31A-325 VDAC
Ilk
TRAVELERS J WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (7PJUB- 0545N1 3 -1 -1 2 )
RENEWAL OF (7PJUB- 0545N1 3 -1 -11 )
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
1.
NCCI CO CODE: 13579
INSURED: PRODUCER:
DELONG CONSTRUCTION LLC WHALEN INS AGCY
76 BANCROFT ROAD 71 KING STREET
NORTHAMPTON MA 01060 P 0 BOX 478
NORTHAMPTON MA 01060
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05 -26 -12 to 05 - 26 - 13 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
cn-
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease: $ 1000000 Policy Limit
Bodily Injury by Disease: 1000000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
0
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
0=
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY .
DATE OF ISSUE: 05 -07 -12 WC ST ASSIGN: MA
OFFICE: DIRECT ASSIGNMENT 701
PRODUCER: WHALEN INS AGCY 28LKF
001990
• City of Northampton •
7 y ; . sib
' Massachusetts , f�,
t D EPARTMENT OF BUILDING INSPECTIONS mo t,'
° 212 Main Street • Municipal Building '`),t.< a z°
• ,a✓° -2 Northampton, MA 01060 -s ` `^...;
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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 Accidents
=',17, 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 Legibly
Name (Business /Organization/Individual): ECG n o n!5 /z`c.,G >v. , G C C
Address: 7 734 Avcre()K % ,e) •
City /State /Zip: 4 /a • --1• /, da A - LI '° 6 3 Phone #: 'it 3 ' Sc T 7- 0
Are you an employer? Check the appropriate box: Type of project (required):
1. E I am a employer with 2 - 4. n I am a general contractor and I 6. New construction
employees (full and/or part- time).* have hired the sub - contractors
listed on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
working employees and have workers'
g for me in any capacity. p i tY 9. n Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3. n I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.] I I
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: "7 - ''P4 tic e' S
Policy # or Self -ins. Lic. #: 72-Tv 3 - c) S 4SN 1' 3 - A - /Z Expiration Date: S / 2 G /'
Job Site Address: /S \/" City /State /Zip: A6 , 4 • , 060
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 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Ic — D lam— Date: {L /1 L
Phone #: ( // 'ag37
II Official use only. Do not write in -this area, to be completed by city or town officiaL (I
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: � ��+� ✓ � � e6v- vrfiA'U CS 0 y2.6 - 06
License Number
7 6- /3.Q A/c ,e 12- . Afo,e-- r- xar-I-Pri7)701/ AA4. 3/ 06,3 3 `L S /2 oo c/
Address Expiration Date
— - t //3 ^ 65S - &6Z
Signature Telephone
9.:Registered Homeilmprovemerit'Contractor Yn „ ; a .. M :, , ; k Not Applicable ❑
"Fc 6- e` , Cc e /S 6ff
Company Name Registration Number
760 -1;..f re
Address Expiration Date
A/o •- - /A 77 4/, ,t--e 4 • 0 Telephone c// 3 -f `i S 3G.(2
SECTION 19— 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 pr No ❑
1 I om D xe i o
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) ' I Roofing n
Or Doors Tg3
Accessory Bldg. ❑ Demolition n New Signs [El] Decks [E] Siding [El] Other [CO
Brief Description of Proposed
Work: /2 e /4 i 'nt -,rr -0' 4i ' -X )fu () 2/' V
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
sa�lf�C�Iewxhouse.and or:add�tion..to.ezistinq housing ,Prcompletethe:rfollowing:
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 S 7a.- ,OWNE RAUTHOR(ZATION.,,TO BE COM.PLETED WHE
OWNER AGENT CONTRACTOR APPLIES: FORBUILDING PERMIT
I, /.( „"'e G o i , ' )7 C,a c EX , as Owner of the subject
property
hereby authorize iI ni vA/
to act on my behalf, in all matters relative to work authorized by this building permit application.
6,0 ` --/ /0 (2 //L
Signature of Own Date
I, c: fr,J ct C cater f 64-4A.,/ , as .Awner /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 of perjury
%_ 0 . 7d LAN
Print Name /
LIZ" —_ /0 / 1 / /L.
Signature of•ewner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
b '
Existing Proposed Required by "honing
This column to be filled in by
Building Departmini
Lot Size L .
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 0 YES 0
IF YES, date issued:,
YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page; and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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.
t
•
De artmepat us on
Ci of Northampton Status of P 4 � ' � . k ' ,
B (ding Department Curb Cut/Dryeway Prermt ' N`
t , r b 4 a j. �n�s ' IY — � ' , _ a w," - i"s�.-
1 12 Main Street View �� +,'t 41, ' E
(� � \ Room 100 Water/W Avallabll tY �` �� `
f�rth mpton, MA 01060 Tw et of Structura� < ;: - „ .
T 58' -1240 Fax 413 - 587 -1272 P ot s� �7��
DEFT. OF BUILQt N -
NO RTNPT f N 0I q �F
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 of
i S V&-<-' o v S %, Map L U ni t
�lO F //►rte Jfir7 e "t /� .
Zone . `- . •Overla District .,.. --
Elm Si District CB District
SECTION 2 - PROPERTY OWNERSHHORIZED A NT
GE
2.1 Owner of Record: IP /AUT
Gc% %/ ;�.i /��1QG 0 (703ek /S Ve.e- ..it>4J i . arcr�/ era�/,i.
Name (Print) �a ,/ Current Mailing Address: ti / 3 � se v e/ 6 5 s
i a iz- t-c) (� ,y ( `� Telephone
Signature J
2.2 Authorized Agent:
1:._ d L&.I,t /ia. 7� l3 A�IC2or %�. o e TNfrflrrr7JI/
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COST . .
Item Estimated Cost (Dollars) to be Official Use . On ly
_ completed by permit applicant
1. Building (a) Building Permit Fee
/3, 33t)
2. Electrical , (b) Estimated Total Co of
' Construction from. (6)
3. Plumbing - Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) /O 3 3 3 �� Ch N
This Section For Official Use Only
Building Permit Nu I ssue d :
Signature:
Building Commissioner /Inspector of Buildings pate
15 VERNON ST BP- 2013 -0378
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 325 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2013 -0378
Project # JS- 2013- 000612
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED LENNIHAN 042506
Lot Size(sq. ft.): 92782.80 Owner: COOLEY MARGO F
Zoning: URB(100)/WP(6)/ Applicant: ED LENNIHAN
AT: 15 VERNON ST
Applicant Address: Phone: Insurance:
76 Bancroft Road 587 -0437 WC
NorthamptonMA01060 ISSUED ON :10/2/2012 0:00:00
TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOWS
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 10/2/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner