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25C-188 0' e _62 Office of Consumer Affairs an d usiness Regulation 10 Park Plaza - Suite 5170 w Boston, Massachusetts 02116 Home Improvement Contractor Registration Reqistration: 118355 Type: DBA Expiration: 3/2/2013 Tr# 209147 ACE CHIMNEY SWEEPS JOHN KAPINOS 115 MAIN BLVD LUDLOW, MA 01056 Update Address and return card.Mark reason for change. (� Address [] Renewal n Employment F] Lost Card s-CA1 0 50M-0404-G101216 � Office i�o�m"e A aift ir.&Bifiiness egu ahou License or registration valid for individul use only - ----= before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR - Registration: 1 18355 Type: Office of Consumer Affairs and Business Regulation Expiration: 3IV2013 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 A HIMNEY SWEEPS J JOHN KAPINOS 115 MAIN BLVD LUDLOW,MA 01056 Undersecretary Not a i ithout signature WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company 54 Third Avenue, Burlington,Massachusetts 01803 =_ (800)876-2765 NCCI NO 26158 POLICY NO. FA 7027806012012 PRIOR NO. BUSINESS ITEM 1. The insured Kelly M Kapinos dba Ace Chimney Sweeps Mail Address: 115 Main Blvd Ludlow MA 01056 Street No. Town or City County State Zip Code FEIN xxxxx8598 ®individual ❑Partnership ❑Corporation ❑Joint Venture []Association ❑Other Other workplaces not shown above: 2. The policy period is from 10/08/2012 to 10/00/2013 12:01 a.m,standard time at the insured's mailing address. 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 work in each state listed in item 3.A. The limits of our 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:Coverage Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsements and schedules:SEE SCHEDULE 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. Classifications Premium Basis Rates code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 362813 SEE E TENSION OF INFORMATIC N PAGE Minimum premium$ 266.00 Total Estimated Annual Premium $ 1,742.00 As indicated interim adjustments of remium shall be made: Deposit Premium $ 1,800.00 ® Annually [I Semi Annually [I Quarterly ❑ Monthly MA Assessment Chg. $1,385.10 x 4.2000% $58.00 6����6-0-a This policy,including all endorsements,is hereby countersigned by 10101/2012 Authorized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY White-Jubinville Ins Agcy Inc STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP P O Box 789 MA 9014 2 707 South Hadley,MA 01075-0788 WC 00 00 01 A(7-11) Includes copyrighted material of the National councit on Compensation insurance, used with its permission. The Commonwealth of Massachusetts Print Form r'f� Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 -� www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual): Kelly M Kapinos dba Ace Chimney Sweeps Address: 115 Main Blvd City/State/Zip: Ludlow, MA 01056 Phone #: 413-547-8500 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 3 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F-1 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 or me in an capacity. employees and have workers' g Y P h'• 9. F-1 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions 3.❑ 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.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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: Associated Industries of Massachusetts Mutual Insurance Company Policy#or Self-ins.Lic.#: POL# AWC 7027806012012 Expiration Date: 10/08/2013 Job Site Address: .5t 3.z 4;j k44,/Acity/State/Zip: yGI�I`"K 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb'certify under the pains and enalties o er u that the in ormadon provided above is true and correct Si ature: Date Phone#: 413-547-8500 Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Page No. k of Pages A PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME CITY,STATE and ZIP CODE JOB LOCATION ARCHITECT JOB PHONE We hereby submit specifications and estimates for: v We Propose hereby to furnish material and labor— complete in accordance with above specifications, for the sum of: dollars($ Payment to be made as follows: 5A a S W;It t�)a t'8 'a c, % 0 All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized 4 manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. owner to carry fire, tornado and other necessary insurance. Our Note:This�rop6sal may be L workers are fully covered by Workman's Compensation Insurance. withdrawn by us if riot a9tepted within days. Acceptance of Proposal —The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature work as specified.Payment will be made(s outlined above. V Date of Acceptance: too Z-1 Signature— Z SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor. Not Applicable ❑ Il et l,/IOlnu,/4 sa)&,a-5 Company Name Registration Number 73/ad JlP36-6- Address 'ell3 Expiration Date CII��O� � Q10 Telephones—PS'DD 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....... U2- 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 W1 J Alesu SECTION 6-DESCRIPTION OF PROPOSED WORK(check all applicable) New House 0 Addition 0 Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks (Q Sidin [Q] Outer[m -, wor tins on l(�r�?�6,r,d of bLL Li s fe 5-�a e ss 51- / Ye Alteration of existing bedroom Yes No Adding new bedroom s No Attached Narrative Renovating unfinished basement Yes 1 Plans Attached Roll "Sheet sa. 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. 1. 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 1, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1, 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. Print Name Signature of 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved kin #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW ® YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES © 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 40 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 Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only ity of Northampton Status of Permit: Ouilding Department Curb Cut/Driveway Permit 01 C' - 7n f� 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability DEFT OF&u" .. - orthampton, MA 01060 Two Sets of Structural Plans NORTygMFTON,IMq p i 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 3 -I, ''/�//�� la-el LCD— Map Lot Unit (I 49 Y Fn �10 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: -3-t Ff s P Name(Print Curr r)t Mailing A re //// /. �' l/ Telephone Si atur 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 rmit applicant 1. Building (a)Building Permit Fee a9 /7 � 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) a g 7, Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2013-0638 r APPLICANT/CONTACT PERSON SYLVAN PETER G&JEFFREY D SHOTLAND ADDRESS/PHONE 168 CRESCENT ST NORTHAMPTON (413)374-1611 Q PROPERTY LOCATION 32 HIGHLAND AVE MAP 25C PARCEL 188 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DAJAPJ ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tpeof Construction: INSTALL STAINLESS STEEL CHIMNEY LINER New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 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.