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38D-018 (10) BP-2022-0339 25 HAMPDEN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38D-018-001 CITY OF NORTHAMPTON Permit: Addition PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0339 PERMISSIONIS HEREBY GRANTED TO: Project# DECK Contractor: License: Est. Cost: 21600 ALLEN GUI EL 054248 Const.Class: Exp.Date:04/12/2022 Use Group: Owner: B ROUNDS CALEB M & MARGARET Lot Size (sq.ft.) Zoning: URB Applicant: GUI EL CONSTRUCTION Applicant Address Phone: Insurance: 63 CHESTERFIELD RD 656OUB-9F66069-2-21 WILLIAMSBURG, MA 01096 ISSUED ON:04/07/2022 TO PERFORM THE FOLLOWING WORK: ADD 12X17 DECK 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Il. . � .. _ I ' I Fees Paid: $140.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner - File #BP-2022-0339 00.1 v APPLICANT/CONTACT PERSON:GUIEL CONSTRUCTION , �r{N 72A-, 6w 63 CHESTERFIELD RD WILLIAMSBURG, MA 01096 PROPERTY LOCATION 25 HAMPDEN ST MAP:LOT 38D-018-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $140.00 Type of Construction: ADD 12X17 DECK New Construction 'I. Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO MATION PRESENTED: (/pproved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Penn it With Site Plan Major Project: Site Plan AND/OR Special Penn it With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Perm its Required: Curb Cut from DPW Water Availability SewerAvailability 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 // .2 y-7-ZOZZ 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. irk.- ar , cok,1 , ei,«c/C :,_ , The Commonwealth of Massachusetts i CO Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY USE 1" Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 ry One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 13P_ ,3 a'07 3q Date Applied: KeVr� �5'S /12 'i-i z ZZ Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION I1 Property(�� Address: ,1 1.2 As s i ap&Parcel Numbers 1.1 a Is this an accepted street?yes X no Map Number Parcel Number 1.3 o i g Information: 1.4 Property Dimensions: I 11 , oco I 1 0 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Own r'of R ord: - - Ccic c N�) N ,1-6,)) M�- or o 6 G Name(Print)LL/ City,State,ZI / S f l ^^ipcIP, 61 13 SS ) /6S F c�,(es, rcvnctj G r.11•C�A-t No.and Street (l Telephone Email Addres SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction tin Existing Building 0 Owner-Occupied l i Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other l] Specify: '/EC.I< Brief Description of Proposed Work': 'gu ��C� 1 X ► l D-ec, — Low v0\4 1tl4AS 1 'A v(k-c-,c,„4-€) --\-cerof i0460-----r.s--- . As4c7 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ a CCjd 1. Building Permit Fee: $ Indicate how fee is determined: / 0 Standard City/Town Application Fee 2.Electrical $ // p(% ❑Total Project Costa(Item 6)x multiplier 21 ,Co do ,6- 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire �+ Suppression) $ Total All Fees: $ 0, 0 u n Awl Check No.1p Check Am unt: h Amount: 6.Total Project Cost: $ e ,1 V 0 Paid in Full 0 Outstan mg Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervii or License(CSL) ,4 e r l `f V fre License Number Expiration Date Name of CSL Hold r U; chg� �_�I-etC�/ n_ � List CSL Type(see below) No.and Street ( (1 Type Description 1 , `1 I` �►/ D/U?6 U Unrestricted(Buildings up to 35,000 Cu.ft.) W 1 /"� R Restricted 1&2 Family Dwelling City/Town,State,ZIP /A M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances d(D S 7doo II-eil ;s(11 f I- Coto I Insulation Telephone Email address D Demolition 5.2 Registered Home Improv ment Contractor(HIC) /ex/o/ 7- 13 -as fiIt e 'I U 1-e I HIC RegistratiioANumber Expiration Date HIC Company Nape y)HI R gistrant Name fob C .es C l-ec( 20Qc g tie v1 ( gule(- COW% a4dStreet,� r Email address ?16/CIgyOiegA9ga :40 City/Town,State,ZP Telephone SECTION 6: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 0 SECTION 7a:OWNE AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize ,4//ckf C i 1,/ to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contain a is app tion is e and accurate to the best of my knowledge and understanding. t �II -a5- Print Owner's or Authori ed Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts . is: Department of industrial Accidents } 71 1 Congress Street,Suite 100 Boston.MA 02114-2017 www.mass.gov/dia )1 corkers'('unlensation Insurance Affidavit:Builders i(`ontractors ElectricianstPlumisers. I l)HI:F114.1)U I111 Tllk I'I:ItMttl-I IM:Al 1HOld 11. -tnnlicant information Please Print I.evaiblr, Name i liu.an.,s Ur_vniviiton Indio.K heal l: 4/4'i a1'e/ £'Address: 4 C( j.Q --ct-eld F-/( CityiStateiZip:1011L; 214/14/Jv(/ 44 0/0q phone#: 7_G 37 j //S ---y Art, a+u ter ctnplu:it-r:"l hurl thy appruptult.loot: Type of project(required): I. I aul.l.I trt' i,i lth nab +:c,t hill arid Of part-tune i.