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18-004 (2) .�' VDAC r v THIS IS A QUOTE , NOT A POLICY ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PROFILE — VERSION 01 POLICY NUMBER: (6ZZUB-703X274-9-07) RENEWAL OF (6ZZUB-703X274-9-06) INSURED'S NAME AND ADDRESS WORKERS COMPENSATION LABBEE , PAUL A. AND DULONG INSURANCE PLAN DAVID I . DBA REALTY WORLD ASR (WCIP) # MA 285 N KING STREET NORTHAMPTON MA 01060 POLICY PERIOD FROM: 01 -07-07 TO 01 -07-08 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 34 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 142 TOTAL ESTIMATED PREMIUM 179 TAXES AND SURCHARGES 1 DEPOSIT AMOUNT DUE 180 Employer's Liability BI Limit: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee INSURER: AMERICAN ZURICH INSURANCE COMPANY Adjustments of Premiums shall be made ANNUALLY Deposit Amount Due: $ 180 POLICY NUMBER: (6ZZUB-703X274-9-07) DATE OF ISSUE:11 -1 0-06 WC ST ASSIGN: MA OFFICE: ZURICH-ORLAN 809 PRODUCER: KING & CUSHMAN INC 26LPY ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PROFILE _ POLICY NUMBER: (GZZUB-703x274-9-07) INSURER : AMERICAN ZURICH INSURANCE COMPANY 80012-MA INSURED'S NAME : LABBEE , PAUL A. AND DULONG DAVID I . DBA REALTY WORLD RATE BUREAU ID: 000189690 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN 042645883 ENTITY CD 001 LABBEE , PAUL A. AND DULONG DAVID I . DBA REALTY WORLD 285 N KING STREET NORTHAMPTON, MA 01060 CLERICAL OFFICE EMPLOYEES NOC 8810 9566 .15 14 ---------------------------------------•---------------------------------------------- MERIT RATING/EXPERIENCE MOD: NONE MODIFIED PREMIUM $ NONE LOSS CONSTANT (0032) 20 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 34 EXPENSE CONSTANT(0900) 142 0.0300 FOREIGN TERRORISM / TRIA (9740) 3 4 .19% MA WC SPECIAL FUND AND TRUST FUND 1 TOTAL ESTIMATED PREMIUM 180 DEPOSIT AMOUNT DUE 180 DATE OF ISSUE: 11 -10-06 WC ST ASSIGN: MA SCHEDULE NO: 1 OF LAST The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations 600 Washington Street Boston, ltlA 02111 �. www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information T /Please Print Legibly Name (Business/Organization/Individual): �pl� Address: 85 !NG City/State/Zip: NOR f�i AM PTO f CV'R Phone.#: 3 5-F6 -33 3.3 Are you an employer?Check the appropriate box: Type of project(required): 1.F-I am a employer with 4. E] I am a general contractor and I �— 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ Remodeling I am a sole proprietor or partner- listed on the attached sheet. 7• ® g ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' g ❑ Building addition comp. # [No workers' comp.insurance co insurance. 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 11.❑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' 131-1 other comp.insurance required.] *Any applicant that checks box#1 trust 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. 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 if or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/'Lip; 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 file of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the sins and gjzen allies of perjury that the information provided above is true and correct Date: �"1.� D Si ature: — Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Version l.7 Commercial Building Permit May 15,2000 J,. SEC-TIOUS:O. SRUC�U.3ALEEf2F2E [lj(�$d,CMR'1�D ,1 �" * ti Independent Structural Engineering Structural Peer Review Required Yes No SECTION-1t U1111NE1 ALI HOR1ZAMION TO BE OMPI=EFEDm"WBE X"' OWNERS AGENT flR CONTRAC'fQ�APP.L1ES EOF2 BCIILlIGERINIT as Owner of the subject property hereby authorize I Ito act on my behalf,in all matters relative to work authorized�y this building permit application. Signature of Owner Date as Owner/A.rthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Si ned under the pains and pena lti of oedurv. Print Name Signature of Owner/Agent Date s>=coN.rzcor. 4 � cES: 10.1 Licensed Construction Sunervisor. Not Applicable ❑ Name of License Holder /J License Number Address — Expiration Date Signature Telephone 7. SE -TIONI -WOFtI(ERS:CONtpENsAt, 1 Std CJ= E D�A�;!' IA O Lxc § SC S 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. LSigned Affidavit Attached Yes Q No r a, Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONALpES1GyAND ®NS3UC�LONSERYJES-EORBl�Ik.D1t+ GS, 1Di9G7S' t�61EG�iO CONSTRl1CT1ON CONTROL.#�URStiA�IT TO TSO>CMit f 16,�NU6 YMOF3E„TtWPO00 CAF EPICL�SED SP 1 E) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): — Registration Number Address � Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility i Address Registration Number J Signature Telephone Expiration Date ( i Name Area of Responsibility Address Registration Number i J Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility ' 1 Address II Registration Number Signature Telephone Expiration Date 9.3 General Contractor I Not Applicable ❑ Company Name: i Responsible In Charge of Construction Address 1 Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 Existing Proposed Required by Zoning This column to be filled in by Building Department • :r,' Lot size Frontage Setbacks Front Side L:= R:= L:= R•= Rear Bul ing ei u Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved #of Parking Spaces Fill: (volume&Location)! A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW Q YES IF YES, date issued: 1 1/6/07 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW © YES 0 IF YES: enter Book Page' I and/or Document B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained © , Date Issued: J C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 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 © ` NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial 1111ilding Permit May 15,2000 i.. SECTiON44CQNSTRl7 y� 0l; � S ,Ttl 35;000 ¢' Interior Alterations ❑ Existing Wall Signs [3 "Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑;.New Signs❑ Roofing❑ Change of Use E] Other❑ Brief Description Enter a brief description here. 7`- Of Proposed Work:l i -'SECTION=S-USE=GRQUI hID USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A 71 ❑ A-2 ❑ A-3 El 1A ❑ A-4 A-5 �❑ 1B ❑ B Business 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U utility >`❑ Specify: i M Mixed Use ❑ Specify. S Special Use El Specify COMPLTi1aSFiO1ST#NGI71� 1t]X. E G`FNUt©! #DDITtDta1S A1VglOR=CF{At*IGE9N 11SE - -- - – Existing Use Group: r' Prfoposed Use Group: Existing Hazard Index 780 CMR 34):1 Proposed Hazard Index 780 CMR 34): "SECmdvs BU111-D1t G--4EIGN n EA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) st St 2nd i ( 2nd 3`d ! 3 rd F 4tn I 4 m Total Area(so Total Proposed New Con truction(sf) r r Total Height(ft) �— ! Total Height ft 7.Water Supply(M.G.L. c.40,§54) 7.1 Flood o Information: 7.3 Sewage Disposal System: 2 Public ❑ Private ❑ Zone I OuWde Flood Zone[:] Municipal ❑ On site disposal system[] 1 a: Versionl.7 Commercial Building Permit May 15,2000 �_- ` of�Northampton ` � --Building Department 212 Main Street h li ;N Room`100 Northarwpton,`MA 01060 phone 413-587= 240.Fax 413-587-1272 APPLICX,TION 6,cO6NSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING _SECTION 1 S{TE iNFORMATtOt�[_ __-- k`­ 6>sect1oaGt6-be comp[efed.byoffi e_ - ) Property-Addres �.vu• w� a� m _. a 8S N a ° OUCi Y 1 ti iO i I DtSIrIi SECTION 2 Pf20PERTY�OWNERSHlP/AUTHORIZ:ED AGENT �' s 2.1 Owner of Record: =7 VLONG /DAUL A-0 /V ,NCsS•f: 140 Name(Print) Current Mailing Address: IF Signature Telephone 2.2 Authorized Agent: � f I Name(Print) Current Mailing Address: Signature Telephone SECTION-.3-::ESTtMATED:CONSTRUCt,!ON d,d T, Item Estimated Cost(Dollars)to be Official Use Onlq completed by rmit applicant ~ 1. Building ' (a,)Building Permit Fee y�- 2. Electrical (ti)Estimated Total Cost of i.'. :' ;:�Constiuctrda°'irom 6 ' 3. Plumbing ' + Building,Perin fFee f I 4. Mechanical(HVAC) d 5. Fire Protection 6. Total (1 +2+3+4+5) _ Chack.Number This Soction'For..bmcfil'U—Offl Builaing Peintt Number "Date _;issued r Signature: Building-Commissioner/Inspector of-Buildings Date BP-2008-0212 CIS#: 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) Category: BUILDING PERMIT Permit# BP-2008-0212 Project# JS-2008-000330 Est. Cost: $475.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID DULONG 064581 Lot Size(sq. ft.): 8407.08 Owner: DULONG DAVID I&PAUL A LABBEE Zoning: SR Applicant: DAVID DULONG AT. 285 NORTH KING ST Applicant Address: Phone: Insurance: 189 PANTRY RD (413) 320-1195 WC WEST HATFIELDMA01088 ISSUED ON:8129120070:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE FRONT WINDOW & DOOR 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 8/29/2007 0:00:00 $50.00427 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo