Loading...
36-145 (4) 21 LONGVIEW DR BP-2018-0986 GIS s: COMMONWEALTH OF MASSACHUSETTS MaRBlock: 36- 145 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv:renovation BUILDING PERMIT Permit BP-2018-0986 Project It JS-2018-001794 Est.Cost:$40000.00 Fee:$520.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License. Use Group: DERRICK J HATWOOD 097782 Lot Size(sq.ft.): 16727.04 Owner., GLENN PATTI G zo> n� Applicant: DERRICK J HATWOOD AT. 21 LONGVIEW DR Applicant Address: Phone: Insurance: 85 MARTEL RD (413) 246-1578 WC SPRINGFIELDMA01119 ISSUED ON.411112018 0.00:00 TO PERFORM THE FOLLOWING WORK:WHOLE HOUSE RENOVATION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House ft Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy signature: FeeTvoe: Date Paid: Amount: Building 4/11/20180:00:00 5520.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File$BP-2018-0986 APPLICANE/CONTACT PERSON DERRICK I HATWOOD ADDRESS THONE 85 MARTEL RD SPRINGFIELD (413)246-1578 PROPERTY LOCATION 21 LONGVIEW DR MAP 36 PARCEL 145 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST SNCL D REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvoeof Construction: WHOLE HOUSE RENOVATION New Construction Non Structural interior renovations Addition to Existine Accessory Structure Building Plans Included: Owner'Statement or License 097782 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: _Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project SitePlan 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 Storni Water Management emolition Delay f / qNote re of ui I Official Date/ /O ! suance 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 r vlavcv Department use only City of Northamptn Dear cx ca-.,� ofP nnit: ..>./` Building Deparl - eway Permit �. 212 Main Street Sewer/SepLC Availability l Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 -,;�( LOnelv'i 4 11) Re Map 21 Le Loi 115' Unit F(cn ee cc r M p Zone Overlay District Elm$L District Ce Distinct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: R ecei �` - `7 ZL,,< (e3 Ma'r S1 cp -tei MAy(I Name(Print) �� Current Mailing Address. Cal Telephone Signature 2.2 Authorized Agent: I �Fk o S Name(Print) Current Mailing Address: 413 - 73L(-!?95S7-Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant I. Building 20 (a) Building Permit Fee 'DU 2. Electrical (b) Estimated Total Cost of C UD Construction from 6 (7 o6Z 3. Plumbing )C Building Permit Fee C (')o U ,l 4. Mechanical(HVAC) 5. Fire Protection ft 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature- Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be COuracted. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column,o be fined in ny BmedmF Detra ir—m Lot Sive Frontage Setbacks Prent iOp Side L: ( CD R: L: R: Rear �OD But lding I]eight Bldg. Square Footage �O D Open Space Footage % ILbL moan mums bide M rued arkinel p of Parkin 5 aces Fill: ice,mme&Lxannni A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW Q YES C) IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page ,,�,,/ and/or Document # B. Does the site contain a brook, body of water or wetlands? NO ` � DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O ',�Date Issued: C. Do any signs exist on the property? YES O NO (7V IF YES, describe size, type and location: T^ D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: E Will the construction activity disturb(clearing,grading,y4cavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO /JyQJ'/Y IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ AdditionE] ReplacemeniJW�rldows AI[erationls) Rooting Or Doors Pk Accessory Bldg. E:1 Demolition ❑ New Signs [0) Decks [q Siding[ Other[01 Brief Description of Prcposetl Work. Itirj-10[.E f�/Ji/S/' .2.GJ'l(/d�T/OJr� Alteration of existing bedroom_Yes No Adding new bedroomYes No Attached Narrative Renovating unfinished basement Yes �No Plans Attached Roll -Sheet Sa. If New house and or addition toexistin housin complete the following a. Use of building :One Family Two Family Other b. Number of rooms in each family unit: --J Number of Bathrooms 1 c. Is there a garage attached? N h d Proposed Square footage of new construction. Dimensions e. Number of stories? f f Method of heating? replaces or Wootlstoves �O) Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? In Type of construction I. Is construction within 100 It of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No I. 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 Ta -OWNER AUTHORIZATION -TO BE COMPLETEDWHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. � �.J� /- L( t 1 I C7, (� Q.Ys/�- as Cdwrrer of the subject property ��'7 hereby authorize ILC 1 to act on mi in all matters rata five to work authorized by this building permit application. Signature of Omw�neeerr�- Date _r..� I, i f 11 6(0n n as OwnedAuthonzed 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 hit thepains an penaltiiees of perjury. Print Name Signature of OwnerlAgai Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 1 , L _ Not(Applicablble ❑ Name of License Holder:��Pi✓✓1(� ETL[f LIDO/Y� �✓ VJ� D 1770 0� �/ License Number S�(J V dl �3o� Os Addres ^ Expira ion Dal /�) `!13 7 X110 151 g Signature Telephone 9.Registered Home Improvement Contactor Not Applicable O I L.4cAl Companv Name Registration Number &L,sk� �{nrvLo 09/�H�d Ila Expire ole vuUlQ ) (II(P,Prf �H}d �/� ()(IoTelephone419 7q/ -3300 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...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS F V 212 Main Street • Municipal Bantling lr�/ Northampton, MP 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC'). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.._orto structures which are adjacent to such residence orbuilding"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity mus[be registered 'type of Work: Est. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): __ _ Job under$1.000.00 Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): __ OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING IN FO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NO'F IIAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANI\ FUND 11NDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED TINDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: i �Nay7 Date Contractor Name I HIC Registration No, OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property Date Owner Name and Signature City of Northampton Massachusetts U1,I DEPARTMEin NT OF BUILDING INSPECTIONS 212 MaStaeet •Nuniu HuiltlingNozNan�toq MA 01 01060 Debris 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. The debris from construction work being performed at: 2� L CAA)"" 1 ��.i (Please print house n tuber antl street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: .so�Ld� U�Wa � (Company Name and Address) _ � Signature of Pe or Owner Date (�C--�f L-C'r) If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of7ndustrial Accidents 1 Congress Street, Suite 10// Boston,MA 02114-1017 www.mass.gov/dia UZI Workers'Compensation Insurance Affidavit General Businesses. 1'0 BE FILED isI'I'If I'HE PERMIT'T'ING At THORITI'. ADDlicant Information qq Please Print Legibly Rusiness/Organization Name: .1AC . Address:._M,d(7aute — City/State/Zip: J Ort �d ) of /21l Phone#: 74(o '3JQ 0 Are, an employer?Check the appropriate box: Business Type(required): I.U I am a employer with _/1/_ employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc) employees working for me in any capacity. [No workers'comp, insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,j 1(4),and we have 10.❑Manufacturing no employees. [No workers'comp. insurance required]* I L❑ Health Care 4_❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req] 12.0 Other 'Aneapu.,,nIlrecreates hos al mast also till Olathe sedan helm,s1s,lr,than,ccr. con.pennnmmion n rohns lnrur . it the cor Ohne Nuters bare exemp24 thein ek,nature wnamuas an s mheremd plo,es .a„ners *" compensation pnllcp is required and such an aaual,seowd ehee[box W I lam an emplover that is providing workers'compensation insurance jar my emplovees. Below is the pot information. Insurance Company Namc_/-/sl MIAIAki _'U5W4Ae_ 69j20rLt4&A Insurer's Address: "A Log 0 CaN/State/zip: k),1aa.50,u.L LOT, pot icy #or Self-ins.Lic.#_WW-1i S13ra.1X��td� Fxpiration Date: LV/023 /&/ 0 Attach a copy or 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 To 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 ofdtis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. /do hereby certifh nn ear tirein n r o epary that the information provided above is true and correct. Signature. _ _ _ _ Date: Phone 4: 7% xJ (] Official use mi Do not write in this area,to be completed 5y ci(v or town official. Cite or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.Citx'(Ibwn Clerk 4. Licensing Board S.Selectmen's Office 6.Other Contact Person: Phone#: „m,,.ln.sseovmla AC"Ra CERTIFICATE OF LIABILITY INSURANCE 03/29/2018 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 condition.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 endomement(s). PRoOucaR CONTACT xOJudith Mabee BERKSHIRE INSURANCE GROUP INC PHDxX TJAACEn, (413(553 3090 (y N.1. DDRESS-.lmabee@berkshineinsurancegroup.com 43 East St _ _ INSUREFUSAFFORTNGCOVERAGE Ni PITTSFIELD MA 01201 INSURERA LM INS CORP 33600 INSURED — "—.- INSURER B'. BAYSTATE HOME GUARD INC - _ - MsuRERc NSUREfl D 38 DAWES ST _-- - _-- - - _--- MsuRERE SPRINGFIELD MA 01109 COVERAGES CERTIFICATE NUMBER: 252342 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 TMBfl LTO TYPE OF INSURANCE . POLICY HUMBER MppryYYV I MpOUCYEXP MNOHVYY - - LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 'VN GE ORENTED _. cLAIMSMApE occuR 1 E ses E __. owl MED ExP 11,­person) IS ____ N/A PERSONAL ADV lnauxv GEN L AGGREGATELIMIT APPLIES PER'. GENE AGGREGATE _ IS Ii POLICY 'ME, '�.Loc Pnooucrs.co"woP AGG 's .. _ . AUTOMOBILE LIABILITY " COMBINED SINGLE LIMIT S 'Eaamaenp ANY AUTO BODILY INJURY1 _. O --r) S ALL LEANED �PLENIICU Amos 1 AUTOS 1NIA 1 1 BODILY i Ell xA,M1A s HIRED AUTOS NONAwrvED " I PROPERTY DGE -T5 -- - 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE IS.. EXCESS LIAB CLAIMSM_AOE N/A AGGREGATE DED HEtlrffi $ 5 WORKS RSCOMPENSATI°x X PER STATUTE EDTH AND EMPLOYERSLIARILIY YIN - - H A orrc OEMP,RE eF E C. CED EEUT VE w�JA x NIA WC531S321203037 05/23/2017 05/23/2018-E_-FAIII ACCIDENT S500,000 UnTe.I.M ED DISEASE FA EMPLOYEE's 500,000 oEsca`i Osie or OPERAi orvs cem.. EL OPEASE POLICY LIMIT 500,000 NIA DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES 'ACORD ml,AJJIRanzl R.NxiSS SCMaae Csy Be emmed R ma..Mwce Is Sq,IMP Workers Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 2003 06 8,no authorization is given to pay Claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This cenificate of insurance shows the policy In farce on the date that this cenificate was issued(unless the expiration date On the above policy precedes the Issue dale of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govdwd/workers-compensation/investigations,. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Northampton Massachusetts Dept of Building Inspections 212 Main Street Municipal Bldg AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Crowley,CECIL,Vice President-Residual Markel-WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and Ingo are registered marks of ACORD 'qct CERTIFICATE OF LIABILITY INSURANCE ITA EIMMIDD Y) 1 3/29/2018 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 policylies)must he endorsed. If SUBROGATION IS WAIVED, subject t0 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 endomement(s). PRODUCERNX.1 TACT Marion Lentea Berkshire Insurance Group, Inc. PHONE (413)447-0306 FAX (un999- "t,NgErtl' IAIt.NoEARN ): 3918 43 East SI AMRL mlen[ee®berkshizeirteurance ADDRE3R: group.COm PO Box 4089 NSUREESSI AFFORDING COVERAGE HAm. Pittsfield MA 01202 INSURER A Nautilus Insurance Company 17370 INSURED INSURER e:National Continental Insurance 10243 Bayetate Home Guard Inc INSURER C: 38 Dawes SI INSURER D: INSURER E-. Springfield MA 01109 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1741448432 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. ILIA TYPE OF INSURANCE ADOL SUER POLICY XUMOER R.00CrE MMIOCYYYESP LIMITS X COMMERCIALGENERALLIABILITY EACH OCCURRENCE 1,000,000 A CLAIMS VALE x occuR MMAGETORENTED P 's',A--r re) 300,000 ¢[P2008515-1] ♦/11/]011 9/19/2018 MED Ell1 11,My ENrs 5 25.000 PERSONAL A N]V INJURY S 11000,000 GEN I AGGRCGATE LIMIT APPLIES PER GENERAL AGGLEGA IF 5 21000,000 X POLICY JECT LOC PRODUCTS COMPiOPAGG 5 2,000,000 OIrvERPILLAQ,Hasty 5 1,000,000 AUTOMOBILE LIAMILLY COMBINED SINGLE LIMITLE, 6 WANI B ANY AUTO BODILY INJURY(Per an, $ 50,000 ALLOVvNED X AUOS0609]39]7 10/28/2016 10/28/2017 ACIDIFY INJURY UTOS CTRULED we,ee'+eenn $ 100,000 X HIRED Amos X NON OWNED PROPERTY DAMAGE AUTOS (Per awaen0 s s UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMSMADEAGGREGATE 5 DED PETER ION y WORKERS COMPENSATION PEO un AND EMPLOYERS'LIABILITY ./IN STAT JUL E OFFANYI CERMEEM.IR PARTEFCLVDEOI%�mwE NIA EL EACH AGGIDEACCIDENT5 MppantlI HER EI DISEASEEAEMPLOYEES OE SGRIPTIONN OF OPERAIIONSNWJA FI DISEASE,POLI CA LI MR 5 DESCRIPTION OF OPE UG ONS I LOCAT ON51 VEHICLES(ACORD 101,ANARMYRI RemaMa SaMdulC May M aNCMJ Fmom space In rW,MW) Project: 21 Longview Road, Florence, NA City of Northampton. Massachusetts and JOE Capital Investment LLC 1163 Main Street, Springfield, MA 01105 are additional insured for General Liability as required by written contract and only ae respect. eured's ongoing operations relative to the certificate holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Northampton, Massachusetts THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department of Building Inspections ACCORDANCE WITH TME POLICY PROVISIONS. 212 Main St. Municipal Bldg Northampton, MA 01060 AUTHORRED REPRESENTATIVE Lisa Lemon AAL/LLC ON 61988-2014 ACCORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025,,HVl Information and Instructions 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 writer" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other l egal 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 bean 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, r25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements ofthis 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 your insurance company's name,address and phone number along with a certificate 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- Ban 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 sure to sign and date the affidavit 'rhe affidavit should be returned 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 Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ofthe 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 most submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). 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 ..it 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 fix.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax 4 617-727-7749 www.mass.gov/dia Porn Rccised n2-2336 ®, Massachusetts Deparimentof Public Safety - Board of Building Regulations and Standards License CS-097782 Construction Supervisor - DERRICK J HATWOOD SR 85 MARTEL ROAD SPRINGFIELD MA 011- ;.�+:�. • - Expiration Commissionert 11/9012018 Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain less than 36.000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Binding Code is cause for revocation of this gcense. DPS Licensing information visit: NNtlw.MASS.GOVIDPS Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation BAVSTATE HOME GUARD, INC. Registration: 164247 38 DAW ES STREET Expiration: 09/24/2019 SPRINGFIELD,MA 01109 Update Address and Return Card Ln omoe or Consumer Affairs A Business Resolution HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TVFE',CwuOrelim before the expiration date. 9 found return to ReeistraTon Ex irr tion Office of Consumer Affairs and Business Regulation _._ 16420}'. 09/2412019 10 Park Plaza-Suite 5170 BAVSTATE HOME GUARD;INC. Boston,MA 02116 /[/� DERRICK HATN000 99 DAW ES STREET . T r�— 9f ,-� SPRINGFIELD,MA 01109 Undersecretary Not vali without signature � �\ i � ��l/, �.�. V✓ �"A LSp�.-`j� lh�J-jr}�\ 'r -}>�.���"�r�'(/