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29-188 prom: 10/03/2007 11:05 #050 P.001/002 ACC?RD CERTIFICATE OF LIABILITY INSURANCE PRODUCER (413)569-292$ FAX: (413)569-2949 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION FSC Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 617-F College Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 259 Southwick MA 01077 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A:Nautilus Insurance Clark Dore Contracting tNSURERB:Hanover Insurance INSURERc:American Home Insurance 442 Silver Street INSURER D: A swam NA 01001 i INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREIAENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THfS CERTIFICATE MAY BE fSSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. REG kTE LIMITS SHOWN MAY HAVE 4REDUCED Y PAID CLAIMS, NSR ADD'L TYPE OF INSURANCE POLICY NUMBER QA CY EFFECTIVE�U,�EXPIRATION L UAITS GENERAL LIABILITYgD1 1,000,000 X COMMERCIAL l3ENEFWt LIABILITY DAMAGE TD RENTED $ 50,000 A CLAIMS MADE ❑OCCUR MC690519 8/9/2007 8/9/2006 MED EXP An $ 5,000 INJURY $ 1,000 000 GENERAL AGGREGATE $ 2,000,000 GOVL AGGREGATE LIMIT APPLIES PER: is 1,000,000 POLICY PRO AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO ADN0442411 06/12/2007 06/12/2008 (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ lOb,000 X SCHEDULED AUTOS (Perwson) HIRED AUTOS BODILY INJURY $ 300,000 NON-0WNED At/7OS (Per acc�Ot'tnl) PROPERTY DAMAGE $ 100,000 (Per acciden3) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN rB.QG.r. S AUTO ONLY: AGG EXCESSIUMBRELLA LIABILITY EArHQ PH. $ OCCUR El CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION c WORKERS COMPENSATION AND TWIWI A - OTH- ANYPR ERIETOR LITY WC00994587000 06/10/2007 06/30/2008 000,000 ANY PROPRiETORlPARTNEWEXECUTNE / � E.L.EACH ACCIDENT 1, OFFICER/MEMBER EXCLUDED? N yes,eescrroe under 1,000,000 SPECIAL PBOMQNS below i F1-DaeaF-wLtcy LIMrr IS 1,000 000 OTHER DESCRIPTION OF OPERATIONSILOCAT IONSNEMICLESMXCLUSIONS ADDED BY ENDORSEMIENTISPECIAL PROVISIONS Contractor Carpentry -The Workers' Compensation policy does not provide coverage for Clark Dare" Sob Site: Walter Dragon 142 Deerfield Dr., Florence, MA CERTIFICATE HOLDER CANCELLATION (413)587-1272 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Northampton EXPIRATION DATE THEREOF, TW ISSUING INSURER WILL ENDEAVOR TO MAIL Northampton, MA 10 DAYS WRITTEN NOTICE TO THE CERTfftCATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO LL IMPOSE NO OBLWALMON OR LIABILITY OF ANY KIND UPON THE ( ITS. AUTHOl�O R ,CORD 25(2001108) ©ACORD CORPORATION 1988 riS0251nIOS}.t}sa Page 1 9TZ �TtiAMp�, $� � �ITlassacf,usetfs - 0 5' DEPARTMENT OF BUILDIJG INSPECTIONS /= INSPECTOR 212 Main Street • Municipal Building Northwnpton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as iris/her construction suv._ ,- sor. 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 Office oflnvestigations d 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): t"\ �l Address: z- del City/State/Zip: 0_S4 Ak, Phone.#: �� ' 1?10 Are you ployer?Che`cK the appropriate box: Type of project(required): 1. I am a employer with 4. F-1 I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. E]New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have I g. Demolition I working for me in any capacity. employees and have workers' ❑ g Buildin addition t?No workers' comp.insurance co =- ce t 9. required.] 5. We are accorporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] - any apptican a c ec ox must a o 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. CContractors 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: ` Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: z ev City/State/Zip: Attach a copy of the workers' compensation policy de c ration 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 Invesdizations of the DIA for insurance coverage verification. I hereby cerd under t e aid ns andpenalties ofperjury that the information provided above is true and correct. Si ature: Date: r� Phone FB�oard only. Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other IContact Person: Phone#: i •T4 SECTION 8-CONSTRUCTION SERVICES License Number 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Address Expiration Date Signature Telephone S�Re istered Home I'm covemer t Contractor._ ,, ; _. Not Applicable Companv ame Registration Number Address /, Expiration Date lephone 7 A Te _ 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....... ❑ No...... ❑ 11 =Ho>r e Q er 36em r» 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-vear 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 Alterations) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [tom] Decks [M Siding[O] Other[[7] Brief Description o osed 3 , - Alteration of existing bedroop Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet fia tf f�evu Frouse anif or ac�f ian.fa. "isttn tiousrn .corn tefe,tte 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?L 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 o. s cons ruc ion wi in IO lies - 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, as Owner of the subject property hereb authorize to on my behalf,in all matters re alive work authorized th' building permit application. Date I, 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 v 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 Repartment Lot Size Frontage Sctbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved 11 of Park (volume&Location) A Has it/Variance/Finding ever been issued for/on the site? ""`" . =.°~ ^_�� . —'__-- IF YES, date issued:, IF YES: Was the permit recorded ot the Registry ofDeeds? �� NO �� DON7KNOVV 0 YES IF YES: enter Book Page, | and/or Donumont# / B. Does the site contain a brook, body of water urwetlands? NO 0 DON KNOW 0 YES 0 IF YES, has o permit been or need to be obtained from the Conservation Commission? Needs tobeobtaiomd x~� Qb�aiamd x�� Date �~� �~� ' � C. Du any signs exist on the property? �� y? Y[S �~� NO �./ IF YES, describe size, type and location: | --'---'----- D. Are there any proposed changes toor additions nfsigns intended for the property? YES x~� NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre nrioit part nfa common plan that will disturb over 1acre? YESK��) NO K��) IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i r Deparfrrterst use only City of Northampton Statusoft irr—r NI `fin-�.t. - � . .. Building Department Cti bF�E,u tvew�,Pre�nt „ 212 Main Street Sewe� ep cAwartabtity� � �� r � 2 � n a Z V,r Room 100 YtatdfAVelt ifAb�� "''-1 Northampton, MA 01060 TvriaBetsofStru�ctcxaTPCns� �� (j, phone 13-587-1'?40 Fax 413-587-1272 Pto(S►te Plans , APPLI_fATION TO,C . , STRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECT101�41 =SITE INFORMA ON' 1.1 PropertvAddress: This section to be completed;byoffice ' L/Z 1�✓ � � Map E of Unit ��/� � Zone OveElayD�strict. Eltrt_St District :_ CB D�strryt ' W , _ SECTION 2-PROPERTY Owl�ERSHIPJAUTHORIZED AGENT 2.1 Owner of Record: -&) -ZA' z�eA N me P. t) `� Current Mailing Address: Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED COI ISTRUCTI.ON COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (r� (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) Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Cc mmissioner/Inspector cf Buildings Date BP-2008-0365 GIS#: COMMONWEALTH OF MASSACHUSETTS 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-2008-0365 Project# JS-2008-000525 Est. Cost: $6600.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CLARK L DORE CONTRACTING 128355 Lot Size(sq. ft.): 18469.44 Owner: DRAGON WALTER S&EMILY C Zoning: URA Applicant: CLARK L DORE CONTRACTING AT. 142 DEERFIELD DR Applicant Address: Phone: Insurance: 442 SILVER STREET (413) 733-4080 O WC AGAWAMMA01001 ISSUED ON.101512007 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing ]:nspector 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 10/5/2007 0:00:00 $25.003069 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo