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17C-108 (3) x OD '0 00 V �7 N) co 0 wooipOI3 ,,O-,tl,k -- - ueqol!N A/I „0-,9 5-0"Lx2 -6"W Tub/Shower co oCF) � o 04 ---- - ----- "9k1k *19k ik CID N m en O -_J Iwo- ISO' . 10'-0" 00 io LO 8: dc Ir 4 a, g P � L N W-o" 1467 4/1-� i ' P OL 1 Cl) LO ��solx/e'x N LO N e F-9' diSd CO co 1-5' 13t-6" I/" N Lam} P -I r e} Q r- 3' t =3 - G i"I;Fl) i . i r1 1 - . . _ - --- . -- . .. - -..._-- ----- _ -. Note:This drawing is an artistic INTERSTA`rT E CUSTOM Designed: 5/23/: interpretation of the general appearance of KITCHEN_BATH INC. Printed: 10/2120, the design. It is not meant to be an exact rendition. Kloc Chip^2 LKloc Chip^2 I Drawin@ 10 11"U P 40-D t Note:This drawing is an artistic ft�-iii��;E�TgZiTsTdi� Designed:3/23!200 interpretation of the general appearance of KITCHEN.BATH INC. Printed:5/23/2007 the design.It is not meant to be an exact rendition. Kloc Chip^2 LKloc Chip^2 I Drawing 4: I i I • I I .... . - en i is II-- --1 II III ;: l) � � ; � ;'► - � _ Ali ' -� _- - - - �4' Note:This drawing is an artistic INTERSTATE COSTOM Designed:5/23/2007 interpretation of the general appearance of KITCHEN .BATH INC. Printed: 10/2/2007 the design. It is not meant to be an exact rendition. �Kloc Chip^2 Kloc Chip^2 I Drawing k: 1 Additional Coverages and Factors 04/11/2007 Line of Business Coverages for General Liability Coverage Limits Ded/Ded Type Rate Premium Factor General Aggregate 2,000,000 Products/Completed Ops 2,000,000 Aggregate Personal & Advertising 1,000,000 Injury Each Occurrence 1,000,000 250/Flat Basis: Per Claim; Applies: Property Dama Fire Damage 500,000 Medical Expense 10,000 Line of Business Coverages for Workers Compensation Coverage Limits Ded/Ded Type Rate Premium Factor WC & Employer's liability 100,000/500,000/ 100,000 Terrorism 11.00 MA DIA Assessment 144.00 0.04200 Expense constant 284.00 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms 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 endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) AG RDM 'CERTIFICATE OF LIABILITY INSURANCE 02/01/2008 PRODUCER (413)586-0111 FAX (413)586-6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Webber & Grinnell Ins. Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8 North Kin Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northampton, MA 01060 INSURERS AFFORDING COVERAGE NAIC# INSURED Wilcox Builders INSURER A: NGM Insurance Company 14788 DBA: Matthew Wilcox INSURER B: 7 Porter Street INSURER C: South Deerfield, MA 01373 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 ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY MPB97721 04/10/2007 04/10/2008 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 500,000 CLAIMS MADE T OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICYF_j PRO JECT LOC 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 $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FI CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ TORY WORKERS COMPENSATION AND WC STATU- FR IMIT EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Chip & Lisa Kl oc BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 87 High Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Florence, MA 01062 AUTHORIZED REPRESENTATIVE___ Jenna Rodri ue, CISR/JER ACORD 26(2001/08) ©ACORD CORPORATION 1988 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 Le ibl r r Name (Business/Organization/Individual): Address: ] City/State/Zip: &lz-:: , Phone #: — a� Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with �2, 4. F-1 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 ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' insurance.$ 9. ❑Building addition comp.[No workers' comp. insurance p' 10. Electrical repairs or additions required.] 5. We are a corporation and its ❑ P 3.❑ I am a homeowner doing all work officers have exercised their I I.El 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 required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. +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. Insurance Company Name: Policy#or Self-ins. Lie.#: z"/ Y 04`9 �".53� Expiration Date: O Job Site Address:_ 7 4'7 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 certify t der th/►"ains and penalties of perjury that the information provided above is true and correct Si atur • l Date: Od Phone 4: 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 Su ervis r: Not Applicable 0 Name of License Holder: d License Number Add r s� Expi tion 15ate Signature Telephone -S. ealOtered Honw-InuftyemeW Oontm tor: Not Appticabi�e ❑ ComDany Name Registration' Number Address 1 ,L� / Expiration Date 7/ olAr �Ol!r y'��'�r'�'/���Telephone �� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8)) 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,- HOM Ow>ur 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 awlicable) New House Addition Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition �. New Signs [0] Decks [0 Siding[0] Other[o] Brief Descyy ti on ppf Pro P ose Work:�/�eiNaa'�� "r�e Alteration of existing bedroom_Z,4es No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes XNo Plans Attached Roll -Sheet ea. ff New house andorsdditloinIi # ko fb 110wing 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. 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 as Owner of the subject property hereby authorize to act on hal, 'n all matte relative to work authorized by this building permit application. )Sirfr1iure of Owner Date 1, '���J�JI ew (N�r �� as Owner/Authorized Age 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�ains and penalties of perjury. 74 t Name Abwner/Agent D to 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 0 DONT KNOW � YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 � DONT KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , 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 IF YES, describe size,type and location: E. Will the construction activity disturb(clearing,grading,2Lgavation, 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 ermit from the DPW is required. 0 o� City of Northampton � Building Department A"k lrt1 212 Main Street Ay' Room 100 W! M,. 1,4a Northampton, MA 01060 � ✓t1n� phone 413-587-1240 Fax 413-587-1272 �s i APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENO T O FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section tojbe co plated by office Urnt Overlay District Elm St,District Ce oistrict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ezoc Name(Pri t) Current Mailing ddress: 4/l 2JY- � Telephone Signature 2.2 Authorized Aaent: Name(Print) op Current Mailing Address: /, g Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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) ,d d Check Number S 'ffO oq 6 �- This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2008-0681 APPLICANT/CONTACT PERSON MATTHEW T WILCOX ADDRESS/PHONE 7 PORTER ST SOUTH DEERFIELD (413)665-8269 PROPERTY LOCATION 87 HIGH ST MAP 17C PARCEL 108 001 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: REMODEL KITCHEN BATH&BEDROOM - New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: -- Owner/Statement or License 075440 3 sets of Plans/Plot Plan THE FOLLOWING 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 Demolition Delay dt��.� QZ, al o Signature of Building Official 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. E s BP-2008-0681 CIS#y 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) Cate�yorv: BUILDING PERMIT Permit# BP-2008-0681 Project# JS-2008-001042 Est.Cost: $64000.00 Fee: $320.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MATTHEW T WILCOX 075440 Lot Size(sq. ft.): 161 17.20 Owner: KLOC STEPHEN S III&LISA J Zoniu«: tJRB Applicant: MATTHEW T WILCOX AT. 87 HIGH ST Applicant Address: Phone: Insurance: 7 PORTER ST (4111 665-8269 SOUTH DEERFIELDMA01373ISSUED ON:21112008 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN, BATH & BEDROOM 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 Si nature: FeeType• Date Paid: Amount: Building 2/1/2008 0:00:00 $320.001595 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo BP-2008-0681 87 FIIGH ST COMMONWEALTH OF MASSACHUSETTS GIs CITY OF NORTHAMPTON map I-ock: 17C- 108 w PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS 'o - T'ertnit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A ]BUILDING PERMIT Category:. Permit# BP-2008-0681 Project# JS-2008-001042 Est. Cost_$64000.00 PERMISSION IS HEREBY GRANTED T Fee: $3?0.00 License: Const.Class: Contractor: 075440 i.Jse GroL ._ MATTHEW T WILCOX______ ILL Lot Size(sq ft)� 16117.20 Owne►: OC STEPHEN S III&LISA Applicant: MATTHEW T WILCOX Zoning:URB --¢7 �;;^� � c -r Phone: Insurance: Al!p!f ut Address: (413) 665-8269 SOUTH DEERFIELDMA01373ISSUE N�ti��RK REMODEL KITCHEN, BATH & BEDROOM TO PERFORM THE FOLLOW[ POST THIS CARD SO IT IS VISIBLE FROM THW- STREET Building Inspector Il-,spector o?'Plulnbini; inspector of Wiring Meter:�lJndergroun�t: Service: Footings: House# Rough: / Foundation: rough: _ 1 ��" /gj Driveway Final: Final 2-C final: 7-a- O sy Rough Frame: I Fireplace/Chimue,% Gas: Fire Department Insulation:O/'� 3 `�� •� o ''�''�� Bough: Oil: Smo1.e Final k 30-0e Y BE REVOKED BY THE ' TY OF NORTILk"✓[PTON UPON VIOLAT N OF THIS I ERIVIIT ILIA ' ON ,. ANY OF ITS RULES AND REGUL Sisuature: Certificate of Occu ancV - Date Pait1_Asll0unt. Building 2/1/2008 0:00:00 $320.001595 212 Main Street,Phone(413) 587-1240,1'ax: (413) 587-1272 Building Coulmissioner-Antl;ony Patillo