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38B-148 (2) 47 COLUMBUS AVE BP-2020-0458 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B- 148 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2020-0458 Proiect# JS-2020-000776 Est.Cost: $26500.00 Fee:$172.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KENT HICKS 66104 Lot Size(sq.ft.): 5749.92 Owner: WOOD KARA Zoning: URB(100)/ Applicant: KENT HICKS AT: 47 COLUMBUS AVE Applicant Address: Phone: Insurance: P O BOX 57 413 296-0123 WC WEST CHESTERFIELDMA1084 ISSUED ON.1011012019 0:00:00 TO PERFORM THE F LLOWING WORK.-ROOF AND PORCH REPAIR, BATH RENO 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: II' Rough Frame: Gas: Fire Divartment 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 IR EGULATIONS. I Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/10 2019 0:00:00 $172.00 12 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0458 APPLICANT/CONTACT PERSON KENT HICKS ADDRESS/PHONE P O BOX 51 WEST CHESTERFIELD (413)296-0123 () PROPERTY LOCATION 47 COLUMBUS AVE MAP 38B PARCEL 148 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out Fee Paid Typeof Construction: ROOF A D PORCH REPAIR BATH RENO New Construction Non Structural interior renovations Addition to Existing Accesso Structure Building Plans Included: Owner/Statement or License 66104 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional ermits 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 Plan ZONING BOARD PER IT 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 I 'll,LI V/ 1/19 S - Si ture 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 hose applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development form re information. G�- CE I` , Department use only -rr City of N ttharet y Statu of Permit: � .. Building Ce urb utlDriveway Permit 212 Man St - g 2019 ewe Septic Availability Ro0 10 ate ell Availability Northampto , M wo Sets of Structural Plans phone 413-587-124 FaxR4'tt-6B7m4r272PFCTIo lot/S to Plans NORTHAMPTON.MA 01060 pecify 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 '�q-L0-w0.c F5")5. kV%.;- Map Lot Unit /U fV2-T1+-h-wC P r cry f �t rt [G hod Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: o�p(Q p L#-0th �jl/D d f) �( � C v t-U Na B cJS h--V 9. 41,�T1 fk-A4 P to N A41), Name(Print) Current Mailing Address:141 Telephone Signature 2.2 Authorized Agent: N R-0 Crf-E'CV`d�L"t M A- Name(Print) Current Mailing Address: Signature c Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 4 / C' e (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing V�7a0 Building Permit Fee 4. Mechanical (HVAC) I -7Z`' 5. Fire Protection 6. Total=0 +2+3+4+5) 7-,(e 0 Check Number C C This Section For Official Use Only BuildingPermit Number: Date Issued: Signature: 0 /1q VU f Building Commissioner/Inspector of Buildings Date 5 acc" I @ V\�ln+!�t c_ICS Uns1YuCA*l can . C-601 EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) EWVir VDDiseaa (HEQfi1KED! E11HEK HOWE-OMMEld OK COII.LKVC10K) rytp l;y;i ,UviU1l22 Gl�L(U2�9Cj0i O1 Rft:i" ii:; DOW - I{;!a 2cc alvu LUL tcsy A OUI - _.. Y�V�N I •!