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17B-024
Client#: 68699 WILLIAM4 RD,. CERTIFICATE OF LIABILITY INSURANCE 09/03/2008YYY) A PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Clark-Mortenson Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 606 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Keene, NH 03431 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Peerless Insurance Company William G.Walker& Company, Inc. INSURER B: PO Box 47 INSURER C: Hinsdale, NH 03451 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. INSR DD' POLICY EFFEC T/YY DATE IVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD M IDD/YY LIMITS A GENERAL LIABILITY CBP8498930 07/15/08 07/15/09 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE T SES a O RE o�NTED $100,000 _ CLAIMS MADE E_x1 OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $11,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO- LOC JECT A AUTOMOBILE LIABILITY BA8495130 07/15/08 07/15/09 COMBINED SINGLE LIMIT $1 OOO,OOO X ANY AUTO (Ea accident) i ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FI CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WC STATU- OTH- WORKERS COMPENSATION AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETORIPARTNER/EXECUTIVE OFFICEPUMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ It yes describe under SPFCiAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DE {��WED POLICIES BE CANCELLED BEFORE THE EXPIRATION Commonwealth of Massachusetts DATE THEREOF,THE ISSUIII=INSURER WI �ENDEAVOR lQ MAIL NIA DAYS WRITTEN Dept of Industrial Accidents NOTICE TO THE CERTIFICATE HOLDER NA ED TO THE LEFT,BUT FAILURE TO DO 50 SHALL 600 Washington Street IMPOSE NO OBLIG/YOON OR LIABILITY OF NY KIND UPON THE INSURER,ITS AGENTS OR � i Boston, MA 02111 REPRESENTA AUTHORIZEgRE Nl'ATIVE P \� ACORD 25(2001108)1 of 2 #S53807/M53805 IfAJ O ACORD CORPORATION 1988 s ACORDL CERTIFICATE OF LIABILITY INSURANCE 09/2 9//08 08 YYY) 09/2 PRODUCER 1-617-723-7775 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Hays Companies of New England ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 133 Federal Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3rd Floor Boston, MA 02110 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Liberty Mutual WILLIAM G. WALKER & COMPANY INC. INSURER B: PO Box 47 INSURER C: 759 Brattleboro Rd. Hinsdale, NH 03451 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. INSR DD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS R NSRD TYPE OF INSURANCE GENERAL LIABILITY EACH OCCURRENCE $ A A O .NT COMMERCIAL GENERAL LIABILITY PREMISES J .occurence $ CLAIMS MADE F1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIREDAUTOS BODILY INJURY NON-OWNEDAUTOS (Per accident) $ PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EAACC $ AUTOONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 1-7 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND WC5 31S 348303-178 10/01/08 10/01/09 X T CyTATIU- OTH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES f EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS This policy covers those employees leased by William G. Walker & Co., Inc. through Surge Resources, Inc., Manchester, NH 03109 CERTIFICATE HOLDER CANCELLATION*10 Days for Non Payment of Premium SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION William G. Walker & Company, Inc. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR PO Box 47 759 Brattleboro Road REPRESENTATIVES. Hinsdale, NH 03451 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001108)mvaughn2 ©ACORD CORPORATION 1988 9874314 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): I� l l�[lker Address: City/State/Zip. i Cell W b6gb ( Phone #:_M3 5 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F1 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working or me in an capacity. employees and have workers' g Y P h'• 9. E] Building addition [No workers' comp. insurance comp.insurance.$ 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.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] "Any applicant that checks box#I must also fill out the section below showing their 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. CC ' je n Insurance Company Name: ots a leA Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 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 coverage verification. I do hereby ce a under pins and enalties of perjury that the information provided above is true and correct Si ature: 2 f 2 Date: Phone#: J�l(i J Official use only. Do not write in this area,to be completed by city or town offieiaL . 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 ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Realistered H e Drovem J� Not Applicable ❑ CN l� Company-Name Registration Number �+ i A 0 dress ,� Expiration to RSUCA 1 t Q�—+�1 Telephone Rite 1 a �;I 16 VV 41Lo"tN 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. - Home Owner Exemption 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 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [r-31 Decks [M Siding[0) Other[dj Brief De iptio f Pr s Work: 1 Alteration of existing bedroom Yes No Adding new bedroom Yes No ((// Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and or addition to existinsa housing, complete the followinla: 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 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 Zoning regulations? Yes No. 1. 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 I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1, 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 un er the pains and penalties of Wriury. U)ILA Pq ame y/A o Signature of Owner/Agent Date Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled 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 ® DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW 0 YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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 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 0 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 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use o �g City of Northampton Status of Permit: n Building Department Curb Cut(Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE,,OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Pro q75-A M'4vv �1 This section to be completed by office Map- Lot Unit f(I rLe 4!i S r done`' Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 24 Owner of Record: lleA Name Cu n aili A dre : civa Telephone I 2.2 Authorized Agent: V111 (IT q)Caktk QCo -Dw, �0�"�'t`1 �1►nsd�,l�- N 0 3u I N (Print Current Mailing Address: � 33 5�. 1 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed b permit applicant 1. Building ?-7© (a) Building Permit Fee 2. Electrical J (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 Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date BP-2009-0881 GIS#: COMMONWEALTH OF MASSACHUSETTS 114711-624"",f, 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-2009-0881 Project# JS-2009-001290 Est.Cost: $8370.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WILLIAM G WALKER & CO 101890 Lot Size(sq. ft.): 10105.92 Owner: HERFURTH PAUL J&LINDA C Zoning:URB(100)/ Applicant: WILLIAM G WALKER & CO AT. 475 BRIDGE RD Applicant Address: Phone: Insurance: P O BOX 47 (603) 336-5539 Workers Compensation HINSDALENHO3451 ISSUED ON:412812009 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL STANDING SEAM METAL ROOFING 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 4/28/2009 0:00:00 $35.00273 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo