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