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24D-064 (5) DATE NY" CERTIFICATE OF LIABILITY INSURANCE 1�5�'2Q16 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 DOE'S NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORt2ED 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 CONTACT L nag—Ann Dawson KAtI�: y Penny-Hanley & Howley Co Inc f � (1160;684-2723 sop�a rxs e� sse2 52 Plain St EADDRESS Lynnann @pennyhanley,com PO Box 127 ..._INSURERIS)AFFORDING COVERAGE NA1C# -.. Stafford Springs CT 06076 INSI9REAATechnology Insurance --- ------- — —-- -- ----- --— - INSURED 3ltSiJRER 8: _ Reich Ragusta fSBA INSURER c Creative Remodeling Solutions INSURER D. 189 Shaker Road }INSURER E: Somers CT 06071 I'M PAR F COVERAGES CERTIFICATE ER.15-1^6 VC cent 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. INSSR - _TYPE OF INSURANCE - .ADDL SUBR" _- POLICY NUMBER ...POLICY EFF _.POLICY EXP LTR COMMIERGIAL GENERAL LIABILITY - !.EACH 1X'I'URRr-NCE 5 CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ f MED EXP(Any one person) $ PERSONAL&ADV INJURY S GEI L AGGREGATE LIMIT APPLIES PER' GENERAL Af GREGATE $ POLICY ;JEC7 LOC , PRODUCT CQMPiOPAGG OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accdent) _ . .ANY AUTO i BODILY INJURY(Per person) S- _. �-- ---- -- --_-.-- ----- -----_.-_------_. _— ALL OWNED SCHEDULED -: AUTOS AUTOS BODILY INJURY(Per accident).,$ .__�i _. _ _. .. NON-OWNED `PROPERTY DAMAGE .... HIRED tiL'705 AUTOS (Pe:accwent) S _ I UMBRELLALL48 I OCCUR EACH OCCURRENCE $. -_._. _...._ EXCESSLUaB CLAIMS-MADE . AGGREGATE S DED RETENTION$ 1 - WORKERS COMPENSA'7S'M PFA TATUTE ER OTH i _ AND EMPLOYERS'LUU31L1TY A i SYIN; -:ANY PROPRIETORtPARTNER/EXECUTIVE _—"-i, E L.EACH ACCIDENT -$ 100 r_000 OFFICERfMEMBER EXCLUDED? .NIA A (Mandatory in NH) - TARCTS9169-01 8/1/2015 8/1/2016 EL.DISEASE-EA EMPLOYEE.$ 100,000 B yes,descf,be uadea DESCRIPTION OF OPERATIONS below El.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORO 101,Additional Remarks Schedule,may be attached it more space is required) Proof of Coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS, 212 Main Street Northampton, MA AUTHORIZED REPRESENTATIVE Lynn-Ann Dawson/LAD a 1988-2014 ACORD CORPORATION_ All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INSn15 nmani� Plot plan, 22 Perkins Avenue,Northampton, MA 01060, showing existing and proposed deck ep z G ��•T s�V U tug' I i i ' e _.J 2 22 Perkins Avenue Northampton, MA 01060 January 12, 2016 Carolyn Misch Senior Land Use Planner&Permits Manager Planning& Sustainability 210 Main Street, Room 11 Northampton, MA 01060 Dear Ms Misch: This is Attachment B (Plansheets) to the application from my wife, Amy Henry, and me for a special permit to replace the wooden deck behind our single-family house at the above address with a larger deck. This attachment includes the following materials: • page 2: a plot plan (drawn by my wife) showing our lot, our house, and both the existing and proposed deck; and • page 3: a drawing of the proposed deck, prepared by our contractor, Keith Kapusta; We thank you for your attention to this application, and for your guidance in preparing it. Sincerely, Edward J Murphy 1 M � r_ _ b j! -4 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.foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association o 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 local 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." Additionally,MGL chapter 152, §25C(7)states"Neither the c mmonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work unti,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 checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone numbers)along with their ccrtifcate(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 surd to sign and date the affidavit. The affidavit should be retumed 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 Ofricials Please be sure that the affidavit is complete and printed legibly. 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"th applicant should write"all locations in (ci f'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 (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank 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 Commonwealth of M, assachusetts Department of Industrial Accidents Office of Investigati®ns 1 Congress,Street, Suite 100 Boston, Na 02114-2017 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia AN The Commonwealth of Massachusetts �1 Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 , � Boston,MA 02114 2017 - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluanbers Atiplicant Information Please Print Leo-lb Name (Business/Organization/Tndividual): �,V(�_ Address: City/State/zip: t Phone Are you an employer? Check the appropriate boa: Type of project(required): 1.9.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 ship and have no employees These sub-contractors have 8. g Demolition working forme in any capacity. employees and have workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance P 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]I 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. 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. Iam[nz employer that isprovidina workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: I gyp f�i� /� ) Policy#or Self-ins:Lic.#: -T4.-ra Expiration Date: Job Site Address: City/State/Zip: l���� ,,� 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 under the pains and penalties of perjury that the information provided above is true and correct. Si--nature: .. _ �_ Datef Phone#: Ll 1 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#: f SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:--.. e l t� ( ,S r License Number Address Expiration Date lei S��k R, p� So ,� mss, C-7— 06 / Signature Telephone Z/ i 9. Registered Home Improvement Contractor: Not Applicable ❑ 8571 0,6FZ /N( )-4vav Company Name Registration Number /Sv 5-Y4k� /�� Z- aCi - -�0I Address Expiration Date Telephone 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 f SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition [✓ Replacement Windows Alteration(s) Roofing Or Doors I] Accessory Bldg. ❑ Demolition 0 New Signs [I3] Decks 10, Siding[D) Other[a Brief Description of Proposed Work:Replace"istmg deck with larger t—twe orsimilar materials;demolish existing deck and remove old materi."- Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing, complete the following: a. Use of building: One Family X Two Family Other b. Number of rooms in each family unit: 6 Number of Bathrooms c. Is there a garage attached? No 1 r nit 1 r n d. Proposed Square footage of new construction. 1 Dimensions 7 X 1 e. Number of stories? 1 f. Method of heating? NSA Fireplaces or Woodstoves No Number of each g. Energy Conservation Compliance.NSA Masscheck Energy Compliance form attached? h. Type of construction wood with Trex rails i. Is construction within 100 ft.of wetlands? Yes X 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 Lb G✓/( (� /g_( yk io K� as Owner of the subject property hereby authorize `\ 7-�-( f4' Ar V! TA- to act on m e If,in afters relative to work authorized by this building permit application. l'�) 13 C) A , Signature of er Dat Age �6-1 77­-� kl�v u1 (- as Owner/ uthorized reby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowTedge nd belief. Signed under the pains and penalties of perjury. Print Nam _ _-�Ul 4 Signature Owner/Agent Date n 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 72'x 54' 72'x 54' Frontage 54' 54' Setbacks Front 14' 14' CSC y L5j.de L: 15'6" R:25'6"- L:15'6" R:24' d 12 6 B lding Height 4' 4' 36Z'k Blc(g Squ`a`re Footage 96 % 214 M Open Space Footage % (Lot area minus bldg&paved parking) # ofParking Spaces 2 2 Fill: None None volume&Location) A. s a Special Permit/Variance/Finding ever been issued for/on the site? j NO DONT KNOW YES IF YES, date is ed: IF YES: Was the ermit recorded at the Registry of Deeds? NO ® DONT KNOW ® YES IF YES: enter B k Page and/or Document# B. Does the site contain a brook, ody of water or wettan 0 • DONT KNOW YES ® 0 IF YES, has a permit been or ne to be obtaine from the Conservation Commission? Needs to be obtained ® btai d Q Date Issued: C. Do any signs exist on the property? YE NO O IF YES, describe size, type and to tion: D. Are there any proposed chang to or additions of signs inten d for the property? YES ® NO e IF YES, describe size, ty and location: E. Will the construction activi r disturb(clearing,grading,excavation,or filling)ov 1 acre or is it part of a common plan that will disturb over 1 a e? YES ® NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is requi y Department use only REC JFL) Ci of Northampton Status of Permit: B Iding Department Curb Cut/Driveway Permit C 12 Main Street Sewer/Septic Availability. 5 �'� Room 100 WaterMell Availability rth mpton, MA 01060 Two Sets of Structural Plans OFauu0 - -1240 Fax 413-587-1272 Plot/Site Plans NOR"fNAM N Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Address: This section to be completed by office 1.1 Pro a oZ� 6721</+US A- Map � ,� Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Edward J M by&Amy L Henry 22 Perkins Avenuc,Northampton, MA 01060 Name(P' Current Mailing Address: 413-237-1741 Telephone Signature 2.2 Authorized Aaent: 0601 Name(Print) Current Mailing Address: Signatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 10,700 (a)Building Permit Fee 2. Electrical 0 (b)Fefmated Total Cost of Construction from 6 3. Plumbing 0 Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 0 6. Total=(1 +2+3+4+5) 10,700 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0843 APPLICANT/CONTACT PERSON MURPHY EDWARD J&AMY HENRY-WILFONG ADDRESS/PHONE 22 PERKINS AVE NORTHAMPTON01060(413)237-1741 O PROPERTY LOCATION 22 PERKINS AVE MAP 24D PARCEL 064 001 ZONE URB(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: REPLACE EXISTING DECK W/15 X 15 DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 107846 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRWENTED: 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 Pl/an n 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 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.