18C-154 (3) 24-32&41 WARBURTON WAY BP-2019-1376
GIs 4: COMMONWEALTH OF MASSACHUSETTS
MawBlock: 18C- 154 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: ROOF BUILDING PERMIT
Permit# BP-2019-1376
Project# JS-2019-002215
Est.Cost: $38220.00
Fee:$267.eo PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: QUINLAN BUILDERS 053107
Lot Size(sp.R.): 0.00 Owner. PROSPECT WOODS HOMEOWNERS
Zoning,URB(100y Applicant: QUINLAN BUILDERS
AT. 24-32 & 41 WARBURTON WAY
Applicant Address: Phone: Insurance:
94 HUNTINGTON (413) 549-5474 11
HADLEYMA01035 ISSUED ON.6.1312019 0.00.00
TO PERFORM THE FOLLOWING WORK.-STRIP &SHINGLE 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: FireDepartment Fireplace/Chimney:
Rough: iI: 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 6/3/20190:00:00 $267.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
. VONNL�CIYn{l
Department use only
City of Northampton Status of Permit:
Buiidin rb Cut/Driveway Permit
1 ... A 212 1 lain Eft E I V E D flis',ite
er/Septic Availability
r R Om or all Availability
Northam fon, A 0106QQ ete of Structural Plans
phone 413-587-1 40 aAA-90-M Plans
eSpecify
APPLICATION TO CONSTRUCT, TMINI DE OLISH A ONE
gOQR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION ��—� N /f-/,4 70
1.1 Property Address: /yT7hhii+s section to be completed by office
j9a`fr 9L,nr-;p �FP9,y Map nl.. Lot � / it
WC1,16jr �OA WqU Zone Overlay District
J Elm St District CB Diable[
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
50ahed "avfac, ag 30 3 a f yl A-Left t kQt-
Name(Print) / Cueent�ilssiig Atl r-gsrs� I
SCC 11FNCn054 Telephone
Signature
2.2 �rd A a V re
Name(Print) Curre[/yntMaRrgVrF
'A�/V, /
RCI
-:y
Signature Telephone
SECTION 3.ESTI ED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by Permit applicant
1. Building 7j O -7 l� r b (a)Building Permit Fee
2. Electrical O OW (b)Estimated Total Cost of I�
Construction from 6 n
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection l
6. Total=(1 +2+3+4+5) 3 4a0.00 1 Check Number
This Section For Official Use Only
Date
Building Permit Number' Issued: 2 p
Signature:
Building Commissioner/Inspector of Buildings Date
V
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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 Dopartmcnt
Lot Size
Frontage
Setbacks Front
Side G R L R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
not mea minus bide E paved
percirt.)
ii ofFarking Spaces
Fill:
Paluote8laalionl
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document it
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 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 O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will one construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over i acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Rooflng
Or Doors
Accessory Bldg. E] Demolition ❑ New Signs"I Docks M n� Siding IE31 Other IQ
Brief DesraigtioFof Pld) Two �ttY6'S A; q11 IUCJr>. ��5�'� '�/�St� Qua OY
Work: �7T�
!ew %0 3cy '
Alteration of existing bedroom Yes__) _No Adding new bedroom Yes No w�A
Attached Narrative Renovating unfinished basement Y s �LNo Icry�kS
Plans Attached Roll -Sheet 5�t 7�
so.N New house and or addition to existing housing, complete the following: O
life
a. Use of building:One Family Tyro Famlly Other
b. >b.
r of rooms in each family unit: Number of Bathrooms
c. e a rage attached?
d. Proposed Square Cage of new construction. imensions
e. r of stories?
I, d of heating? Fireplaces or Woodsloves Number of eachg. Conservation Compliance. Masscheck Energy Compliance form attached?
h. f constructionI, truction wlthin R.of wetlands? Yes _No. onstruclion vrithin 100 yr. floodplain Yes No
of base nt orcellarfloor below gni shed grade
it inti conform to the Building and Zoning regulations? YesI. Tank_ Ctry Sewer Private well City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Y�Qr_ Z� .as Owner of the subject
property t 6
hereby authorize � 1A 1 N
to act on my behalf,in all matters relative to k authorized by this building permit application.
Signature of
Owner Dale
/
I, gM dVV rN�+t ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are We and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name /
Signature of Owner/Agent D le
A4 4
Section 7a: Owners Authorization -to be completed when
owner's agent or contractor applies for building permit:
I, as Owner of this property. Hereby authorizer Tom Quinlan to
act on my behalf, in all matters relative to work authorized by
this building permit application.
#24 Louise
Lucht: ys�� �&f, -
DATE:
#26 Rbent)
��LsAiAo Kintz:� grJIWA,,,
DATE: 6. 2,f& rz Iq
#28 Chris-. II. , I
Aubrey:' 111i`�fIIU� ry�J(
DATE: 66.119
#30 Deirdre
Scott:/Je &/1&L
DATE: giyf lq
#32 Sean
Devlin: 7k
DATE:
#41 Alex
Cohen: v"
DATE:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Summits". Not Applicable 11p p
Name of License Holder: V_ M QV Is. 1q w CS —611 F 9 1
License Number
7`1 htiFn� I w, aaa� ;l ;; l a0
Address Expiration Data
W3-3611-97$1
Signature Telephone
f� a
9.Registered Home Ira a ent C dor: Not Applicable ❑
To M 6Pw,,( (W d1 /oi 7b'7
Company Na ms 11 n Registration Number
qY f�lya6'^ LS A gC16L lI 61.19/au
Address �1 A f/ �)� r Expiration Date
AA- O(U3S Telephone Y� 3dy'7*
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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
•"� ...,f Massachusetts
3 t
➢6PAH0'2RH0' OF HOILOIHG INSPECTIONS
212 win Strout •Municipal BuilGinq
Northampton, MA 01060 i�PYa.
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:
'its ay x43D.3, yYl Wr,r� tr " way
(Please print house numb r and street name)
Is to be disposed of at:
Vatle4 &Cydka .
(Ple print name a location f facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Ar ��/�lisl�ia �plb� RU n,aAC'&Pk-I
(Company Name and dress)
y7, - al,,e�;
Signature of Permit licant or Owner Date
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 of Industrial Accidents
7 Congress Street, Suite 100
Boston, MA 02114-2017
wrs' v.alass gov/dia
R orkers' Compensation Insurance Affidavit:Bumders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TUE PERMITTING AUTIIORITI'.
Applicant Information Y Please Print Le ibis
Name (Business/OrganizatioMndividml): J
Address: 99 Ffv.t 6f,4OA Rot
.- City/State/Zip: Wifla M e( S Phoneg: yR - sy9-Sy>L/
Are,....etaple,ar7 Clunk rhe appropmme Is: Type of project(required):
I,[]I am a employerwith employws(full a.dorport-umcl.• 7. ❑New construction
2.❑l am a ole popictorarpamaship and have no employees worlJrg fmmcin 8. Remodeling
any capacity.[No workers'comp,insurance required.]
d.OI amu learawnm doi.sall work myself.[No vvanm'comp.inswmmcc nquirdj' 9. ❑Demolition
4.❑I am a homeowner and will be hiring contrueton to condwt all..A an myproRMY. I will 10❑ Building addition
ensure that all canlmnors either hove workcrn'wmpemmion insumime...wl< I L❑Electrical repairs or additions
Proprietors wiN an e"have s. 12.❑Plumbing repairs or additions
seam a g..[cunmacmr rad 1 have hired the sub-cvnmacmn lined mt the wmeh d sheat. I J.�Roof repairs
tmm
v sub�concrx have employees and 1m,a wmiucrz camp.insurance:
6.[]We ane a vmpmation and itsolftcers love exercised their rishtnfc`empua.W%IGL a 14-[:]Other
t52,4t(4),avd we have m emPlayees.INo workers'comp insurance rcqumed.l
Ari,apokrm that ei eks bus al muss also fill out smtion below shoring their workers'compemation poli,information.
t He...who subnut at alidmif indicmmg rhe,art doing all woA avd the.him,outside contractors must submit o new mlidavit indicating such.
rC..tmaos that check this Mx tutor mtxhed a.additional sheet shawias the w.c of the subcm.aaors and sate aha v rat vat than entities hmx
emplyees. Hthe s.l mtlramrs haccemployees,they must pros ide their x.,keW camp.policy number.
I mu a+employer that is providing worhers'rnn+peusatim+insurance jar nry•crap/glees. Beloit,is the policy and job site
information.
Insurance Company Name:
Policy#or Sclf--ins.Lia#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workera' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
7 do hereby certify/under a+eRai is and pena0ies of perjury that the information,provided abot•e is true and correct.
Sienatal Date: }'L-zY//9'
Phone#,
Oficial use only. Do not write in this area,to be completed by cirl,or tom official.
Citv or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/fown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 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 or 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 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 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 subcontractors)name(s),addresses)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,arc not required to carry workers'compensation insurance. If an LLC or LLP docs hart
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insumnce coverage. Also be sure to sign and date the affidavit. The affidavit should
be retuned 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 luted 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
of the affidavit for you to fill out in the event the Office of Irn estigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that most 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'the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided in the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02.23-15 www.mass.gov/dia
City of Northampton
�
Massachusetts -
I DEPARTMENT OF BDILDING INSPECTIONS x
J
" 212 Hain Staa< • NeM DBuilding
NorthantmFA, 01010 60
LOUIS HASBROUCK
BUILDING COMMISSIONER Effective July 1,2015
Phone: (413)587-1240
Fax: (413)587-1272
Residential One and Two Family Building Permit Fees
hRoltwww.northemotonma.govl702/l3uild ing-Dewrtment
Fees for work not listed will be determined by the Building Department
Any work beginning before a permit has been issued is subject to double fees and a stop work order removal fee
Hours of operation are typically Monday thru Friday 8:30 to 4:30,Walk-In hours are closed at 12:00 pm Wednesday
Permit Fees are paid to the CRY OF NORTHAMPTON CHECKS OR MONEY ORDERS ONLY: NO Cash or Credit Cards
Checks or Money Orders Must Be Submitted with the Application or it will not be acted upon
To Be Processed,Applications Must Be Complete and Include ALL Required Attachments
All Applications Are Subject To Zoning Review.The Weekly Filing Deadline is 12:00 pm(noon)on Wednesday.
Building applications-Require a plot plan,floor plans, elevations,structural and energy information as appropriate
Sign applications -Require a photo of the existing elevation and a photo shopped placement of the proposed sign
Applications may be subject to Central Business, and or Historic and Demolition Delay reviews
It is the Owner's responsibility to verify property bounds and conservation issues
COMPLETE DEMOLITION Accessory Structure-------- --------------------------------------------------- ---------------$30.00
One or Two Family House.--------------------------------------------------------------------$75.00
NEW CONSTRUCTION All Occupied Floors per sf--------------------------------- ----------------------------$.50
%Floors,Walk-In Attics, Basements, Garages per sl' $.20
Decks, Porches,Canopies, Porticos per at------------------------------------ -----
NEW ACCESSORY STRUCTURE Free Standing Decks-------------------------------------------$.20 per sf, Minimum $50.00
Shed up to 200 at zoning review----------------- $30.00
Shed over 200 sf------------------------------- ----------$.20 per St. Minimum $35.00
Tent over 200 sF---- ---- ----- _._---------- ---_-..___.__.--..._.._-----------_.-$30.00
Above Ground Swimming PooH-------------------------------------------------$40.00
In Ground Swimming Pool.......................................---------------------------.-..$75.00
REPAIR, RENOVATION.ALTERATION $6.50 per$1000 of estimated cost(rounded up)--------------------Minimum $65.00
SIGNS Wall Sign for Home Occupation $40.00
SPECIALTY PERMITS Roofing------------.-------------------------------------------------------------------------------------.$40.00
Siding ---------------------------------------------------------------........_......------"---------$60.00
Non-Structural Door&Window Replacement--------------------------------- --------'$40.00
Solid Fuel Burning Appliances----------------- ---------------------------.---------.. ----_.$40.00
Sheet Metal---------------$25.00 with building permit on site;Otherwise $50.00
SOLAR Roof Mount---------- ----_ ----------_ -------- _______._------_------------------------$75.00
Ground Mount up to 8kw or 100%of demand------------ $75.00
Ground Mount up to 200% of demand-------------------------------------------------$100.00
Ground Mount over 200%---------------------Use the commercial rate calculator
OTHERSERVICES Request For Zoning Determination--------------------------------------------------------$30.00
Home Business Review&Registration-----------------------------------------$30.00
Replacement Permit---------- ------------- ------------------------ -`---`-$30.00
Contractor Change---.---.-----------.--------.----------------------------------------------------$30.00
Temporary Certificate of Occupancy-----------------------------------------------------$75.00
Additional or Requested Inspections------------------------------------------------------$75.00
Removal of Stop Work Order..................................................................$75.00
Commonwealth or Massachusetts
Diviston of Professional Lkensere
Board of Building Regulations and Standards
ConstrYClNd Supervisor
CS-011289 Expires:021272020
u ;
THOMAS F t7WNL11N
I MLLHADLEY MA 01038
Commissioner !�
�\ The Commonwealth of Massachusetts
Department of Industrial Accidents
*X1.vkcrs'
I Congress Street,Suife 100
Boston,MA 01114-2017
wwitninasc.gov/dia
Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITII THE PERMITTING AUTHORITY.
Applicant Information 00, 244
� p Please Print Legibly
Name(Bmincss/OrganivatioMndividml): Va b B!6�-kr ,.a :14L
Address: 35 Ederilda0 51 <- I-
City/State/Zip: M/4' ILLW-L Phone#:
Are you.n employer?Check the.ppr.prliam that: Type of project(required):
ij&am n employer with__a cmpluyces(6dl aadm pan-timcl.• 7. ❑New construction
2.❑lam a sole molonnmrm p vtomhip and have no employees working Ibr nk in g. ❑Remodeling
am capwity.[No work comp,insurance nos ti s!]
3.❑I am a h.wor doing all wmk myself.INo workers.'emtp.imumme n.wircd.J• 9. ❑Demolition
4.[:]l oro a h..er and rill be hirm,emtmuturs to cundun all noA on my pmRny. I will 10❑Building addition
enema thn all eammet.either hove workva'emspcmmlun nw.e or arc sale 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.01...n p..,cmtmemr and I have hird Ilk suh-evntmeum wedon no,ounchdabeet. I S.�Ronf repairs
iM1 ve w�bantngnn M1ave cmpinyvxw arN here warkrn'ru oto inxumnae:
h.❑Wcarcacogmimadnson"maslnvccxmrt ihmrnghtolexempdmper}I(iLc. 14.00ther
152,§1197,and we havem employers.INo xorkeri chommmmncer timd.l
*Any nppliemul that checks box 11 most also fill not the seem.Mi.. shmr int:Weir workers'mlrpensation police infnrmalion.
�Humrowners whu submit Ihi>aaidavil indicating thry arc doing all rvorA any then hire umside emmacmn mull submit a ocx.amdavit mJicming yah.
ennvl,non tial eheek this eno muu auuhd an:Wditimml shcn o&lbta the tome of Ne he,
,orlon and slalncherher ur nnl throe rmilies kme
cmplm s. lf rhe subKmna<Ion h.e empbvees,they mm�prmide Weir xortm'camp.policy aumbtt.
1 am an employer that is providing workers'compresudoo insurance for my ernplorees. Belmr is the polity and job site
information. '�77 � AA
Insurance Company Name: Ag I V (-e sG-n$✓r4rtCt` /T egg
Policy 4 or Self-ins.Lic.#: VrJ9Fyyovl7yylq ExpirationDate: a�1 /aloaO11 --
Job Site Address: W CIA✓r lenW City/State/Zip: No! m. TQq
Attach a copy of the workers'compensation policy dee aration page(showing the policy number and exit tion date).
failure to secure coverage as required under MGL c. 152.§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerr;fy under likeepaiins and'penaldes of perjury that du information provided above is true and correct.
S'glu
tarr Date:
Phone 5:
011icial use only. Do nor write in this area,lobe completed by city or town officiat.
Citv or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CByfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
DUBASRoat
A`O/RO' CERTIFICATE OF LIABILITY INSURANCE °A 311P2019
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 ME COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TIE ISSUING INSURER(S),AUTIIORI2ED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poliry(ies)must have ADDITIONAL INSURED provisiom or be endorsed.
N SUBROGATION 19 WAIVED, subject to the terms and conditions of the policy,wrtain Policies may require an endomennent A ateteh and on
this certificate does not confer Nghis W the certificate holder in lieu of such endorsamanl(s).
_CONTACT
NAME:
McClure Insurance,Agnry,IM. °H° FAX
So DINNER Aw. IA ..EM,,(413)781-8711 ,x):1413)737-
85
West
Springlfelq MA 01089 Mss; r
INSURERLSIAFFOR06NGCONERAGE NNF0
_WSURFRA:Endurance American Specialty
wWMUED INSURER e:Ace Amerk an Iris.Co.
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35 EdMdala ShaBt INSURER O:
Springfield,MA 01104
wwPER E:
nMwaen r:
COVERAGES CERTIFICATEN REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POU:Y PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT YVITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREINISSUBJECTTOALLTIIETERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PND CLAIMS.
INSn TWEaF 1161MAM.E AODM SUBR POLICY NUMBER 'iPopC eFF B%CcYw ' lealS
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�EXCI�UDEEW CUIIVE N/A .ELFACXACCI�M ,S
E VS SE.EA EMPLGYEES 100.000
rtypa�aesoRs uaw 500,000
DESCPIPLICN OF CPEMR eM:+ E.L POLICY Mn
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CERTIFICATE HOLDER CANCELLATION
SHOUM ANY OF THE ABOVE DESCRIBm POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Proof Of Covarapa ACCORMANCE WITH ME POLICY PROVISIONS.
ALBIUNMEDREPRESENTATME
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ACORD 25(2016103) ®1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD memo and logo am registered marks of ACORD
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Builders Letterhead
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I request that you grant a modification to waive the requirement for control construction for the(Upmrt
project)at(Insert address)in Northampton because the work is of a minor nature,will not affect health,
accessibility, life and fire safety,or structural requirements and is impractical in that the cost of control
construction is considerable when compared to the cost of the proposed work.Thank you for your
consideration."Mass Amendments,sections 107.1 allows for an exclusion from control construction for
this project"
Respectfully,
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Your Name I STT______/C
Your Company uc
Your Address a�f
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