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17A-159 Jul - 12 - 2010 08:07 AM Remillard Insurance 1413 .itsoviv 16 . CERTIFICATE OF LIABILITY INSURANCE OP 03 1 07!x211 THIS CERTIRCATE IS ISStI3) AS AMATTER OF 1IFOR11AT1ON ONLYANO CONR5RS CO NO RIGHTS MON TffE CERTIFICATE HOLDER. THIS CERTIRCA1E DOES NOT AFFMOMATNELY OR NEGATIVELY AMEND, EXT S) OR ALTER THE COVERAGE BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETYME3f THE ISSIMIG INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: Wths sarencese Inkier Is as ADisTIOTUCHNIBM the policyOes) must be endowed. IrMAIRIXATION IS WANED, subject to the teems and oandlioas attic PAY, certain packs Nay require an endorsement Aunt on Via certificate does set confer rigida tothe I , holder Is lien of each PRODZR MAIM IRemfllard Insurance Arley, Inc ,F imt. 1 `_ 79 Lyman Street 1 South Hadley MB 01075 mae DO 7--25 2hone:413 - 538 -7862 Fax:413- 538 -7179 ammo erell�nPFaRlonsoore+aGE MACS A: Merchants rasurance Group - Pelletier & Patricia mss: ACII TAIL 0 7 Nam St etc: Holyoke MA 01040 INSURER 0: i 1 MINIM S: COVERAGES ERA CERTIFICATE NUNBER REVISION MEM i 3 Tj X51$7'0 YTIVEITHEP OF ffii USTIDSELOWUWEe lIDTODIE IM1A O MAW MO1EFOR THE POIZYP@BOQ INOICK(ID. 1101INITIISTPSIDSIG NW REQUIRRIEMIERNIOR(XINDIT5510FANY CONTRACTORONEROOCUMITWITII RESPECT TOMCMINS CSFITO'IUS taw SE m TllEe1 agma aFFOROR3 T RIME POLICIES t ef B ITO/ALIHETERAIS, a EXRtISIUORI OMS ilI�7SNeillR pQy" Th at e> IWO POum d- stIM MIS s �r�ALLNBe TY EACH OCCURRENCE *1000000 A 0 Solissicsa.Gassisusesurt 12 1 16 9 0 swam asnstu PABr swiss mweaoe) s 100000 1 ■■ GAS a al= • MED19P (Am one pemore $ 5000 _ a II g lERSOWL&AWrICU 1RY $ 1000000 - 1 II GEMERALAGGREGATE s 2000000 - GE AGGREGATE LeETAPPUESPEM PRODUCTS - LmiSmaPAOG : 20 0 0000 1 n n ,s AUTOMOBILE a I.ITY T SNOW L TT * 1000000 ValesdleaS A II e lYAUTO >O1Za7 015141 es/seise es/Isni em,1311U Atl/(Perp r mp s ALLOPAIIEDAUMS e0O8.YJIJURTrerscosoM S 1 : AOTDS Z s r I 1 o WIEDAOtoe $ - 1 UM L , C � * wasuAOE * I IrCESSUAB �ucT 11LE _ $ 1 RETIOMON 5 $ B N w e�Lw ilae C46327342 a7tsslta aanslsx I r s 1 Ii EL. Ixr - EAERWLOYm * 500000 OF EL_ DISEASE L1iRr $ 5 000 00 1 # (1a M•W liAC IIONS EWLIN {aACORn1a1,4 eMenelRemerls9aediie. erespace es led) i CET aETi i s enasaredd, Western NA Blect rasa]. Company & Berkshire Gas Co. are I c CERTIRCATE HOLDER CANC$ ATRON • anew serornermovrown neo POUF= OSCANCSUJIDEMPOSS CinfTleOR 71lEEIIAeIMION asTatissoraF, aQ" IIALL sE0natlms N • AGOGRIM CCINIRTREPOUCYPRO fl$0iis AMMO - A 1 i 018$82009 ACORD CORPORATION. All rights mewed. 1 ACORD 25 (21109/09) Thus ACORD mete and logo are registered matins ofACORD i a a The Coaimonweakh emassathisem; Department o.fIndustrialAcddents . • — :-...—..,..--- ,,,,-: • Office ofhwestigadons --: 5 ) --- - --,- MO Washington Street Balton, MA 02111 -. ••.•,,,L,...-;* _:: - wwwanmagovh0a Workers' Compensalion Insurance Affidavit Boullen/Contractors/Elecirielans/Plumers Anolicant laformadon Please Print Legibly , Name (Business/Organizsiegandividual): ' . - .IV krb au An 4 _, ' * ' , 0 Address: )J07 M,q, S1 cit ildobiokia- Na. olotio ph #: ( -1/3- 53 6 6DD---- Are , , an employer? Cinch? appropride bac Type ef project (required):. 1. Ki. I am a employer with 4. 0 lain a general contractor and 1 employees (full andlorpart-tirae).* have hired ihe sub-contract= 6- 0 New construction 2.01 am a sole proprietor or partner- Wed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contraenns have 8. 0 Demolition working for me in any capacity.. employees and have swims' 0 BaarTmg a [No workers' comp. insurance — comp. insurance.* . ddition , regalia] 5 iti Wenie a corporation and its 10.0 Electrical repairs or additions 3.1__iI am a homearmer doing all work- officers have exercis' ed their 11.0 Pkimbing repairs or additions myself [No wodrers' comp. - right of exemption pa MGL 12.0 Roofrepairs insurance required.] t . c. 152, §1(4), and we have no 130 Other , 1.-) 0 ;; SU le-A I employees. [No workers' comp. insurance lapin:di *Any appliamt that decks box #1 met also Meet de section below allowing their workers' compensation policy information. t Honnownerawboadnalt this affickvit iodating they an doing all work and than bins madder contractax must submit a aow affidavit iodating sock tCoranactors doodad( ibis box east attached an additio' nal sheet showing the name of the sub-contract= and state minden- or not dame entities have employees. Ifthe sub-cononoton; have employees, they most ;maids their madras' comp- policy number. lam an employer that i s prositike workers' compensates imarrance for my emplo yee& Below i rase pug mail* she information. . Insurance Company Name: 0 ce tiSlq Policy # or Self-ins. Lie' . #: e Expiration Date: Job Site Address: L/ 3 46 Arz-ifY\ 4(.° atotaterrap: Attach a copy of the workers' compensation polity declaration page (showing the policy amuhernrad expiration date)._ . . Failure to secure coverage as required under Section 25A of MEL c. 152 can lead to the imposition of criminal penalfies of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in-the form of a STOP WORK ORDER and a fine of up to 1250.00 a day against ihe violator. Be advised that a copy of this statement may be- forwarded to the Office of Investigations of the DIA fir insurance coverage verifiadion. I da hereby — t , wrier the paha; and parades ofpajary that the information povidedabirre is *me and coned ‘ I / Signature: - # 1 ''' • P...611.,±44._ Data 1 0 /9a-1 i 0 Phone #: t113 - 63 Official use ally. Do not write in this arra,* be completed by cky art ofrsdal 1 City or Town: PITT PernfitiLicense # Itanfing Authority: Baring Department , - Contact Pawn: Phone #: (413) 499-9440 • 8.1 Licensed Construction Supervisor. Not Applicable ❑ NUne of a. Holder : �av�l1� \ c c,� J , .\\ �' 1 j a • License Number l� CYO �� S� • . c� VS--1C) —1)(4)Add Expiration Date l !� • Nl 3 S 3' - 1 Signature Telephone Not Applicable ❑ Company Name . Registration Number Adds ( Expiration Date 4 14"rWi.tilt ) f �� - � Telepho See `3oI8" REC lilPiENSATIM1NSV 1 Vit st #le 4 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 ❑ The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780. Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned " homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • . ? x oL, ; �, -,.-i.,:;.1.; ,E..,<. '. , +,fry A; S . . ..1,..' LK ._?i. .. s New House 0 Addition Q Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks at Siding [0] Other Work: 0 JAsed , ar X -. 3'' (, Lieu_ i�e�v / Alteration of existing bedroom Yes No Adding.new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet a. Use of building : One Family i 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. Masschedc 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 t 7a OWSER 'flON **04 0 i S A� # A � T �� P : , is 1, , as Owner of the subject proPenY _ hereby authorize -� r � v� '- Pe-1/12 1_' to act on my behalf,'" all matters relative to wo a orized by th' building permit applica n. M - . /. A . 1 � -%l< Date I, 1 OOA)g /o/ I9f.I M as Owner /Authorized 'Agent hereby dedare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Sig / n under the pains and pe nalties of perjury. j),i At)1'd'f (� Pe t / -e-� c e Print Na / 1)n kit Re/i/bi /° f D Signature of Owner /Agent Date 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 1 I Frontage H Setbacks Front l I Side L: _ RLJ L:� R:� i] ._ 1 Rear Building Height L] I 1 I Bldg. Square Footage El] % Open Space Footage paved ((lot area minus bldg & panting) # of Parking Spaces I SWIM Asaser Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued:1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES IF YES: enter Book Page _ and /or Document #L B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , 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 ® NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 1r ci rct1� 1ca.41 • City of Northampton Building Department 212 Main Street ` ' Room 100 Northampton, MA 01060 1 1 phone 413 -587 -1240 Fax 413- 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION #{ 1.1 Property Address: * w' n k Y ' II b �e rAr 1-15 12c1 yr1 ♦ L s . l I �. t ' ' � ,.} ' • Wx ' } ' ' w StiOPl D 2.1 Owner of Record: nre Gray-) X13 �0A r V (Print) / Current Mailing Address: icje KC( C`e_. c=w4 r Signature! FO 2.2 Authorized Ascent: • rAi,1 �.eM `e-ru 11 0 1'U�,i aJ 1 / 01�e A Name • rint) Current Mailing Address: < 1 14.4,- !11 iede ,��.t� . 9l3 .5- to zy Sig : re Telephone Item Estimated Cost (Dollars) to be O completed by permit applicant ,4 t 1. Building ' - SI7 0 p FP I O st 2. Electrical -o E' red Totat O o nn'f� 4 3. Plumbing 1 Ne 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) 4 011$401101V - -900604.10,c/40.. *lildil Nvr , is . File # BP- 2011 -0370 APPLICANT /CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002 PROPERTY LOCATION 43 FOX FARMS RD MAP 17A PARCEL 159 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid C g , / Typeof Construction: INSTALL WALL INSULATION C (� (GU{V New Construction j ♦ �Jf 7 Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 101876 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved Additional permits 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 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 Storm Water Management Demotion Delay /I() 9X - �� 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. V • • 1 ' BP- 2011 -0370 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2011 -0370 Project # JS- 2011- 000613 Est. Cost: $2221.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq. ft.): 27007.20 Owner: GRANT GERALD S & BERNICE B Zoning: URA(100)/ Applicant: DONALD PELLETIER AT: 43 FOX FARMS RD Applicant Address: Phone: Insurance: 1107 MAIN ST (413) 538 -6002 WC HOLYOKEMA01040 ISSUED ON:10/25/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL WALL INSULATION - INSULATION INSPECTION REQUIRED POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/25/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner