31B-104 (4) //
Vial
�d
Extension of Information Page WC 00 00 01 A Item 4.
State Of: MASSACHUSETTS
Classification of Operations Premium Basis Rate
Entries in this item,except as specifically provided elsewhere in this Code Estimated Total An- Per$100 Of Estimated Annual
policy;do not modify any of the other provisions of this policy__ No. nual Remuneration Remuneration Premium
0001-01 ITS TIME HOME IMPROVEMENT LLC
FEIN # 45-4351241
SIC CODE 1521
NAIC CODE 236118
162 MAIN STREET
HATFIELD MA 01038
CARPENTRY NOC 5403 $ 0 9.86 $ 0.00
PAINTING OR PAPERHANGING NOC 5474 $ 0 5.22 $ 0.00
6 SHOP OPERATIONS, DRIVERS
ROOFING NOC & YARD EMPLOYEES 5545 $ 0 31.79 $ 0.00
DRIVERS
ROOFING — BUILT UP — YARD 5547 $ 0 15.85 $ 0.00
EMPLOYEES & DRIVERS
CARPENTRY — DETACHED ONE OR 5645 $ 7,000 8.06 $ 564.00
TWO FAMILY DWELLINGS
CARPENTRY — DWELLINGS — THREE 5651 $ 0 8.06 $ 0.00
STORIES OR LESS
TOTAL CLASS PREMIUM $ 564.00
INCREASE LIMITS 1.01 9807 $ 6.00
EMPL MINIMUM DIFFERENCE 9848 $ 44.00
STANDARD TOTAL $ 614.00
EXPENSE CONSTANT 0900 $ 250.00
TERRORISM RISK INS ACT
2002 .03 9740 $ 2.00
MACHWC (SURCHARGE) 1.058 0936 $ 33.00
FINAL TOTAL $ 899.00
POLICY TOTAL ESTIMATED COST $ 899.00
Experience Modification: RISK ID: 001024541
Policy No. WC2-31S-609250-015 Page No. 1
GPO 2923 WC 00 00 01 A
Broker Copy
WORKERS COMPENSATION AND EMPLOYERS LIABILITY
INSURANCE POLICY Liberty Mutual.
INSURANCE
AR INFORMATION PACE
175 Berkeley Street Boston,MA 02116
Issued by LIBERTY MUTUAL FIRE INSURANCE 16586
Policy Number WC2-31S-609250-015 Issuing Office 016C
NEW BUSINESS NEW Issue Date 03-06-15
Account Number 1-609250 Sub Account 0000
1. Insured and Mailing Address
ITS TIME HOME WPROVEMENT LLC
RISK ID 001024541
162 MAIN STREET
HATFIELD,MA 01038
Status 46 — LIMITED LIABILITY CO
Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE
2. Policy Period: The policy period is from 02-14-2015 to 02-14-2016 12:01 A.M. standard time at the
Insured's mailing address.
3. Coverage
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 work in each state listed in Item 3.A. The limits
of our liability under Part Two are:
Bodily Injury by Accident $ 500, 000 each accident
Bodily Injury by Disease $ 500, 000 policy limit
Bodily Injury by Disease $ 500, 000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE END WC 20 03 06B
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
4. Premium: 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.
Code Premium Basis Total Rate per $100 Estimated Annual
Classifications Number Estimated Annual Remuneration of Remuneration Premium
See Extension of Information Page
Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 899
Premium will be billed ANNUAL
Producer 0004-049497
WHALEN INSURANCE AGENCY INC
71 KING STREET
NORTHAMPTON MA 01060
WC 00 00 01 A 0 1987 National Council on Compensation Insurance,lnc. WC 00 00 01 B (CA)
Ed. 07/01/2011 All Rights Reserved Page 1 of 1
Broker Copy
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: lgs�pAc (k
r
The debris will be transported by:
The debris will be received by: 1 MCI olDo
Building permit number:
Name of Permit Applicant Z_&A"t.
Date Signature of Permit Applicant
City of Northampton
l /
Massachusetts
s��{•:,
DEPARTMENT OF BUILDING INSPECTIONS ,'
212 Main Street • Municipal Building .J1 fib`
- Northampton, MA 01060 rs� �lti?
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
w
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. 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 backfill), 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
1, 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
J�1`�
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 Pleas4 Print Le ibl
Name (Business/Organization/Individual):
Address: Qp,�;z Mck� '54
City/State/Zip: C, C�1 8 Phone #: y 13- IS S<° - q`�
Are you an employer? Check the appropriate box: Type of project(required):
1.&1 am a employer with t 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
5. ❑ We are a corporation and its 10.El Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work officers have exercised their 11.E] 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. Other1�ca„ �
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors 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. Lic. #: CC1` - (O o qQ 5 d ' V l Expiration Date: "� -4D 1b
�'�T
Job Site Address: r -` -A S City/State/Zip: f_
Attach a copy of the workers' compensation policy declaration page (showing the policy number and ex iration 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 hereb ertify under t e ins and penalties of perjury that the information provided above is true and correct.
Si ature:
Date: rJ`
Phone# y��` S c1 Ci y S
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
(�- �/
Name of License Holder: k C.'L - V 7 7 / s 7
License Number' �
Addr s M ,4 Expiration Date j
Signatu re Telephone
9.Re
gistpred Home Improvement Contractor Not Applicable £
-rr-s Lu 7aa-70
Company Name Registration Number
I �L( MGM►� S -/b
Address- Expiration Date
t Telephone �'�3 sS9 X65
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 Otivrier funip'tion
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,
x
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors 17
Accessory Bldg. ❑ Demo'tion ❑ N Signs [0] Decks ( Siding(0] Other(I--3J
-CSC
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement es __QS,,,_No
Plans Attached Roll -Sheet
.,. ..
sa:if New house and or addition to existing housing;'comtslete tiie foilowinq
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 A ENT O ONTRACTOR APPLIES FOR BUILDING PERMIT
I, '1�0 f , as Owner of the subject
prope ly
hereby authorize T f-� ^'`�
rr L-��. Yet✓�-'[�
to act on my behalf, in all matters relative to work authorized By this building permit application.
Signature of Owner Date
I --=W M I
I, KijJ a ' as Owner/Authorized
Agen a are That the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sig d th' ins and penalties of perjury.
Pri N
Sign ture 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
Ibis column to be filled in by
'
Building Department
Lot Size
Frontage
Setbacks Front
Rear F-7
Building Height
Bldg.Square Footage 0110
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
»~� �~�
NO �_/ DON7KNO0/ ��� YES ��^
IF YES, date issued:' �
IF YES: Was the permit recorded at the Registry nfDeeds?
_��
NO � DOM7KNUw 'ES
�
|F YES: enter Book Pog and/or Documen�#
�� ��
B. Does the site contain a brook, body of water orwedands7 NO DON7 KNOW �~� YES �~�
'
IF YES, has a permit been or need to be obtained from the Consehvadon Commission?
Needs tobeobta/ned �~� Obtained �~� Date
i
\_� �J ' ' �
C. Do any signs exist on the property? YES K ) NO
IF YES, describe size, type and location:
D. Are there any proposed changes tour additions of signs intended for the property? YES 0 NO
IF YES, describe [ \
' (_-_--------'----------------'-------------� \
E Will the construction activity disturb( hng. grading, excavation,or filling)over 1 acre orisit part ofo common plan
' that will disturb over 1acre? YES NO
|F YES,then a Northampton Storm Water Management annit from the DPW iarequired.
f
_ _-. __ Qeartmentuse only
City of Northampton Status ofPermrt
Building Department Gar b cu#EDrlueyay Perirttt
MAY —62016 4 212 Main Street Sewer/SeptieAvaiCab�l�ty
Room 100 �lVater/Ve1iA�atlablllty His
--1 Northampton, MA 01060 Twa Sr✓fs ofS#ructural t?(ans z
EI ctnc,Plumbing&Gas Ins ciions
Northampton,MA 01opFione 13-587-1240 Fax 413-587-1272 P[oflSite Plans:
F
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be;completed by office ` _
Map Lot Unit
j f _
erlay D st ct
m ck 0 ' Zone Oviri
District CB District
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(P nt)' Current Mailing Address:
Telephone
Sig iature
2.2 Authorized Agent:
LPL I ,1 c �� ,
T
e(Print) A�+L,J ��YCurrent Mailing Address:
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) `-6r-d Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionedlnspector'of Buildings Date
File#BP-2015-1075
APPLICANT/CONTACT PERSON ANTHONY NOVAK
ADDRESS/PHONE 162 MAIN ST HATFIELD01038(413)247-0188
PROPERTY LOCATION 141 STATE ST
MAP 31 B PARCEL 104 001 ZONE URC(100)/
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: RENOVATE PORCH(SAME FOOTPRINT)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 99754
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO,RMATION 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
S r B dig fficial 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.
141 STATE ST BP-2015-1075
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B- 104 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2015-1075
Project# JS-2015-002031
Est. Cost: $9500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ANTHONY NOVAK 99754
Lot Size(sq. ft.): 6011.28 Owner: NOVIELLO JOHN R&SCOTT G WILLIAMS
Zoning URC(100)/ Applicant. ANTHONY NOVAK
AT. 141 STATE ST
Applicant Address: Phone: Insurance:
162 MAIN ST (413) 247-0188 WC
HATFIELDMA01038 ISSUED ON.511112015 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE PORCH (SAME FOOTPRINT)
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 5/11/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner