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43-090 'NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. 0090063 -00 WC 009 -93 -6606 - : 3072 ------------ - - - - - -- - 013 • VANIA COZY HOME PERFORMANCE LLC C H A RT I S 14 LYMAN RD NORTHAMPTON, MA 01060 -4228 A Chartis company EXECUTIVE OFFICES: rXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 175 Water Street New York, NY 10038 MA UI_: PRODUCERS NAME AND ADDR KEATING GROUP OF MA LLC WORKERS COMPENSATION AND EMPLOYERS 144 TURNPIKE ROAD LIABILITY POLICY INFORMATION PAGE SUITE 150 SOUTHBOROUGH MA 0 SURED iS PREVIOUS POLICY NUMBER _iMITED LIABILITY COMPANY RENEWAL 007453941 3THER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 `,W Z POLICY PERIOD 12:01 A.M. standard time at the insured's mailin address FROM 11/02/10 TO 11/02/11 iLM i A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed ! here: MA B. Employers Liability Insurance: Part Two of the policy applies to the 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 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: 1 SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 m The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. AL' information required below is subject to verification and change by audit. 1 Premium Basis Rate Per Estimated Cassifications Code Number Total Remuneration 5100 OF Re- Premium 3 Year muneration a Annual ❑ 3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 -AXES /ASSESSMENTS /SURCHARGES $549 I XPENSI- CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $338 MA '.11NIMUM PREMIUM $500 MA TOTAL ESTIMATED ANNUAL PREMIUM TOTAL ESTIMATED ANNUAL PREMIUM �'. nred be low, interim adjustments of premium shall be made: Semi- .Annually El Duarterly Monthly DEPOSIT PREMIUM 39/14/10 PARSIPPANY 8 ?- ..,sue Date Issuing Office ` Authorized Representative WC 00 00 01A "ur iT:iv'd 04iC8j w The Commonwealth of Massachusetts Department ofln& Accidents Office of lnvesiigations 600 Washington Street Boston, MA 02111 www mass_gov /din - Workers' Compensation Insurance Affidavit: Builders/ Contractors /ElectricianslPlumb.ers Applicant Information Please Print Le_yffiIv Name usiness/or ondndivi ' Address: City /State/Zip: , \ F y &:' ` Phone 9: Are you an employer ?.Check the appropriate bo= Type of project I am a homeawner doing an work ofncers have 11. ❑ Plumb ( requfred):. r _ I m a employer with 4. 1. 1 a ❑ am a contractor and I general 6. -New conshuction employees (fall and/or part time).* have hired the sulr contractors 2_. L] I am a sole proprietor or partner- listed on the sheet 7. [] Remodeling ship and have no Wi ley e Ti c These ontractors have 8. ❑ Denio,ruon working for -me m any capacity_ cxAI_yees. and .- save workers' 9 � .13uug �difioa R\10 workers' Comp insurance comp. incrtran�P _ required j 5_ ❑ We are a corporation and its 10 ❑ -Electrical repairs or additions 3. Gercised their mg repairs or additions j ❑ x t myseI£ [No workers' comp. of exemption p� MGL 12 ❑ Roof repairs insurance required t c: 152, § 1(4), and we have no caiployeas. [No workers' 13 Oth x s v I comp- insurance rid_). "Any appiicant That checks box gl: tttast.also fill out the section belawshowing policy mfor-aiiou- t Homeowners who submit this affidavit.md3C2tMg they are doing all work and thm bite outside contractors mast submit a mw . affidavit indieafna such. - Counactnrs that check tbis box m=attached an additiaoal sheet showmg the name of the sub-c=== and Stara whethe or notdme-eatities have employees_ If the sub- caanacmts bave aaployer, they mast provide their wark=7 co¢tp. policynamber. I dui an employer that is providing workers' compensation insurance for. my employees Below is the policy and job: site information Insurance Company Name: Policy # or Self-ins. Lic. Expi-ation Date: J ob Si Address: _ W I 00 Attach a copy of the workers," compensation policy declarafiou page (showing the policy number and. ezPiratioa date). Failure to secure coverage. as reilume3 uriefier.Secfion 25A ofMGL'c: 152 can leadto the imposition of camiaal penalties of a fine up to $1-500.00 and /or one -year ia>pnsonn=t, as well as civil .penalties in the form of a STOP WORK-ORDER and a &- of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded.t the.021 of , Invest iili ns of the DIA for insurance' coverage ven3icaiion - d do ketch certi under the hens and f�veayury thafthe tnformatian provulthav rte aaden -- - P penalties o _ Si - -- - ' tree: - Date: Phone #: Official use only. Do not write in this area, to be completed by ciiy or town of,6ciaL City or Town: PermitUcense # Issuing Authority (circle one): . I_ Board of Health 2_ Building Department 3. City/I own Clerk 4_ Electrical Inspe71PIumbing 6. Other Contact Person: Phone #• A SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable ❑ Name of License Holder V . I.�r,�.r, z License Number Address Expiration Date /{ o Sign ture I Telephoner/ L / a// 0 � / L 9. Registered Home Improvement Contractor: Not Applic ble ❑ f I fi- - /C 0 Companv Name Registration Number L;b CJ Address // / Expiration Date Telephone z !/3 , Vo` / b 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....... 412 No...... ❑ 11. - Home Owner Exemution 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 10835.1. 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 a SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [[3] Other [O] Brief of Proposed _ /�-j ' 5�� /l�'r l Alteration of existing bedroom J Yes No Adding new b room / Yes No v � t �V`'� Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building: One Family Two Family Other L 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 / i as Owner of the subject property hereby authorize to act on my behal in all m ers relative to work auth zed by this building pe it appli tion. 3o h/ Signature of Own 4r/ Date 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. Signed under the pains and penalties o�ury Print Name Signature of Owner /Agent Date r 4 s r i r Department use only ity of Northampton Status of Permit: 70CT 11 Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability ROOM 100 WaterMell Availability OEPL OFBURnW INSPECTIONS orthampton, MA 01060 TWO Sets of Structural Plans NOR7HAMprpN MA c P one 3- 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 Proverty Address This section to be completed by office 0 I,J�a {fj'e /L. Map Lot Unit �%lu �(enf Mdj 0/06), Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record - A N G -e c- A M . A /Z Atj a C g0 l y �l,t iT7' �� ��� /ZC'v�J C Cam. HA U( U� Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Cozy Home Performance � ' 74 LYman Rd. Name (Print) Northampton, MA 01060 Signature I elepnu, ti SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by rmit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) S Check Number This Section For Official Use Onl Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date .a File # BP -2012 -0410 APPLICANT /CONTACT PERSON MARK LANTZ ADDRESS/PHONE 74 LYMAN RD NORTHAMPTON (413) 320 -7611 PROPERTY LOCATION 90 WHITTIER ST MAP 43 PARCEL 090 001 ZONE SR(100) //WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 102169 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 Demolition Delay 1 2 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. 90 WHITTIER ST BP- 2012 -0410 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 43 - 090 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2012 -0410 Proiect # JS- 2012 - 000655 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 46173.60 Owner: MISTRY BIPINCHANDRA N & MEGAN R C/O ANGELA M BARDAWIL Zoning: SR(100)/ //WSP II Applicant. MARK LANTZ AT. 90 WHITTIER ST Applicant Address: Phone: Insurance: 74 LYMAN RD (413) 320 -7611 WC NORTHAMPTONMA01060 ISSUED ON :1012512011 0:00:00 TO PERFORM THE FOLLOWING WORK.-ATTIC INSULATION 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 10/25/20110:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner l i1 . T Fo