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WORKERS COMPENSATION AND EMPLOYERS'LIABILITY
INSURANCE POUCY—INFORMATION PAGE
INSURER: POLICY NO: WCF5898Y
NGM INSURANCE COMPANY
4601 TOUCHTON ROAD EAST
SUITE 3400 NEW BUSINESS
JACKSONVILLE, FL 32245-6000 NCCI Company No: 16322
Account No: CACF589SY
ITEM 1.NAMED INSURED AND MAIUNG ADDRESS: AGENCY NAME AND ADDRESS:
AXIOM LANDSCAPE & HOME FINCK & PERRAS INS AGCY INC#2
(SEE NAMED INSURED ENDT)
40 PINE VALLEY RD 6 CAMPUS LANE
FLORENCE MA 01062-3600 EASTHAMPTON, MA 01027
AGENCY PHONE NO.:,(413) 527-5520
AGENCY NO.: 200294
LEGAL ENTITY: LIMITED LIABILITY COMPANY
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule)
ITEM 2. POUCY PERIOD: From: 04-17-2013 To: 04-17-2014
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM a COVERAGE:
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 work in each state listed in Item 3.A. The limits of
liability under Part Two are:
Bodily Injury by Accident: $ 100,000 each accident
Bodily Injury by Disease: $ 500, 000 policy limit
Bodily Injury by Disease: $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
all states except ND, OH, WA, WY
and states designated in ITEM 3A of the information page.
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit. Please see Classification Schedule.
Total Estimated
Minimum Premium: $ 320 Annual Premium: $ 855 j 71 3
Audit Period: ANNUAL
Date: 03-06-2013 Countersigned by
WC 000001 A Copyright 1987 National Council on Compensation Insurance
(41.)VV0 A‘.1-/`
cdi41 l c AGENT COPY
=Er
The Commonwealth of Massachusetts print Firm
Department of Industrial Accidents
* ) Office of Investigations
y�l 1 Congress Street, Suite 100
.ifit Boston, MA 02114-2017
tk -t www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): A ric w, L,,tiaSCiPx f 14 0,4 1.1-,-,-(/NI N f /--/-6-Address: `/v P1■t U //r, If2G4 vl _
City/State/Zip: 'iuq,4,e" /4/4 0/(4,2_ Phone #: V/3 - $ - .5 4)-G;
Are :u an employer? Check the appropriate box: Type of project(required):
1. A I am a employer with L1 4. ❑ I am a general contractor and I
employees (full and/or.* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.,Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
g Y p tY 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.11 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 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' 13.0 Other
comp. insurance required.]
*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: 416/✓1 .J'i S.,M 1 c L
Policy#or Self-ins. Lic. #: l,"'C.F 5551 b7 Expiration Date: "f--/7- l'I
Job Site Address: t Z 5"c-1.4 /r1't,A Si ris,l„4f nd oluL 1 City/State/Zip:
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 tlJ,pains and i enalties of perjury that the information provided above is true and correct.
Signature: �`� .._ Dated c, ziI s3
Phone#: Ll13 C-S4 ` S-9`64 /
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 Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: !71 i S L t PI , /J y s l..-J - /063 .1 .
Q i / License Number
Liv 0144_ ��1/ie
gi�:,�> f !U,-(ticr n G/OG z Zf Z_-6/z '/
Address / Expiration Date
`113 S-Csc
Signature Telephone ti 13 _ 3 ZG _ 4c
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address / Expiration Date
(f I. ( Vc /l7- /2bcc/ N4 v1Gf,LTelephone L1' 5—056 - $L
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 buildi g permit.
Signed Affidavit Attached Yes No ❑
11. — Howe 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 n
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [U Siding[0] Other[0]
Brief Description of Proposed, �/ J
Work: ¶� ri�L1 A. Mua/f�✓M E✓-° h g� �y ff<<�.t t,-GII rhaf C7,..h2 AlmOffe4"
Alteration of existing bedroom Yes No Adding new bedroom Yes X 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, GrGC4 G,`rt ,as Owner of the subject
property
hereby authorize /4-1iSL., Ph //,0.'
to act on my behalf, in all matters relative to work authorized by this building permit application.
2---: S/2 ,e(l/F
Signa e of Owner Date
Gcc l-,V,.t ,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 of perjury.
G:a c C.
Print Name
/f/ 2� a/
Signatur- .f Owner/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 P f 45-1/ Sry
Frontage
Setbacks Front
I f,
Side L: ? - R: 1.1_ L: R:
Rear (1'
Building Height
Bldg. Square Footage 2 '1 �I % 2 2
/ srF� ,
Open Space Footage % y
(Lot area minus bldg&paved ' 701
parking)
#of Parking Spaces lotn Poi k.4 (1 , t c,•
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO t I DON'T KNOW 0 YES 0
IF YES, date issued:..
IF YES: Was the permit recorded at the Registry of Deeds?
NO (3 DON'T KNOW ® YES 0
...... ..._
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ►4,4 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 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO per
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES i NO
IF YES, describe size, type and location: 'i!!
E. Will the construction activity disturb(clearing,gradin., exc ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Dep&rtmnt use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
u 20[3 I 212 Main Street Sewer/Septic Availability
Room 100 Water/Weil Availability
DEPT OF BUT: orthampton, MA 01060 Two Sets of Structural Plans
NcRTHnti;P3uv,w. o ne 4 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 Property Address: This section to be completed by office
1e� S`14r1) M�iin S1 Map Lot Unit
/v/ro z t "1,1- 0/6 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
lJ/mact l_,', L, l S�fnrL /11tiin 3-/ F/v'rsrr lift/e
41/612-
Name(Printl, Current Mailing Address:
Telephone
Signs e
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /q.uc (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
410U Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 4 Ivey
5. Fire Protection
6. Total=(1 +2+3+4+5) i► U1 Check Number lda /5 1 / a4
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-1186 dk
APPLICANT/CONTACT PERSON ALISHA PHILLIPS 76dii` Vi ADDRESS/PHONE 40 PINE VALLEY RD FLORENCE (413) 586--f5986 / �evl
PROPERTY LOCATION 62 SOUTH MAIN ST p `P p am
MAP 23B PARCEL 079 001 ZONE URB(100)/ 1
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ��� 6.47-Fee Paid Cv
Typeof Construction: ADD MUDROOM DOORSTAIRS/OVERHANG TO CREATE MUDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106378
3 sets of Pla• ' of Plan
THE F• OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
i F' ' ATION 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
:-,.lon R-la
-7 " /„.- Z(-7Z-- —7
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.
62 SOUTH MAIN ST BP-2013-1186
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B-079 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2013-1186
Project# JS-2013-001948
Est.Cost: $21000.00
Fee: $126.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALISHA PHILLIPS 106378
Lot Size(sq.ft.): 10585.08 Owner: LIN GRACE
Zoning:URB(100)/ Applicant: ALISHA PHILLIPS
AT: 62 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
40 PINE VALLEY RD (413) 586-5986 WC
FLORENCEMA01062 ISSUED ON:6/19/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD MUDROOM DOORSTAIRS/OVERHANG TO
CREATE MUDROOM
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 6/19/2013 0:00:00 $126.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner