$e
resuonRible for all such work[serfnrmed uts rr_t►gt baildirA�nAm"k.
As actrni CoustMctioti Supervjsor your presence on the job site will be required from tirne to dme.during and upon:
Completion of the:vork for which this permit is issued.
A:so be advised that mith reference to Chapter 152(Workers'Compersruion) and Chapter 133(Liability of Employers to
iml!i4;eec fnr i171urie;trot re5�lting in Death)V the klassachusetzs G*GY'vul Laws Annotated,v„air�a L `it la for p n(�)
you hire eo perform work foryou underthis permit.
The undcrsigncd"honrcowncr"ecrtifea and assurnes responsibility for compliance with the 5tatr.Building Code,City of
Northa-n»eon Otdinanccs.Stall:and Loual Zoning Jaws and Stxtc cif wsa sachxrscits C=cral Lawi.Annotated.
Homeowner Siguature P�Zk —
iE� !1/2C,137 L`17, D-1 -12 3 Z= -`AG-7 D 5 0 6
JgQjLqN S.QE$rRFTl0N OF
New House AddlitJor Replacenon t WIVIdows Alterations)Or Groans 0
I Ar-cessery MO. Dernolifion New Signs frml Dft+.s jrj oldling[0 Othw r-- l
A A
BH-&f Description of Pr9opsed
Work:
.7�-q/7
Alteration of existing bedroom__YeS Nei Addingn&w bedroom yes No
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roll Sheet
Ise:;If I!1e�ew hi�uf`� fir,, ' tt'to e�#�tI � asa�sc �� ,lmvM��: `
a Use of building !One F2rrltiy Two FnmlIy__.0th*f
15, Number of rooms in aWh family Number of Bathrooms__
c It,Inem a garegin&ffaohed')
d. Proposed Square foutalle of new construction— Dimensions
e- Nurn"r of stories?
f. Method of heating? Fireplaces or Wooistoves Number of each
g. Energy Conservation Corriplianoo. Ma-eMdIeCk Energy Con.pliance form attached?
h. Type of constr,totion
i, is construction within 100 ft of wetlands?_—.Yes No. Is wnstruction within IGO yr. flooispijmr_Yer- No
J, Depth of basement or cellar floor balaw finished grade
k. 'Will bvi1ding conform to the Building am,Zoning regulations? _—Yes No,
i. SepticTank_- City Sewer Private well-- City water Supply
SECTION 7a -*OWNER AUTHORIZATION-TO BE GC MPLETED WHEW
OWNERS AOENT OR CONTRACTOR APPILIES FOR QUILDIMIG PERMIT
lk6:k i 11 ' as Owner of the subject
properV
1
hereby authorize 17741
to art on my behalf,in all mAtf--rs relative to woT authorized by this biding p9mut ariplie8tion.
1'l;21147-1i7-77
Ignature Qr Owriar ` hate
as Dwrier/Authorized
Agent hereby declare that the staterrems dnd information on the foregoing application fire true and awurale,to IM beat cif my knowledge
and belief
Signed vridet the pairs and penalties of porlurV
pxt4t , rig- dg554,ff
print N2rr1e
A*Faii
Sigruatueo of Owner/Agant
U i i 2 01 D 7 0 1. a- '--4i 3-P27- S-2--,"EE P4,iGE"i '.a '0
Section 4. ZONING ki IrrIormatior,m4st Be Completed. Permit Can Be Denied Dveft To 1m=mPILLte information
Existing Proposed column Ro,,,,, ,II y Toning
TUP to be.filled in h
Building in
u Building Dc"'TT&ME
...............
Lot Size !, . ._...
.......... ........... ............. .............
setLacks Front
............
Side P.:
Rvar .......
Building Hcighl
...............
Open Spacc Foutago
s'wt area minus hidg&wvoi
parking)
Hi of Parking,ACS
I (valurne&T=iaion)
A. Has a Special Permit/Variance Finding ever been Issued forlon the site?
NO 0 DOWT KNOW YES 0
IF YES,date issued:�
IF YES: Was the permit recto,-dtil at the lit esistry of Deeds?
NO C DON'T KNOW SOM YES 0
IF YES: enter Book Page and/or Cocument#'
B. Does the site contain a brook, body of water orweltands? NO DONT KNOW 0 YES
IF YES, has permit been or need to be obtained from the Conseryation CommIsston?
Needs to be obtained Obtained Date Issued:
0 1
C. Do any signs exist on the property? YES 0 NO
...........
IF YES, describe size, type and Locatii-.)n: i
................
D. Are there any proposed changes to or additions of signs Intended for the prop"? YES 0 No
........... -------
IF YES, describe size, type and Location:
................
E Will the construction activity disturb(olearing,grading.excavatiDn,cr filling)over I acre Dr is I',part of a common plan
that wN disturb over I acre? YES 0 NO Q
IF YES,ther.a Northampton 5torrr,WalerManacernent Permit from ft DPW is required.
1 : 1,"20-i' ? i;?: D -4'1_-! ? PAGE -
��V�
_Pity of Northampton
l
I
� OCT � �f3uiiding Department
2°1'2 Main Street
Room 10�! !� J .1" r'9! �I ftl1 Y,li4 )y. 41 ,1 Ildq�l'� Ili11t J 1 i r
s lR rpt>, IJ1�S ! l i. I Ml. t�
A �e y /�
OF (,�'=� �OP>~ 1111tUl1. �4[06V � � !
3 587-1240 Fax 413-587-1272 'p�; I'
f
ion iii il i�Gsy i�t�id� :�s}!�jtqi;�.',�
APPLICATION TO CONSTRUCT.ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWi t_UNG
SECTION i-SRS INFORMATION i
r
i.1 f�ronernr Address; _ SIS 1I1`*ctlgrrtO be C;Wiiefrd b r ffllcme
r c.44J C�. P Lot UhI ---- ----
T Yft 17+&
_ Elrh alti Lliatrfct :
SECTION 2-PROPERTY OWNERSHIPdAUTHORIZECi AGENT
2.1 Owner of Record: �
JS16me(Print) _ Current iJfsulxV ftddre4a:
Telephone
Signature _
• i
2 2_Au tia[cxJed Agent: /^� p er' 'r+q 4 rtw ox ivu
hiarrw(Pnni) � / Cur nt M219V Address;
" ecl JMal3 I
Signature TeleptaonC G,f
SECTION 3-EST VI TE:D CQN-S—'.RUCTION COSTS
!tern Estimated Cast(Coirar&q to tae OfFlClel Lite Only
cam leted b permit a kcent _
I. "mS (e)Building Permit Fee
2. Electrical _ (la)Ettimated Total Coat of
Consintotion}from 0 8)__
3. Plumbing _ — Bullding0enritFes {
d. Me&2nicai(HVAC)
S.Fire Protection
AIL I-
6 Tata!=t 1 +2+3*a+5) Chess Number
This Section For Official Use Only
8t iidirrg Permit Nlumber; Bate
- Issued:
Signature:
Building CommlissionerAnspeetor of Buildings Cate
File#BP-2008-0422
APPLICANT/CONTACT PERSON MORGAN A&I)LLC
ADDRESS/PHONE 114 WILLIAMS ST LONGMEADOW (413) 567-4400
PROPERTY LOCATION'95 BRIDGE RD
MAP 17B PARCEL 027 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED :DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out s�
Fee Paid J O
Tweof Construction: DEMOLISH DET GARAGE&:SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 072783
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATIONSENTED:
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
- IV 2—
Signature of Bui ding ffcial 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.
- �- k i y!` "� .+: �^ r '4 Rb»4 �, � 'v. Y..°' ,k� rn.�. w .,gyp 'F., ;•:.�'
�: r �}��g e�°i•^ y k'"°i�Lt� A�' y yk*�. .., '3 t ��w�� ���,._tk,.r�. .�� x' �yd"
-° �..3a •f' C ff '� �'`"',�.,sy..� }. '-a,k�' � •�-.� per.� k� _ � � _ � v,'`� � .!t:
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11 77"
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 foregoins engaged in a joint enterprise,and including the 1e2a1 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 Iocal 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 with the insurance coverage required." /I
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 checlang the boxes that apply to your situation and,if
necessary,supply sub-contractors)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 carry 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 Iegibly. 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
(Le.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit ...
The Office of Investigations would like to than 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 Corn nonwealth of Massachusetts
-AcefdeSts=-
Offiee of Investigations
600 Washington Street
Boston,MA 02111
Tel. -A-1 617-727,900 ext 406 or 1-$77-MASS.4FE
Fax?1r 617-727-77=!9
Revised 11-22-06
,Yvr,x,v.mass_govfdla
The Commonwealth of Massachusetts
Department of Industrial Accidents
Of ice of Investigations P
vi 600 Washington Street p�
Boston 1MM4 02111
rvww.massgov/din
-Workers' Compensation Insurance_Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leiliblv
Name (Business/Organizarion/Individual):
Address:
City/State/Zip: Zan G-W,04hoiae
are you an emplover? Check the appropriate box: Type of project(required): �
1.❑ I am a employer with 4. I am a general contractor and I
employees(full and/or part-time).*
have hired the sub-contractors 6 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. []Remodeling
These sub-contractors have
ship and have no.employees 8 remoli-u'.on
working for me in any capacity.� employees and have workers'
D Y $. 9. []Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. We are a co oration and its 10.❑Electrical repairs or additions
❑ officers haveexezcised their 11. Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work ❑ P
myself.[No workers'comp. right ofexemption'per MGL 12.[]Roof repairs
insurance required]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#1 next also fill out the section below showing their workers'compensation policy info nation.
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 shoving 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'workes'comp:policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information. _
Insurance Company Name:
Poiicv m or Self-ins.Lic. r'2,57 7lJ ""Z J Expiration Date:���"
Job Site Address: a, O&zc/7 ���/ J�i�.J Ciry/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 w a ell as civil penalties in the form of a STOP WORK ORDER and 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 DLA for 1TlstrrAnce coverage verification.
I do hereby certi n the pains enaldes ofperjury that the information provided above is true and correct
Sianaaure: ^ Date:
Phone#r:
Official use only. Do not write in this area,to be completed by city or town o ciaL
_-City or Town- - - - Permit/License
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/T'own Clerk 4.Electrical.Inspector 5.PIumbing Inspector
6. Other
Contact Person: Phone#-
�0/zz/2mo7 07. �7 �_4�o-nz7-868g SUZz 8�ZZEE PAGE 05/06
or boom 0
Bri--f Description of Pr $ad
Xteration of exiting btidtoom No Adding rew bedroom Yes AQ
Plans Attached Roll Sneet Rerovatnq
b. Number of roorns in eAch tanly Lxi, Number of Bathrooms,_----___
d. Proposed Square footage of now Dimentions
I. Method oi heating? Fireplares or Woodstoves------__Number of each
h, Type of constniction.—-
15 00MRtructiOn within 100 yr. 9=1piRin_—Yes_No
Depth of basement or 0618f floor boll-*finishsd grade
i. SepticTairill City$ovmr—__ Private well_ C;ty water Supply
SECTION 7a -OWNER AUTHORIZATION-TO BE COMPLETED WMIN
OWNERS ACENT OR CONTRACTOR APPUFS FOR QUILDING,PERMIT
as Owner of the subject
nerety authorize
to act on my behalf,in all mIttiFs relative T6 XN—ohorized by ilh,&
14:2 1277
AgerA hereby declare that the statements dnd informatlon on thR foregoing application tire Rv-e=an tc the beat of my 1(ni:iwledge
and belief
Pfint Name
. .
I ilf 1.1/20,-17 07; 3 7 1--413•-527-1x699 SUZI E'.JZZE.E PAGE a6/06
SECTION 8.CONSTRUCTION SFRVICES
8.1 Licensed Canstrucki ///�f Not Applimble ❑
An w_of,Ucans&"wemr; 1� _.5 J C�
AVt.ieens8 Numbs!
