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30A-059 v� A CORD ' CERTIFICATE OF LIABILITY INSURANCE DATEtMMlDDIYYYY, 4 ....- - ' 08/17/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Aon Risk Services Southwest, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Fort Worth TX Office HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 301 Commerce Street, Suite 2101 Fort Worth TX 76102 INSURERS AFFORDING COVERAGE _ NAIC # INSURED INSURER A: ACE American Insurance Company _ 22667 InStar Services Group, L.P. INSURER B: National Union Fire Insurance Co of Pittsburgh PA '9445 1111 W. North Carrier Parkway INSURER O. Suite 400 INSURER D: ( Grand Prairie TX 75050 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. y �F7 ����� p L �7�p �p� Y) LIMITS SHOWN ARE AS REQUESTED LT R I TYPE OF INSURANCE POLICY NUMBER , DATE (MrarD�/YYYY DX7EC€yMMIDDM/Y LIMITS A GENERAL LIABILITY HDOG24933581 8/19/2009 08/19/2010 EACH OCCURRENCE 5 1,000,000 I� COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED , ita PREMISES (Ea occurrence) S 100,000 Ej CLAIMS MADE n OCCUR MED EXP (Any one person) 5 5,000 • Z' 1,000,000 S2mi1 Agg per project PERSONAL & ADV INJURY _ 5 1,000,0 _J GENERAL AGGREGATE S 10,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG S 2,000,000 POLICY n PROJECT n LOC A _ AUTOMOBILE LIABUTY ISAH08580546 08/19/2009 08/19/2010 COMBINED SINGLE UNIT S 1,000,000 • -= 21 ANY AUTO (Ea accident) D ff ALL OWNED AUTOS BODILY INJURY S SCHEOIILF-DAUTOS (Per person) — HIRED AUTOS BODILY INJURY NON .OWNED AUTOS (Per accident) S .._J D ) PROPERTY accident) 5 : __ 1 GARAGE LIABILITY AUTO ONLY - EA ACCIDENT 5 OTHERTHAN ANY AUTO AUTO ONLY: _.'...t._' R S -' B �, EXCESS IUMBRELLA LIABIUTY 08/19/2009 08/19/2010 EACH OCCURRENCE S 5,000,000 (..r/ OCCUR D CLAIMS MADE AGGREGATE S 6 • 000 ,000 S DEDUCTIBLE 5 yi RETENTION $ 10,000 $ A WORKE COM PENSATION AND WLR C45701414 08/19/2009 08/19/2010 X) TORY LIMITS n E'R EMP LOYERS'UABIL ITY Y IN ANY PROPRIETOR/PARTNER /EXECUTIVE N E.L. EACH ACCIDENT 5 1,000,000 OFFICER/MEMBER EXCLUDED? [ _.___ (Mandatory In NH) El-DISEASE •EAEVPLOYEE S 1,000,000 It yes describe under 1,000,000 SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT 5 OTHER U8 RIPTION OF OPERATIONS7 LOCATIOW IVEHIC_E:S7 EXCLOSIONEADDEU BY ENDORSEMENT/ SPECIAL PROVISIONS Certificate Holder is included as Additional Insured (except workers' compensation/employers liability) with a waiver of subrogation as required by written contract subject to policy exclusions, limitations, and conditions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED WORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR 10 MAR. 30 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 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE t Aon Risk Services Southwest, Inc. ACORD 26 (2009/01) Page 1 of 2 4D 1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill) sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location .. • . .,. The Commonwealth of Massachusetts Department of Industrial A Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia . -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv - , Name PusinethiOrganization/Indivith 1.1),512t-st, Siege C-e S ,--- Address: /6 L S 74 Te... City/State/Zip: 4 ,„.1h ,.. e .,,,, - 0/0,3(,, Phone.#: 1 //3 - 5 — 2eft) ,, Are you an employer? Check the appropriate box: 'Type of project (required): / 1. El I am a employer with le • 0 I am a general contractor and I 6. N i ew coistruction have hired the sub-contractors employees (full and/or part-time).* fisted on theattached sheet 7. 0 Remodeling 2.0 I aril a aole proprietor or partner- These sub-contractors have ship and have no c..loyees 8. 0 Deraolition • working for me m any c.apacity. employees and have workers' . . 9 - 0 Buildng additiiin t " [No workers' comp. insurance 5 0 We are a corporation and its 10.0 Electrical repairs or additions required.] - .. . 3. Di am a homeowner doing all work officers have4xercised their .4. 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t • c. 152, §1(4), and we have no „ „- employees. [No workers' 13.1.1C1 Other CoSiroulie comp insurance required} *Any applicant that checks box #1 must also fill out the section belovv showing theirworkers compensation policy information: ,..: 1. Horneowneri who submit this affidavit indicating they are doing all work and them hire outside contraCtcas must submit a new afrrdavit indicating such. :Contactors that check this box must attached an additional sheet showing the name of the stticontractors and state whether or not those entities have employees. lithe sub-contractors have anployeea, they must provide their workers' comp policy number Jam am an employer that Ls providing workers' compensation insurance for my employees. Below is the policy and job site Information. . litsurance Company Name: • /q C.01/..,f:L . • Policy # or Self-ins. Lic. #: id I,k e.. Y5 / Expiration Date: - 0849,2:24/12 „, City/State/Zip , _ ., . _... , . . lob Site Address -1:1 (.• driOfi.. CeA-Ce ft-.-- : /toff/Li- /.A *fie ele Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under SectidiT25A"cifMGL 152 can lead to the iiiipOsitiori of Crirniaal penalties 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 &_e of up to $250.00 a day against the violator. Be Oyi.Sed That a copy of this statement may be forwarded to the Office of IiiViitiOna Of the for insurance coverage lie Iiiii herek certify under tiittins.a14 en dairies of; iijtiti that the informatto* nprovidiiiibOue_tiorreci _ Sienature. 1 - - : Iia ,, ,.., Phone #: / 1/ 3 3 / , / r 7 5 .- - • , Official use only Do not write in this area, to be completed by city or town'OfficiaL City or Town: -. Permit/License # ' Issuing Authority (circle one): • 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical,In 5. Plumbing Inspector 6. 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JA 00 6 uly;!M uoi;arli;suoo sI 'ON sa r, 4spuel;9M ;o -}; 001, u!y1 uo 4,payoeue uuo; aouelidwoO A6aau3 )Ioayosselry - aouelidwo3 uo - r. goes ;o aagwnN sano;spooM JO seoeidaal3 suolsuawlo •uouoru;suoo Mau ;o 96e ;c ipay; f swooay;ee ;o aagwnN :pun Ailwe; q: 19 41O AIIwe3 oMl , .^ IIlw , 711"S rri+c LP' A,1 u 519 -1©r Pu1PsPx P I ON , ,,`1 saA ;uawaseq payslu6un 6ul ;enouaa oN .+ saA wooapaq Mau 6ulppy ON ,A saw, r ya : - r r Pi "WO [o] suips dJ sipo j [Dl suDrs MaN 0:1 UOr s Q £1000 .I0 0 (s)uogjgy smopubn ;uawne/day Q a /9ei,� a %/�,va „t,,T--- .-�. 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 i �� ��.. f __ I . Frontage Setbacks Front i , Side L:... 1 R:l _._.x L:?. € R:; J r , Rear I - Building Height j Bldg. Square Footage r °"" 1 I% 1 L. ""' Open Space Footage (Lot area minus bldg & paved I f i ? -� parking) # of Parking Spaces - -- Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES 0 IF YES, date issued:f IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I Page' € and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ,Date Issued C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • City of Northampton s l 44 AVI Building Department 212 Main Street u ' - s ,X72 fslo, Roo 100 a � £ � 4 Northampton, MA 01060 P d phone 413 -587 -1240 Fax 413- 587 -1272 a : sts figt : 41, APPC.4 T1ON 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 a 66, f/c 't'a g. fret- Map Lot Unit e'tc4 tenet. eldO a Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C7a iP7 S /osK� a otzeq, Name Pri Current Mailing s : ,QI � 'i,3 f 0 � Telephone Signature ^— 2. Agent: ; / �[ JUNGt. /L /�o bin/ _tovs =Sit/MI/Co-5 /!1T S //f /' (5 / 4 u,lier' Ma Name (Print) Current Mailing Address: y(3-3/3-/ 03 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building tif O l , (a) Building Permit Fee ere 2. Electrical � o � (b) Estimated Total Cost of / , 0'1� Construction from (6) 3. Plumbing Building Permit Feentil PC1 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) j 5 �,� .OD Check Number 30/;.?? #0479 This Section For Offic Use Only Date Building Permit Number Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0866 APPLICANT /CONTACT PERSON INSTAR SERVICES GROUP LP ADDRESS/PHONE 100 STATE ST LUDLOW (413) 594 -7800 PROPERTY LOCATION 260 FLORENCE RD MAP 30A PARCEL 059 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 3Oidg / �J / 4 ) Typeof Construction: DEMO & REPLACE CHIMNEY, REPLACE & REPAIR FIRE DAMAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 017755 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: 1, 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 r 10 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. BP- 2010 -0866 GIS #: COMMONWEALTH OF MASSACHUSETTS a : 34iii . 59 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: FIRE DAMAGE BUILDING PERMIT Permit # BP- 2010 -0866 Project # JS- 2010- 000934 Est. Cost: $46502.00 Fee: $279.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: INSTAR SERVICES GROUP LP 017755 Lot Size(sq. ft.): 28183.32 Owner: MASLOSKI FRANK & EVELYN B Zoning: URA(100) / /WSP Applicant: INSTAR SERVICES GROUP LP AT: 260 FLORENCE RD Applicant Address: Phone: Insurance: 100 STATE ST (413) 594 -7800 Workers Compensation LUDLOWMA01056 ISSUED ON:4/8/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: DEMO & REPLACE CHIMNEY, REPLACE & REPAIR FIRE DAMAGE 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 4/8/2010 0:00:00 $279.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 260 FLORENCE RD BP-2010-0866 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30A - 059 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: FIRE DAMAGE BUILDING PERMIT Permit # BP -2010 -0866 Project # JS- 2010- 000934 Est. Cost: $46502.00 Fee: $279.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: INSTAR SERVICES GROUP LP 017755 Lot Size(sq. ft.): 28183.32 Owner: MASLOSKI FRANK & EVELYN B Zoning,: URA (100) //WSP Applicant: INST.AR SERVICES GROUP LP AT: 260 FLORENCE RD Applicant Address: Phone: Insurance: 100 STATE ST (413) 594 -7800 Workers Compensation LUDLOWMA01056 ISSUED ON :4/8/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK :DEMO & REPLACE CHIMNEY, REPLACE & REPAIR FIRE DAMAGE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: '7s a 1- Ph-. Meter: Footings: Rough: Rough: 40 �p House # Foundation: r Driveway Final: Final: Final: O p 1-7 [ Id: L ` t - ' / 7)..-/o 2P I . Rough Frame: Q . 27/ / C.: (..c,i4 ( S i Gas: Fire Department Fireplace /Chimney: . Rough: Oil: Insulation: Final: Smoke: Final: 0 k 74,9- /0 G,y)^ THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATION i * Ai titpewari• Certificate of Occupanc !� ' ignature: FeeType: Date Paid: Amount: Building 4/8/2010 0:00:00 $279.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo