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29-163 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 CONDfTtONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TV TYPE OF INSURANCE POLICY NUMBER DATE(MDDNY) DATE(MWDDIYY) LIMITS Ml GENERAL LIABILITY OCCURRENCE 1,000,009 COMMERCIAL GENERAL LIABILITY t3[TO REiCTL'D PREMISES(Ea 0=1 ce) CLAIMS MADE ©OCCUR ny one person A , , GENERAL AGGREUKTr— 3 Z' , 'L ArjUREGATE LIMIT XPPrM%PM: PRODUCTS-CZ5MP10P AGG $ Z'UUU,uiu POLICY D PRO- JECT COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) ANY AUTO OTHER THAN —_ A A" AUTO ONLY: OCCUR a CLAIMS MADE DEDUCTIBLE RETENTION $ TORY LIMITS ER EMPLOYERS'LIABILITY tee.oee A ANY PROPRIETOR/PARTNERJEXECUTIVE OFFICER/MEMBER EXCLUDED? 'MI'Le"t If yes,describe under SPECIAL PROVISIONS below . . see, ny] EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY City of Easthampton OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Easthampton Building Inspector AUTHORIZED REPRESENTATIVE ACOAD 24(2994/06) CAI 3)q7Z-O;RQ:t 30% upon completion: $1770.00 45 Days Gi ty of Xazt4a1n:ptvn z �11834A[1t 3t4iff4 5f DEPARTMENT OF BUILDIJTG INSPECTIONS INSPECTOR 212 Main Street • Municipal Building '>o V , Nortluampton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as Lls/her construction sup:.:-,-isor. 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 your), 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 s _ V The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / P ase Print Le ibly Name (Business/Organization/Individual): LAO C 4 ito ` Address: �►� n, r�S'" - — City/State/Zip: (�tS (`� Phone.#: q13 -S Z-2-S( V Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with 4. � I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. 0 Demolition working for me in t employees and have workers' b any capacity.P tY• ,. 9. ❑Building addition [No workers' comp.insurance comp.insurance.* required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 LE] 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.❑ Other comp. insurance requited.] 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. xContractors 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: ��us Policy#or Self-ins.Lic. #: �,�'(�_ G ( � / Expiration Date: 6 2 116 Job Site Address: �� ���� Q, ! �Z�C&Lr- City/State/Zip: l oten 1�� ()(D w 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 InvestiEations 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 Sign e: Date: 0 1:3d/0 Phone#: 7 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: License Number G��or�v�� S 'a � �� ��,ua►� �'�z�lv9 Address Expiration Date X13 X L2 Sl , (4) Signature Telephone 9:Re isteiecl Home''im rovemerit Contractor, w_ Not Applicable ❑ c . �0-3� Companv N me Registration Numb r S'60322 d �� � aX�r1r1UTJ UIU�3 -- Address // l Expiration Date Giv . Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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 -Home�Owner.Egempt><on 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 buildinE 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 maybe 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 J t. '. ,... SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House [] Addition ❑ ReplacemenX]plfipdows Alteration(s) [❑ Roofing ❑ Or Doors (r-v Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [p Siding[f]] Other[[3] Brief Description of Proposed Pmo�e ���Sfi rie�� W,t1Cma I)CA 4 lww Work: Alteration of existing bedroom Yes 0 Adding new bedroom Yes No _ Attached Narrative Renovating unfinished basement Yes _ No Plans Attached Roll -Sheet 6a.] Nia*house-and oradtlifi Sri`#o`existing houstna:complete the follow rlg: 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 D4V as Owner of the subject property r hereby authoriz e M-4 0A �c C"-� I o to act on my behalf,ih all matters relative to work au t prized by this building permit application. _Q Signature of Own r Date I, 1l[l tin lam- as Owner/Authorized Agent hereby declare that the statements a d 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 ell 1, e 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 _ parking) ##of Parking Spaces Fill: (volume&Location) A. Has a Special Perm it/Variance/Findin ver been issued for/on the site? NO 0 DONT KNOW rV YES 0 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 0 DONT KNO YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Date Issued: C. Do any signs exist on the property? YES 0 NO 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, ex vation,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. "'"wkr QeparfineRt UStr only, City of Northampton Statrr�l Eeiml Building Department urb Cr�t/QrnrewayPerrn�t ,i s l Vr 21,2 Main Street SgHrerlSeptrc Rya labElrt�r U Room 100 1Nater/Weli Arca�iabiGrt Northampton, MA 01060 Two Sets'ofStructural Ptaixs f or5l 0413-587-/1240 Fax 413-587-1272 P�ottslte Ptans OtherSpecify . ;> AF LICATION TQ CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTidN 1 -SITE INFORMATION - T his-section`to be completed by office 1.1 Property Address: PMap Lot Unit f (' �� 0)0� Overlay District WC�3 Elm St Dutnct y CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 64 0,.. y. "1 c Aaaj plmi) h f>e�Nu-. Name(Print) '. Current Mailing�Address: �—e- � T le" one Signature 2.2 Authorized Agent: Name(P Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building $ i (a)Building Permit Fee S U 2. Electrical (b)Estimated Total Cost of Construction from'6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection --Wy _ 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date d6b ! i i I I I I 48 HICKORY DR BP-2007-1080 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29- 163 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-2007-1080 Proiect# JS-2007-001730 Est. Cost: $5500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Thomas C McCarthy 100364 Lot Size(sq. ft.): 17859.60 Owner. DE TURCK HENRY M&BETTY law Zoning URA Applicant: 'i'horrias C, wicuannv AT. 48 HICKORY DR Applicant Address: Phone: Insurance: 3 BRODERICK ST (413) 527-5141 Workers Compensation EASTHAMPTONMA01027 ISSUED ON. TO PERFORM THE FOLLOWING WORD .INSTALL REPLACEMENT WINDOW 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: ()K G 6' 21 10 7 Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: Oh a7. 7- •r�t THIS PERMIT MAY BE REVOKED BY THE P& OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL IONS or Certificate of Occu anc si nature: FeeTvpe: Date Paid: Amount: Building $25.002434 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 4 w ' WWW.RUGGLUMBER.COM Email: TCMGCI @AOL.COM Henry Deturck 413.584-0878 4/30/2007 48 Hickory Road Same Florence,MA 01062 Same MA HIC#100364 Exp 5/16/08 MA Const.Supervisor#053221 Exp 5123/09 Estimate for the replacement of a bow window at the above listed address. This Estimate includes removing the existing bow window, preparing the opening for supplying and installing one Pella bow window; five casement-units, of these the middle three will be stationary and the two end flankers will be operable. This unit will be white exterior, clad, with a wood interior, all glass to be Low-E insulated glass, two operable sashes will have two full-screens, standard hardware is included. We will finish the top exterior with white vinyl soffit to match existing. The underneath will be insulated with foam panel insulation and finished to match the siding. The interior,we will finish the wood trim, head &seat to match existing house trim, stain, poly. We will supply and install removable standard grids for all windows, stain& poly the interior and paint the exterior white. We will remove and re-install the aluminum awning on the exterior. All rubbish removal and cleanup is included. Add for Northampton Building Permit. Fifty aim hundred and xx/100....................................... -5J908�@" 20% Down for ordering &scheduling: $ 1180.00 50% Upon Start: $2950.00 30% upon completion: $1770.00 45 Days