/'Vt f t r enjIgIuB bGLU)If LGA f..Ok `. 3) i1s10 ya ;o p6 naG ow % , I10 R COQ clowV,5ft..,Oti;n.�ts2? I s. �"_ � "`-• sus t i.r fr, ....I�,l 1 � , 1 biSJbEkSIA On At,'A.Ef381W1b,,vf11H01mSEDdL'EVI1 . EIUJ 2r DIZILIC4- oil <M sous. pns149A l7latAiCt R roc fir`_^nuts ,. ivs.i acctloU to p_s cowbIalaq pA oklce - i r VtelY, ._ a tar, a Vl�usulbolj' W OJOJG }} M6ra<<or 2itnwns! btaux' }Soou► a0 l �f .v r gnqq:uca (jabsGuf I`.tQ nr�( WMSA b6 -----=—�-- ror� o �a�tuslip @t y�, t _ 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 Frontage --- Setbacks Front 1. J Side L: I R:1___._.___. L:L__....___� R:I Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved L J parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW YES O IF YES, date issued:[-', IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW YES O IF YES: enter Book . Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained O , Date Issued: 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 O NO e IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors Er Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[Q Brief Description,of Proposed Work: i�00F Pd� R�Pr41rz Igpy � 2aw�6L)L Alteration of existing bedroom Yes__X_No Adding new bedroom Yes K No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. If New house and or addition to existing housing, complete the following: a. Use of building : One Family K 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? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes 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. I. 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, (A "n as Owner of the subject property .� hereby authorize raN t Ef't �-�` S C&,i s?Tra %) 0-V to act on my behalf, in all matters rel�tive to work authorized by this building permit application. �Z_- 'u'�-___1 [d/ �dl Signa Owner Date 1, k-p/J i- i�t Gu-S 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. Signe der the pais nd nalties of perjury. Prim Name ' jO� elle, Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: I Not Applicable ❑ Name of License Holder: �,,r 1f'I GALS C-5 O 6 6(O License Number (? D •��� `�}. G� CN-as W� F-1 LAID . A4f� 14 g 1 �/� -Lo Zo Address Expiration Date '((3 - lei& - 0( 2-3 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ �z&Wr crN (!�o . ( Z-0x71- Comp ny -1- Company Name Registration Number P.y• (�oy�5� 2f 2T I202O Address Expiration Date (,J - (ffdSre-kzt:�t LgLo _ Q L✓� 610� Y Telephone 4{(3 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....... H-' No...... ❑ City of Northampton / .+��:�'i--:.� �S�S,•......„.SIC! Massachusetts DEPARTMWT OF BUILDING INSPECTIONS ?� 212 Main Street • Municipal Building Northampton, MA 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....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: Wc.4-VKnGI=atT-P,4t1 , kA'71+ J2e31ueborl- Est. Cost: 2(o, 4;"494 Address of Work: y (oW u tQySya rN P1 Mt4 0 [D 4'� Date of Permit Application: (O-all rt 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 INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER 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: /iqlF/la l .,Wr A dtLs 1 Z°X7 Date Contractor Name 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 i qbf,;! }UL J PflIjq!E1 = brL0IIt' {}1:+hIAGL O jJIr 4}OtC tAQI CIJ)j : L OUtUSCIOL Otl1'IG fil(, Ks 1 jl.gjloU y{o -L:,pi,9i.l{,11 < ;. r{;n1{c{:u :bfAL Ijl) 'Id t{J<. 11411s11, (;, };'.1)N%UGI.. 1,' ISI (I2<;Ild:l>e' 1sE4f l III: H#•11'!)110 hfJQ40.' v'FF;JFX.1. h`JCF 1;UK OKE 1 AEOKA*J,Rjv.- f ifE'?bt)I21131I'lLE2 EI Wlot'F r-OI fAD 1)()vtt)_I [IYl.1; `JC.( E � 1.0 i.Hir VKSILK`J.1.lC)/ hKOC'KYA C)K('I:'MVV-LJ, EC;141) ICK e?.f;RCO'/.,LKIC.LUK?LON 4I,IA'1C;fBF'F 110f1E 141:K()1,1;NF:v':.I.MOKK 11f Vol ,(.V, t)R.LYIAI1C-1.11 t.IIf 0*,A bFKWl.L 0K 1'.r. 1_FKI✓C lV_I.C)COi?i.K`/C.1'l. imi_H r.vWECi?-tuKirI) (y .:IJ(;t ;wll !.W3Iu11 1 r rt ll;)i.:, ��.�•tom.. • x . .° -i, �*_V. ,t 4.:-.'�.1�„i�.,Y..�,.SY_�t:;� _'.-_ .—_4,..+►t _ . 1 '°t.Il;�UY• ;.`•'-tz.•* .-t�.�, ��•�b�#�`�. ►Z�at � �'• ��tt►�, �t�zut4,ttM11b1.ttlt7.c.l1LItLUCZ6i�H+1�ilt tt G04t)t1l.t9t[Ota (!1.rl C.'i�t�t c��ctcit,>,snit.��►.5��1►v4�cs; - . ' A}.n Lr"711fr r&t# :'2 F Gtl���t1S.'•;4�JlG:.fl tjI:JU i<Oi1l C;h".«�'��1.1C�tt1}t�2' X1.1 jt:.:Si��«.`i1k32 M�.!It;+sS 9lH 8C4��3C:fit1(t+:�2I1C�3►$21C+61)CF Ot.git1��111�, {!G I.1 v,?Sti'... I6i3.;i:',S3"; ^�ti.`..lt),S(IUi1' OL CCilSa11.S1C1`C;L1!;t':111�!I l'jt�.;CIS1 GQ-'JUS S)ll;•-t+kl2k�lllj t111,11ti1-OGC:t1b\,eq �f1tltxUCS t;p1J(`.ilUVl)ll jj f 1-t3-yrLs+^t1n 2 f{1'Jj t{S6' ..lfir U2j;ri�.;K7J +S1L815+�tOU' lciihl�.cey:Ga 1Ei`J3G' iS1°')C�BLUtI9[tG11 COUftf+12,t?i1 sl tiouit. ,l; tiV.}t.F,tlJaJt {;t)Il(LYSLUI I I_t{(.+} I rt (:1Le jiyLFt,l(.li,it1A I11J{.1Lrli,1IIf.11j2 OI. Lr, LH)f,Yf10!)?OU 9 jSrjK({ UW: (1) I(AIL }`:11J ljk{JOUAI ;,' NWA LO j.l) 1•+ . ',t? (U!;iiii;"L Vj�'{ilG :a11CS ft`a1u(-,? Gift `jmLj -LGKt`1C1.`Jt1011 Q. tf)1ril.''1G tIL'!. `JLIti ;,mbb#c1ll .m to l,cuu11 yMp.ca>t)ou no"IGfill imcyt.rli'a,(J(( f-oM11CtOL ["10 Ho=Fvqu(b.<:r.r' YiSd J?Ui 0 375 igriU 8r;-oGr • Krurcrbg7 :i;:,r r:'� t + DE `,fiES':k+YSl, UE. eturram 3S.2F,�Cni%�? - I -C\ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Avvlicant Information Please Print Legibly Name (Business/Organization/Individual): �_„r�U !-f t U�g t�pwJ SO►�yC f(O0J Address: 6yc S t lo- e 4-iff re-Ft u-11--o M o 1 o tV City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.®I am a employer withemployees(full and/or part-time).* 7. ❑New Construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.[:]l am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[316Flumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.&OOf repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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. 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. , r Insurance Company Name: V N(or) 1 WS . Cn . eF PAh V,10 er- u Policy#or Self-ins.Lic.#: Ltc1 — 20 Expiration Date: �l S12 0 Job Site Address: 4 7- C~&LtF3tf4 Ally•,Naft TIFI#u-TOOI,M*-'0(060 City/State/Zip: Attach a copy of the workers'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. I do hereby certi u der he pains nd pen 'es of perjury that the information provided above is true and correct Si nature: ( Date: 0 �' Phone#• (9 O l L2j Official use only. Do not write in this area,to be completed by city or town ofciaL 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#: i! +� ;;+.�,�.�: 'Ji.b{�a)rp S• gnl{qlu�psbai.Fu►ct:{ •3'C;It��,.LrJlr.0 f',Ic.>;.M .�' {;iGttt.lc•a) �uxfx;ctot. �• I,In1u�1s1D; lasiw�ta. • :.�sDi''j:+(}St1,.eF.!{ctYrlr,tit16): rr c•r. 47ir.et' 11"lult`+1'lower, f j (�\,:�ci.,•s rc,+»tl�' t�'t 4 ��t N.t.}1v tyu+ut}t qt.(.q'1:t}x.;r„��1t}r,�,<',c}pr c��h c►�'t�t[.0 ci��9ca4t� . ; {� ,+` 4 iitl t�cgr.i`t}u s: ,ate.l�iiclur w o1,t�c;ilciV,tewmw)m�ksmgq q«pun';TA este UUAC.0►.vc(.t� CJDJ + iU . ci'3• >'. {� j })!, rr! i�'i)?jh,C,?11!.iiF jJi4A. ��- >+�:.lt'llrlt,'{ {�vy( C'C,f!{.�Ill,fiD123.9.iLDQ[F/Q[.l{l,..:)f`j,I17t. 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I �. ! isl n 131r1)7rr,nr);li:ru ; Ph WOW We Olt , U MM- ucr,u;.l:rucq 1 AW itl i { l Ic. ,., .. :,• ,�tli. .__ 1 i. .c: ,:r+,)auc),trt;ra[r-t,r�cJ. �. � �'y)Glr rrnJ�( •..: ,a I, /rr r.,,n 7iU t WD,{o} -4.,!D' tyi';•rLl,+t-1 tr p,: .I,r•f+t;uC LLr?ifr,} as!L44Y f /"'t'i} ij��.�t►xD j'�iir,t.w• o,�..�. .._-____.__ � ...__..._.�....�v.. __.._. h ,9af. 1,t.►u{ i '�1; t.rl a+'p.tt'1•°!�tt".t t t) !;tw')rF'{seit_r_�.F,��� 1`1�_F.ttt)If{.Lt•' r rsr.pc,r C ilwbr-o"11po" 1weRLahCL lgqunli' :i�Dif41`t?\L.OIDit.:)fF1)I� Ir4t11�1Ut1T\61Auipv:,� ' . t 4 :.• ,t '�,'�? �)':11ttt.s`ttClei +;:, 1�t3C}t5�,1,.t(t� .yz,s tt�tti,s}`x _� - 3�.@" (t►a4ttat�,i;t+,�,u���ro� i�`.i.��.tt<:.gattrt.}1,2• C EM INSURANCE UNION INSURANCE COMPANY OF PROVIDENCE (17612) NEW INFORMATION PAGE WC000001A WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY *------------------------ ' * THIS INFORMATION PAGE ALONG WITH THE ' POLICY * POLICY NUMBER PROVISIONS' COMPLETES THE NUMBERED POLICY. * 6 H 0 - 0 9 - 4 9---20 *------------------------* ITEM 1 N A M E D I N S U R E D P R O D U C E R - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - KENT HICKS CONSTRUCTION.CO INC WEBBER & GRINNELL INSURANCE PO BOX 57 AGENCY, INC WEST CHESTERFIELD MA 01084-0057 8 N KING ST NORTHAMPTON MA 01060-1150 AGENT: DG 7330, DIRECT BILL AGENT PHONE: (413) 586-0111 CLAIM REPORTING: (888) 362-2255 PHONE NUMBER: 413-296-0123 SERVICING CARRIER: (401) 244-1800 INSURED IS: CORPORATION INTRASTATE ID: 471165528 FED. EMPLOYER'S ID: 042054911 SIC CODE: 1521 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ITEM 2 POLICY PERIOD: 12 : 01 A.M. ,STANDARD TIME AT THE INSURED'S MAILING ADDRESS FROM: APR/05/19 TO: APR/05/20 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ITEM 3 A. WORKERS' COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE WORKERS' COMPENSATION LAW OF THE STATES LISTED HERE; MA *Awl B. EMPLOYERS' LIABILITY INS. : PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3 .A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $ 500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $ 500, 000 EACH EMPLOYEE BODILY INJURY BY DISEASE $ 500, 000 POLICY LIMIT C. OTHER STATES INS: PART THREE OF THE POLICY APPLIES TO ALL STATES EXCEPT ME, ND, OH, WA, WY, AND STATES DESIGNATED IN ITEM 3 .A SHOWN ABOVE. D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: IL7004 (09/16) *, IL7131A(04/01) *, IL7609 (01/99) *, IL8363 .2A(01/15) *, IL8576 (10/17) *, WCOOOOOOC(O1/15) *, WC000406A(07/95) *, WC000414 (07/90) *, WC000422B (O1/15) *, WC000425 (05/17) *, WC200102 (01/14) *, WC200301 (04/84) *, WC200302A(09/08) *, WC200303D(08/10) *, WC200403 (01/91) *, WC200405 (06/01) *, WC200601A(07/08) *, WC200604 (11/02) *, WC7003A(09/86) *, WC7005 (07/11) *, WC8081 (03/96) *, WC8081. 1 (03/96) *, WC8130 (10/14) * - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ITEM 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ESTIMATED ANNUAL PREMIUM SEE CLASSIFICATION OF OPERATIONS SCHEDULE ATTACHED PREMIUM SUBTOTAL - SEE SCHEDULE ATTACHED $ 25, 699. 00 LESS: ESTIMATED PREMIUM DISCOUNT $ -1 , 034 . 00 `4w COPYRIGHT 1983 NATIONAL COUNCIL ON COMPENSATION INSURANCE ISSUED FROM: EMC INSURANCE CO, PO BOX 7911, WARWICK, RI 02887 DATE OF ISSUE: 03/07/19 (BPP) COUNTERSIGNED BY: DATE: FORM WC7002A 09/86 (BPP) 04/05/19 021 SM 6H00949 2001 City of Northampton • " `` '' Massachusetts �. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building yJd., ;Cam Northampton, MA 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: 4 -(_m-v K4 r> s �4 ve3 (Please print house number and street name) Is to be disposed of at: [_0-M P L P 6SA-tom , /k*i IJ 5-f• JU A - (Please print name and location of f cility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) l�rO�l Signature of Permit Applicant 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. I 4W/ u z I Ia Note: z z y U Dimensions are approximate. x of 1 Ceiling height extrapolated Fixture dimensions guessed 000 10 I ° Q • I I 2 .`EN • I I c'p � 1 (Ac_ m I 1 � mUN �c T 2� Y CD Plan view 3/8" = 1 ' 0 Z � Uj W � uY i N Z Back wall 1.E 3/8.. = 1 . a 1 Ti Pft Wall 3/8" = 1I ca co Existing 0 Existing bath Front wall R wall layout 3/8" = 1 ' 3/8" = 1 ' A.01 74" - u new toilet Note: dimensions approximateP-0 0 x H � Small pedestal N Shower pictured: Custom - the and glassT �,�%� 2'-6" sink Sink pictured: Signature Hardware Farhnam Z rolling mini pedestal sink $190 z cart p ] x U ## Toilet pictured: generic M I Washer/ Dryer - full size GE frontload 3'x4'shower I Rolling cart: generic /TBD 1'-8° ,l 3 walls tiled 0 0 V V `�' o 1 /�f N U Q 2'-/ CC - t+7 '0 O�_ O N C iV FUN +, 0 CO existing cased doorway d , dryer vent out side wall if possible (gable vent shown here) v 0 shower in front A Z W - washing machine 1'-6 5/8" 2'-8" U Y 2'-4 1/4" in front L 2'-2 1/4" 3'-3 3/4" tub in front 0 i (O N �. .___- _. S�_...... .�.__..�..._..... .;� Z t t t LU O O -F,77- 5)............ Ik 2'-5 3/8' new shower, glass door 'm rn z 1'-8" 3'-11 3/4" (A Q 9 U) 3'-10" 4'-10 1/2" laminate Laundry countertop cart w/backsplash 27"wide ° Rear ° washer/ dryer set z Bath - 2. 1 MM COCO �° CO M N A.04