• 7. 11 `eo ct+nstructiun 2.D 1 3111:l.,sic i•c.'rta.t,a.,1 r.oincr.tler ae,J has.n..:uq.loycc.Mo rkteir tilt me on art}recut}. t..,•.•tk.r .our.wuWtan.c rcynit:d.l . 9. ❑Demolition E.771 JUL.114•t11.t•..114.r J col:all,.....tit.en.•c11.I\......rk a.'.urlq., nn.ur.ul.-.room-oil. 10 j 1luddult;addition t.j l I.e1et a lk.tla.l"ur1.7 acid nail IN:Enalal.a.rlit:l.Y..e.6,,..n.1.La.1 all.aaeki,u ntr rr ,.I intIx. I N.tli �.J cu.wty ghat all ciaua.r.Yur.cltl>.I Ila.c ntrrkcl' 1:1K/110:11,44*11111.ut.urancc tsr:u..a,lc 11.Q Electrical repairs or additions I n..rn.1..1...all,Ir..anrl..+.c., 12.0 Plumbing.repairs or additions +-1:71 I am a 31.1:11.3nlra:k.r maid I luny:hni:d Ilk wl,o3tetrackrrs 11.lhJ ulr thy aita.Ilt I.Ik•.q. 13.1 Roof repairs I lr.....:1 I, ....nh.kh'I.kV...ynhalut,c.I.111J lu.c a,Ik:r.'.omp.ut.LIU M . I4.Whel 'j eCk f.-Li N c.nc a ompoialu..•la anti et.istlr.n bah.c.wes:1.A their rigid.al:vcrtgstetAtt r.t\Net-c. -- 1'2.;9111.aria,c ll.u'..Iru cntpluy:r:s.I`.n t utLi` comp.In.trutxc h.:to :a l '1ut arrltr:ala Iliad.31::k-.h..'. 1/nu.t mini till cool til:.aclitlt Iklu»showing t1r:m u..tk.s.'.ulnp:n+alnn tt,li.•%iILI inalaln- Il.•r•.tc.+n,,ram.,'h.,-4u9Mill9 Iltl,all A1d.71 n1t.111 i Ill::arc diNnt.'all..i...nk:Ind then tiu.iWb4Lie.191iCUA:1 K.rnuhl.aInut a la:+t atlt se mdtelerlre,.w.In. I veils a.t.•1.11ta1:t1:.9,tilt.h:...anla..I al l a.lioil an additional.la.^:t.INY»in='Ilk mots nit the it.-.lettra.l.K.and Ntat.4.It:itt:t air not[hum:Wilily.h■.. 0,11'101,.c' II t11.'.UI,....'Ialr_:Ian.la;:u..calq*Ines...191.ti Irtual pion id,:that aurkcr,"event.pulls*mmtilwa I um an t mplar er that is providing n orAer.'compensation insurance for my employees. Below is the polity and job site information. ilistuance Compacts Nall II:: %/ rT 1.4KCI 0 14 dects.)Sl i-,5 Jo ,,,r c e cc, — Policy a or Self--ins.Lin. =�)6 j�pdU�j `" rF(60�p9 '; E"acptrniun Date:�7'as Job Site Address: 9 5 Tl 2m p o 4 City State•'Zip: 1 G 2 i Of'(0 Attach a copy of the nurkri compensation policy declaration page(shooing the policy number and espiratioa date). Failure to secure coverage as required under MGL e. 152.§25A is a criminal violation punishabk by a line up to SI.50(i.00 :Ind+'or one-year imprisomncnt.as well as civil penahics in the form of a STOP WORK ORDER and a line of up to S250.00 a day against the.iulator.A copy of this statement may be fats ardcd to the Office of Investigations of the DIA tier insurance coverage scnlication. i do hereby c under Ili ins and Penalties of perjury that the information provided above is true and correct Signature: 11• I I r.:. " �•_ � c' Piton.I:: '1/ � `-/� `7( / I/ Official use only. Der net urine in this area.to be completed by city ur town official cite or i on n: Perntit'License 4 Issuing;.tutharily (circle one): I. Board of llealth 2.Building Department 3.('its/Town Clerk 4.Electrical Inspector 5. Piunnbing Inspector 6.Other (-contact Person: Phone 4: Commonwealth of Massachusetts l`t Division of Professional Licensure Board of Building Regulations and Standards C o nstwet)fiitSp1frvisor CS-054248 . . F�t�pires:04/12/2022 ALLEN GUIEV 1 N i 63 CMESTE + O �O ItComtiObierwir daelZ fs. EL Office of Consumer Affairs&Business Regulation Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR i TYPE:Individual before the expiration date. If found return to: finistration gxoiration Office of Consumer Affairs and Business Regulation 1 07/13/2922 1000 Washington Street -Suite 710 ALLEN R.GUIE4 -'� , .•n,M 02118 ALLEN R.GUIEL i) V ,`` 63 CHESTERFIELD.OD;". f#4,,x,.da.l:c/. i WILLIAMSBURG,MA 91096 Not va id without signature Undersecretary ACCORD DATE(MM/OD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/25/2022 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 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 Destiny Joaquin THE DOWD AGENCIES LLC PHONE No.ExiL (413)538-7444 FAX (AIC,No): nooRess: djoaquin©dowd.com 14 Bobala Road INSURER(S)AFFORDING COVERAGE NAIC f HOLYOKE MA 01041 INSURER A: HARTFORD UNDERWRITERS INS CO _ 30104 _ INSURED INSURER B GUIEL ALLEN R INSURER C: DBA GUIEL CONSTRUCTION INSURERD: 63 CHESTERFIELD ROAD INSURERE: WILLIAMSBURG MA 01096 INSURERF: COVERAGES CERTIFICATE NUMBER: 757157 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 AWL SUBR POLICY EFF POLICY EXP LIR TYPE OF INSURANCE INSD,WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any are person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PERRrUTE W- AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S60UB9F66069221 04/27/2021 04/27/2022 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,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 certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date 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.gov/lwd/workers-compensation/Investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton Municipal Building ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Street AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD /� ® DATE(MM/DD/YYYY) A ll..` E ? CERTIFICATE OF LIABILITY INSURANCE 3/25/2022 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 have ADDITIONAL INSURED provisions or 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 The Dowd Agencies, LLC NAME: —Diane LaFleche FAX 226 Russell Street, Suite B (NC,No,Ext):413-538-7444 Hadley MA 01035 E-MAIL dlafleche@dowd.com (ac.No):413 536 6020 INSURER(S)AFFORDING COVERAGE NAIC I INSURER A:Utica First Insurance Company 15326 INSURED ALLERGU-01 INSURER B:Commerce Insurance Company 34754 Allen R. Guiel dba Guiel Construction INSURER C: 63 Chesterfield Road INSURER D: Williamsburg MA 01096 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:148239832 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 TYPE OF INSURANCE ADDL SUER (MOM DDNYYY) IMpM�EXP I LTR INSD WVD POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY ART5142731 4/22/2021 4/22/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) S 50,000 MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL.AGGREGATE $2,000,000 POLICY X Tel: LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: $ B AUTOMOBILELIASIUTY RVT614 2/22/2022 2/22/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) _ S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT S OFFICER/MEMBEREXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation Certificate of Insurance to follow separately from the carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Municipal Building 212 Main Street AUTHORIZED REPRESENTATIVE Northampton MA 01060 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton °' K ay\ SAS.. .- if` /1-..' 1,:ti Massachusetts ��? - '<< I� -AA 14 ; c. 1 � DEPARTMENT OF BUILDING INSPECTIONS S e �n _ Z rr lif 212 Main Street • Municipal Building J,S �i '1.74 Northampton, MA 01060 jS111 1,0 ' CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: s. �1\ Ys...° C` [z11V1 I The debris will be transported by: Name of Hauler: 6,i -.1 L(')t,,c, o Gtlov^ ✓ 4/te�1 (iui-e. ,", Signature of Applicant: l Date: ?\;Lt , f 1 110'± \ BOOK 8384, PAGE 116 : }. GAR, \ i BOOK 526, PAGE 50 \ LOTS #20- 21 & PORTION \\\\\\\\\\ \NH! OF LOT #22 11111111*--':- \ \\ \ \''''\ , iiir* ----: --- , ,...._ , ›ik, ri-)e)—I\ (i) \ -Cvv, w Q 2 // -} (-) ± 7/.i'10 .,/ j o / #25 rY / /lll A 110'_ +,. at- `-- AV ' D ----- 1\1 STREET C 3' o 1 t-'-i< ek 7 1 d 1 PF) P t � 1 0 41 _ 1 (� , , '• t • fit) ;LPL 1 T c e.. t L �1. 11 11 La _ Si: . 'f' 7 . CITY OF NG � -- RTHAMPTGN ?czt L 1 pi �"�Z9 EJILDING DEPARTMENT S —c. 1 2 ' -=0 , . These plans have been reviewed l '7:n a approved. �, 4y i L.. o r 9-7- ZO12 ---r ��V...7-- ,ta„ 4 aere4160,1„960, � , v � As. *y ., } p • N .....MP ��F J 1 I 1 (( -- Le.I9 7Gr ♦ 14 t. r .[- - \t ,I Al sr -O- q 0'.r.='=��u.liwvwv.Y.+.wwui.iv.+ ., ...-00•1 , ? , (F) 9 /.. ip i.?eNAA EL.. Log S7 Acii--- cLoav* - 7 I/A, • 1,0e-----•' 6 VG POCT • -----------__________________ i''' CITY OF NORTHAMPTON ,4, --------------913-e-C'eS-+------Vier BUILDING DEPARTMENT These plans have been reviewed And approved. DZZ _ Date -/_ 2 I 1