Expiralon Date
�.���✓ail s...�_ ��_1�SS���/�l\)
ig lure T6Itsphone
9 Ria netfY u _m CA atoL Not Appii.able ❑
Comaanv Name ReGistration Number
Addreii ExpiratioKDate
-ZL
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L..c.162,h 28C(6)) - - —
Workers Compensation Insurance affidavit must be completed and submitted with this application,Failure^o provide this affidavit will result
in the denial of the issuanoo of the building per ih.
Signed Affidavit Attached Yes...... ❑ No,,.,,, C)
11. _ Owner ExEmftn
The current exemption for"homcmmcn;`was c-ctc:ndcd to include Owner-occupied Dwellings"of one(1) or two(2)familles
rnd to alk1w such homeowner to"Sagc an individual for hire who does not possms a license,provided that the owner sets
as sulnrvisor.CMR 780 Sixth E Iticrn Salon 1011.3.5.1.
Definition of HonMrntvntr;Person(s)who own a parcel of land o;a which lrwlshe resides ar intends to reside,on which there
is,or is intended to be,a one or two+.'amity dwelling,attached or detarchod..structures acecsson to such use artdl or farm
structures.A ncrson who cons u is mores ti►an oyes ltotne inn;two-resr period shall not be won idered a homeowner.
Such"homeowner"shall submit to the DwIding Official,,on a form acceptable to the Building 0fficia] t at be/she..shall_be
restionsible for ell such work 6rcrforn+ad under the bRildine D.ePlmit.
,�s acting ConstracitioigSup�rvl r your presence on the job site will be required fmm time to tine,during and upon
completion of the work fbr which this permit is issued-
As 5o bu advised that with rrfcrcrce to Chapter 152.(Workers'Compersation) and Chapter 153(Liability of fmpliyert to
Empioyees for injuries not res',.alting in Death)of the Massachusetts Gencrtal Laws Annotated,v,,f9;t A h LJkd&for r n(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes resporisiullity for cornpliance with the.State Building Code.City of
' orftrrpion Otdinaniocs,State and Local Zoning Laws turd State of`sfaysashtasctts Clennral Lawn Annotated.
Homeowner Sigunturc �� /!
10/11120J7 07: 07, 1-413-527-8635 SUIZI B-ZZLE PAGE =4 '86
Section 4. ZONING Ali InfQrmation Must Be Ci5mpleeted. Perrnft Can Be Denied NO To lncffnrilete information
Existing Proposed Rcquhed by?tiring
Th'i Column to lie filled to by
Ruildirlg DeparVnent
Lot Sizc
SetLacks Front
R: U1
FAZ
BITIj—din-g—Heighl
Bldg.Square t'notage
-6f7;0-�SPRCC Foquige
i Lot fireamilils bldl-1& wco
A. Has a Special Permit/Variance/finding eyer been issued forlon the site?
NO 0 DON'T KNOW (8D YES 0
IF YES, date issued.�
IF YES: Was the,per(nit rc-co�ded at the ry of Deeds?
No C DON"r KNOW YES
I r ils,
IF YES. enter Book ! Page and/or 00CUMent#1
13. Does the site contain a brook, bndy of water or wetlands? NO DONT KNOW C) YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 'Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES,describe size, type and Location: i
D. Are there any proposed changes to or additions of signs intended for tl)e property!? YES No
IF YES, describe size, type and tociWon'
E tUill'he construction activity disturb(olearing,grading,o cavation,cr filling)over I acre Dr is it part of a wrinnion plan
triat will disturb over 1 acre? YES 0 NO it
IF YES.then a Northampton Storrn water management ParrM from the DPW is required.
163:'11:''20217 IJ?: 07 1-a13-'.�2 Ec' �UZ I B'_?ZEE PAGE 031636
2007 Cty of Northampton
fj..
OCT -Building Lepartme nt
t II � t Uh u!I I y i it f �f tl
a 2'1� Maim Street
-t d {I 1' q rll dli f q f iyfI
F100� 100 i�i� I�! I �1+ I 1
i s "l ,I
Hors, mpton, MA 01000
587-1240 Fax 413-,537-1272
APPLICATION TO CONSTRUCT,ALTER.REPAIR„RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWi LUNG
SECTION 1-SITS INFORMATION
Z.1 Prooeety Aare:
- — This wfJorr to be c+t>,opkA,eri by o ici
9,~ h 4I ? �` C"� �, Map Lot�p Unit __ .,.-.,,.
�
Elm at Diatftt
SECTION 2-PROPERTY OVMERSHIPIAUTHORIZED A(iS
2.1 Owner of Record:- —0ftWej,*--#,/-j�,'!e-',/
Name(Print) q g+ Current M&IkV Addra4e:
�
Signature 6&4 0 :Z:
2.2 A o iZed i4gent: . ._^�> 1"t+� 4 rP,"j�?,AX TO;'
Name Print Cur nt Mail MailkV Address:
Signature Telephon! + ( _ 7 ~ - - -- -
3ECTION 3-E$MTLD Gf3NSTRUCTtON g Lqk S_
Item Estimated Cyst(Gollam)to be Official(Jae Only
completed by parmit applicant
1. (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Canstruction from 6
3. Plumbing -------- -------- -----_ Sullding Perrnit Fee
4. Mechanical(HVAC)
S.Fire Protection
Total-(1 +2 ;Check Number
This Section For Official Use 0*_—
Date
861ding Pon-nit t vmWr, W_ __ ita9uad:
Signature:
Building Commissioner/Inspector of Buildings bate
File#BP-2008-0422
APPLICANT/CONTACT PERSON MORGAN A&D LLC
ADDRESS/PHONE 114 WILLIAMS ST LONGMEADOW (413)567-4400
PROPERTY LOCATION 395 BRIDGE RD
MAP 17B PARCEL 027 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: DEMOLISH DET GARAGE&SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 072783
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION P"SENTED:
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
_.. ,,V L S_ z
Signature of Bur ding ff-icial 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 rr eet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
DEMOLITION REVIEW APPLICATION
Activi"F Tracking Sheep
Property:
Map Parcel __ _.._..____
Receiveb in Building Department: O
Referred from Building Department: 1
Action Talcen/ Northampton Historical Commission
Action Taken Bv: Entire Commission
Sub-Cornmittee of the Commission
Commission Designee/ Staff
Date Action Taken: Initial Determination
Public Meeting held
Public Hearing Held
Determination Made:
Property has been determined not to be
Significant according to Ordinance definition.
No further action will be taken. Demolition
Permit: may be issued.
Property has been determined to be Significant
according to the Ordinance definition and a
Public Hearing has been/will be scheduled.
Demolition Permit may not be
issued at this time.
Public Hearing has been held, Property was
determined Significant but not Preferably
Preserved. No further action will be taken/
Demolition Permit may be issued.
Photo documentation may be required.
Public Hearing has been held. Property has
been deemed to be Preferably Preserved. The
demolition review period has been initiated. No
demolition permit may be issued until the
Historic Commission approves an alternative plan or the
twelve month period concludes.
Alternate plan has been approved/ delay terminated.
Demolition may or may not be approved as part of plan.
Twelve month time period has expired, demolition
permit may be issued.
Referred by: Date
File#BP-2008-0422
APPLICANT/CONTACT PERSON MORGAN A&D LLC
ADDRESS/PHONE 114 WILLIAMS ST LONGM:EADOW (413)567-4400
PROPERTY LOCATION 395 BRIDGE RD
MAP 17B PARCEL 027 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: DEMOLISH DET GARAGE&SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 072783
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF AT ION 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 Co ion Permit DPW Storm Water M/na ement
///,7/4
Signature o uilding O ficial 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.
BP-2008-0422
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-2008-0422
Project# JS-2008-000622
Est. Cost:
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MORGAN A&D LLC 072783
Lot Size(sq. ft.): 13372.92 Owner: BASSETT PATRICIA A
Zoning: URB Applicant: MORGAN A&D LLC
AT. 395 BRIDGE RD
Applicant Address: Phone: Insurance:
114 WILLIAMS ST (413) 567-4400 WC
LONGMEADOWMA01106 ISSUED ON.111712007 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMOLISH DET GARAGE & SHED
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 11/7/2007 0:00:00 $30.001722
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo