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24D-064 (2) DATE(MWDYYY) A�" CERTIFICATE OF LIABILITY INSURANCE D/Y 6/5/2015 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(ies)must be endorsed. 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). PRODUCER CRIMMINS-GRAVELINE INSURANCE AGENCY INC =TVCT 1382 MAIN STREET PHONE FAX PO BOX 905 E-MAIL lA/c Not: PALMER, MA 01069 ADDRESS: INSURERS AFFORDING COVERAGE NAIL 0 1_NSURER_A: LM_insura__nce Comer oration _ 33600 INSURED INSURER B: DAVID LANE DBA DAVE LANE HOME IMPROVEMENTS iNSURERC: 1371 MAIN STREET INSURER D: PALMER MA 01069 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 24984697 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. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMIT'S LTR POLICY NUMBER MW MM/ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $_ CLAIMS-MADE D OCCUR REMISES Ea occunence�_ $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ POLICY F PRO ❑LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ F $ AUTOS Per accident UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-382933-025 3/28/2015 3/28/2016 / STATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED? ❑Y NIA — ---- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 1000000 if es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR DAVID LANE This certificate cancels and supersedes all previously issued certificates,only as they relate to workers'compensation coverage Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION ED MURPHY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 22 PERKINS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. NORTHAMPTON MA 01060 AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 24984697 1 1624449 1 2015-2016 1 Anne Chandler 6/5/2015 12:52:17 PM (EDT) I Page 1 of 1 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: 3,;), Q R�Y—X.^3 S c� The debris will be transported by: C Z rwe The debris will be received by: O:�r�QS� Z off- N� TE— Building permit number: Name of Permit Applicant )+R� Date Signature of Permit Applicant 4 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: " , Not Applicable £ Name of License Holder: IT�-+� �il r/�!iG�-- C-�;— 'ug 4 License Number r Addr Expiration Date Signature Telepho e 9.':Registeted Home.lmpravement'Contractor Not Applicable £ Company Name Regis trati n Nu ber Address p Expiration Date (V 1,A• Telephone 1 xv-q)I? 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 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other[0] Brief DescUpption of Proposed ---- Work: KF-?�.1'YI�iL (Zip O�$2 QUfL C�c1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes /No Plans Attached Roll -Sheet sa:If New house and or addition exisfiin housin com late the followin 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? 'E�LL4I' f. Method of heating? Fireplaces or Woodstoves NO Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction Wdvb i. Is construction within 100 ft. of wetlands? Yes V No. Is Is construction within 100 yr. floodplain Yes�No j. Depth of basement or cellar floor below finished grade Q �f-�/ k. Will building conform to the Building and Zoning regulations? V Yes No. I. Septic Tank City Sewer V Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR.BUILDING PERMIT (IVIK jJ lVl V r vM`r as Owner of the subject property hereby orize �f'1v� �- 11 t* n. 1 t* n. to act y b If, in all matters relative to work authorized by this building permit ap -6 7 Signatu of Owner Date Li e V&p r( 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 under the pains and penalties of perjury. E-b V VA9 b J-- A v"H- Pr Signature o Owner/Agent ate .� Section 4. ZONING Alt 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 --- Rear Building Height Bldg.Square Footage % Open Space Footage % #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? v_~� x—� �—� NO DON7 KKNOW YL\ �~� IF YES, dateioued.| / IF YES: Was the permit recorded at the Registry ofDeeds? NO C) DON7 KNOW 0 YES ` IF YES: enter Book Page and/or Ducument# �� B. Does the site contain a brook, body nf water orwetlands? NO K�� DONT KNOW �~� YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained «-\ Obtained �~� Date Issued: ��' . ��' ' � x�< C. Do any signs exist on the property? YES K ) NO |F YES, describe size, type and tocatiun: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size' type and location: E. Will the construction activity disturb(clearing, grading. excavation,or filling)over 1 acre oriait part ofa common plan ' that will disturb over 1acre? YES NO *& IF YES,then a Northampton Storm Water Management Permit from the DPW is required. j' � ' Department use only , R Oh City of Northamptontatus;of Building Department Curb GutlDnyeway Perrrllt r ,! i 212 Main Street Sewer/S�pticAvaifabllrty '' F Room 100 Water/We1lA�.... l y` Northampton, MA 01060 TwaSets of 5tructural'Plans ' ' phone 413-587-1240 Fax 413-587-1272 PIotlSite Plans Othery5pecify P LICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE.INFORMATION Th 1.1 Property Address: is secfion to be comp leted byoffice �El K,�J 1 l� Map Lot Unit: Overlay D�strtct EIm St D�stnct CB Distract SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name Current Mailing Address: / Telephone %� r 17 r Signature y 2.2 Aut orized Agent: Name(Print) Current 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) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 22 PERKINS AVE BP-2016-0164 GIs#: COMMONWEALTH OF MASSACHUSETTS MU.-Block: 24D-064 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2016-0164 Project# JS-2016-000270 Est. Cost: $2870.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID LANE 108477 Lot Size(sq. £t.): 3484.80 Owner: MURPHY EDWARD J&AMY HENRY-WILFONG Zoning URB(100)/ Applicant: DAVID LANE AT. 22 PERKINS AVE Applicant Address: Phone: Insurance: 119 STATE ST (413)205-9790 WC PALMERMA01069 ISSUED ON.81712015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE PORCH ROOF 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 8/7/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner