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17C-091
itt CERTIFICATE OF LIABILITY INSURANCE OP ID DA DATE(MM /DD /YYYY) SOVER -1 10/13/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Haberman Insurance Group Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 95F Ashley Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Springfield MA 01089 Phone: 413- 781 -7000 Fax:413- 733 -9545 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual 14788 INSURER B: Sovereign Builders, Inc. Cellura Construction INSURER C: 135 Southampton Road INSURER D: Westhampton MA 01027 -9535 INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWL POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE (MM /DD/YYYY) DATE (MM /DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X X COMMERCIAL GENERAL LIABILITY MPK9789N 06/21/09 06/21/10 PREMISES (Ea occurence) $ 500000 CLAIMS MADE X OCCUR MED EXP (Any one person) $ 10000 PERSONAL & ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OPAGG $ 2000000 — 1 POLICY X PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A ANY AUTO MIK9789N 06/21/09 06/21/10 (Ea accident) $ 1000000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STAI U- OTH- AND EMPLOYERS' LIABILITY Y I N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE 1 E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS City of Northampton is named as additional insured with respects to general liability. Revised certificate from 9/28/09. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITYN21 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR City of Northampton REPRESENTATIVES. 212 Main Street AUTHORIZED REPRESENT TIVE Northampton MA 10160 E ACORD 25 (2009/01) © 198 -2009 RD CORPORATION. AtH rig is reserved. The ACORD name and logo are registered marks of ACORD ✓/ee oPammaoouuectld apiiaaaac%uaelta Board of Building Regulations and Standards License or registration valid for individul use only - _•.Akt= - C/ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: k Board of Building Regulations and Standards Registrdtlpq, 158240 One Ashburton Place Rm 1301 �.�. Eora_ 27/2009 Tr# 262706 Boston, Ma. 02108 AArf:1 Ff te Corporation SOVEREIGN BA 'WINO TODD CELLURAs's i !/ 135 SOUTHAMPTON" `''02 Not v alid without signature WESTHAMPTON, MA 0'1027 Ad m i n i strator nature g a >- I =_ =_ c/ Boar. o : ui din e ulat ons an . an . ar . s =„s,�— One Ashburton Place - Room 1301 �" =4 Boston. Mass. chusetts 02108 - Home Improvemen s tractor Registration Registration: 158240 Type: Private Corporation Expiration: 12/27/2009 Tr# 262706 SOVEREIGN BUILDERS, INC. TODD CELLURA 135 SOUTHAMPTON RD. .. .0 WESTHAMPTON, MA 01027 j A %t • Update Address and return card. Mark reason for ch i ge. ? f Address j Renewal Employment [I] Los Card DPS -CA1 0 50M- 07/07- PC8490 1 II \lassachusetts - Department of Public Safe • 9 Board of Building Regulations and Standards Construction Supervisor License License: CS 60176 Restricted to: 00 TODD G CELLURA 135 SOUTHAMPTON RD WESTHAMPTON, MA 01027 Expiration: 1/19/2011 ( 'on u nissioner Tr#: 8416 (< • . 06/25/2009 11:48 FAX 0002/002 • • ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. 0075190 -00 WC 006 -94 -0533 13072 - — -- — 013 0109 -00 INCORPORATED UNDER THE LAWS OF k ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO.: SOVEREIGN BUILDERS INC. Member Companies of 1 SOUTHAMPTO ROAD dill American International Group MA 07027 -0000 p EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE EXTENSION OF ITEM 1, OF THE INFORMATION PAGE - WC990610 1.D# MA 1; ' PRODUCERS NAME AND ADDRESS PMC I NSURANCE AGENCY INC. WORKERS COMPENSATION AND EMPLOYERS 50 CABOT STREET LIABILITY POLICY INFORMATION PAGE PO BOX 920179 , NEEDHAM, MA 02492 -0002 INSURED IS PREVIOUS POLICY NUMBER CORPORATION RENEWAL 006982253 OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 ITEM 2 POLICY PERIOD 12:01 AM. standard time at the insured's mailing address FROM 01/06/09 To 01/06/10 ITEM 3 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 CO CT DC DE FL GA Hi IA ID IL IN KS KY LA MD ME M1 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 SEE EXTENSION OF ITEM 3.0. OF THE INFORMATION PAGE - WC990612 • 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 Total I Rate Per Estimated Classifications Code Number Remuneration 8100 of Re Premium © Annual ❑ 3 Year muneratlen © Annuaf 3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES /ASSESSMENTS /SURCHARGES $1,0811 EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $338 MA MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM $17,768 If indicated below, interim adjustments of premium shall be made: DSemi• Annually Ej Quarterly El Monthly DEPOSIT PREMIUM 12/09/08 PARSIPPANY 82 ramp - Issue Date Issuing Office Authorized Represent I I ive WC 00 00 01 39967 (FReV 04/08) 5:" .i Ire t.onnrnonwealrn of 1v1uJ'JUvIIKJGtta t Department of Industrial Accidents 600 j � u ►.= Office of Investigations "' Ar t ;,, < Washington Street 4 . c� _,., Boston, MA 02117 �eai - WWW.mass.gov/dia Workers' Compensation Insurance Affidavit General Businesses • Applicant information Please Print Legibly Business/Organization Name: S 0,{L,t r 15 t c if :A 7 5 - r, , , 1 tau -tha 1- - d - - . _ . _ Address: ,. City /State/Zip: esstia.roffi '1'1 Am 6/02-1 Phone #: l ( - - - `Z "7- /r I Are ou an employer? Check the appropriate box: Business Type (required): • 1. I am a employer with employees (full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment . 2. ❑ I am a sole proprietor. or partnership and have no 7 Ej Office and/or Sales (incl..real estate,.auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non -profit 3.0 We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10. ❑ Manufacturing • no employees. [No workers' comp. insurance required] ** • 11.❑ re Health Ca 4. ❑ We are a non -profit organization, staffed by volunteers, /)�_� with no employees. [No workers' comp. insurance req.] 12.P Other (.2( lOA . .e, ti Any applicant that checks box #] must also HD outthe section below showing lbeirworkets' compensation policy information. `' the cotpotate officers have exempted themselves, but the corporation b other as oer employees, a workers' compensation policy is required and such an • f organization should check box WI. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. 1 Insurance Company Name: 1 _ li f , .L • Insurer's Address: S( (': + ; q s �y - . i. ?C ' l( q ,-) 6 i , 7 City /State/Zip: i ti .et ,4 h CI.Yh � M t >- () li cj — 0n 6 a • • Policy # or Self -ins. Lic. #i \\I C'''. 0 Q ( q y -0533 Expiration Date: (— 62- ( 0 • Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure•to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa 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 $250.00 a day against the violator. Be advised that a copy of Ibis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, und he <. ains an enalties of perjuzy that the information provided above its true and correct. Si ator'e: '-- Date: 6 --- q - ____ Phone Official use only. Do m it write in this area, to be completed by city or town official . • City or Town: Permit/License #I • Issuing Authority (circle one): • 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #t: • • www.tnasagov /dia SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : (0 Ci C2 l e I (LAX C$ 601 License Number Address 1 Expiratio bate 6 CO Sifnature Telep one 9. Registered Home Improvement Contractor Not Applicable ❑ ompanv Na a Registration ) Nu 7 mb er rt .I• f. AA. ill 1.. . _r. • Al I . _ 7 � r2 -` -7 - 69 Address , ' -7 Expiration Date Telephone 4 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 tlk No ❑ 11. - Home Owner Exemption 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [O] Other [O] Brief Description of Proposecj. Work: S-► v i C.tr c.ki ,�,,rE ��'tS �r� - r ac 4.vi t v1 t-a/ S(�tvt.4��S: Alteration of existing bedroom Yes l/ No Adding new bedroom Yes J No . 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 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, I Q e5C1 , as Owner of the subject property J !� hereby authorize So-Jet { g 04 jy � D t Y,(' to act on my behalf, in allll matter relative to wor authorized by this building permit application. 10 — 114 C Signature of Owner Date I, - ^ ei • .Iii A • , as Owner /Authorized Agent hereby dec .re that the statements and inf. , ation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print 0 rne Sign Z:& oV6wner 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 Frontage Setbacks Front Side L. R. .........,' L: ...... R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) .. — ... A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW CI YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW er YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: % D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO er IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, e vation, 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. , Department use only City of Northampton Status of Permit Building Department Curb CutlDriveway Permi 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availabil Northampton, MA 01060 Two Sets of Str tctural Plans Phone 413 - 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 Property Address: This section to be completed by office 7- l-ft� �1 nu+ Sf reek. Map Lot Unit �' Ce ( MA °(0(i) Zone Overlay District Elm St. District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1- e.5ed n 12i) MA njCil� Name (Print) U Current Mailing Address: 21 ,( 14 1 - 1 / k el <2 , ,d - Telephone Signature 2.2 Authorized Agent: 9 Kl e f f i < 1 t 1;t l , ' 4' j J-n l C- .s..1 . 1191 retain ._ 11 a ri /i 0 Z7 Name (Print) ' / Current Mailing Addr- .s: --.! 1-- 13 - 53 7 A CC 1 Signatur. Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit 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� 000. 0 0 Check Number ` _ _ This Section For Official Use Only Date Building Permit Number: Issued' Signature: Building Commissioner /Inspector of Buildings Date • 4 BP- 2010 -0417 GIS #: COMMONWEALTH OF MASSACHUSETTS ; k.I7C -091 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- 2010 -0417 Proiect # JS- 2010- 000568 Est. Cost: $5000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SOVEREIGN BUILDERS INC060176 Lot Size(sq. ft.): 7187.40 Owner: VISHAWAY FREDERICK M & THERESA & LISA DEE & SUZANNE RAUSCHER Zoning: URB(100)/ Applicant: SOVEREIGN BUILDERS INC AT: 120 CHESTNUT ST Applicant Address: Phone: Insurance: 135 SOUTHAMPTON RD (413) 527 -8001 Workers Compensation WESTHAMPTONMAO1027 ISSUED ON:10/19/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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 10/19/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo