Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
44-022
The Commonwealth of Massachusetts Department of Industrial Accidents w Office of Investigations d 1 Congress Street, Suite 100 �= Boston, MA 02114-2017 v www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 21 Al City/State/Zip: IV G ra 6VS3 6 Phone #: tea'8 -%Y3% Are on an employer? Check�the appropriate box: Type of project(required): 1I am a employer with ?`/ 4. ❑ I am a general contractor and I 6 E]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, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.F] 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#I 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: Yet y_1e,1-S — Policy#or Self-ins. Lic. �43 Expiration Date: ( �� Job Site Address: ��0 Z644'/ 1241 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: uu6 un cUIJ 10: 13AM MANCUSO NOWAK INSURANCE 15087526712 p. 2 A�,,,,.°.-R° CERTIFICATE OF LIABILITY INSURANCE 10/412013"' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLLER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(NIS)must be endorsed. If SUBROGATION 19 WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certiffcats holder In Neu of such endonemen s. PRODWER aw.OT Angela Rel2y Mancuso-Nowak Insurance Agency Inc. PHONE (508)756-431D (aoerTas-6712 252 Boston Turnpike Rd. E'*k aka11 @msnau,so-norak.com INU 8 AFFOR004COVE-RAGE N"# Shrewsbury MA 01545 sreURERA.W"tQrn World 13579 8018 INSURED weuRER s:Travelers Ind. Cc of IL-ARATC Northeast Hone 6 Energy, Inc, INSURE c: 21 North Main Street INSURER D: INSURER E; No. Grafton MA 01536 COVERAGES CERTIFICATE NUMBER-13-14 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOWATHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH16 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. t TYPE OF INSURANCE POLL UWTD GENERAL LWeimy EACH op-M RLMCE S 1,000,000 X COMMERCHU.GENERALLMBILrTY I '1'rj}I� S 0000 (FA a0MROM)Pl CLAIMS-MADE ®OCCUR 1318954 0/4/2013 0/412014 MED EXP YVW one S_ 5,000 ' PERSONAL a ADV INJURY S 21000,00 GENERAL AGGREGATE : 2,000,000 GENLAGGREGATEUMITAPPLIESPER: PRODUCTS-COMPIOPAGG S 1,000,000 X POLICY P LOC $ AUTOMOME LIABILITY pNGM OWN ANYAUM BODILY NJURY(Pa Parson) S ALL ED SCHEDULED BODILY INJURY(Pwamid nt) S HIRED AUTOS AUTO$ g S UYB MLA WAS OCCUR EACH OCCURRENCE S IDIO 8 UAD C1.04II-MADE AGGREGATE S DED I I Rummow i $ WORKERS CONIPENSArON S BTU O ANO EAIPLOYERS'LNAWLrrY & ANY PROP RIErORNPARTNERIDIECUTWE YIN E L EACH AOCIDENT $ S00,000 OFflCERMESMER EXCltJ0ED9 NIA P-ft"InNIO 045255-9-13 /15/2013 /15/2014 E.L DISEASE-EAEMPLOY S 500 000 r>!w,daaatDe unrAr DEBCRO7TION OPERATq E.LDISEASE-FOUCYL4UT S S00,000 DE5CIBP7I014 OF OPIRATIONS/LOCATIONS!VENICLEB{Math ACOIID 104,Addw wW Ramoft kheduk,M more space Ia rj9Aradl CERTIFICATE HOLDER CANCELLATION .SHOULD ANY OF THE ABOVE DESCR9D POLICIES BE CANCELLED BEFORE THE EMRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, A11THORCM IMPR981W^7 VE Joe Mancuso/buavu l ACORD 25(2010JOti) 0 1988 2011 0 ACORD CORPORATION. AN rights reserved. INS025(2010mol The ACORD name and logo are registered marks of ACORD MASS. REG.#106353 r R.I. REG.#6634 ® NHOME & ENERG east CONN.REG,#005339919 A„rt RPY� 21 N. MAIN STREET(RT. 140) • NO. GRAFTON, MA 01536 r►� �7 (508)839-7001 • 1-800-828-7001 �J ql 3 S l��g /We, the Owner of the premises mentioned below, hereby contnict Frith :uul authon/e you as Contractor. to furnish ull necesuiry m.ttetials, labor and workmanship,to install,construct and place the improvements according to the following specifications.terms and conditions,on premises below described with reference to which we wan.mt roc are the record holdeArs of title. C/- '/ p �t 2 / OWNER'S NAME: 5 JE _ _ rL!-l�'�I-/-�-�`�1i.�1-I!r/��---- �._—"I'1.1..: 7 3 -Tb 6 (n 77`7 JOB ADDRESS: 348 � P)L_L. � Ih-LQ�NCf� - CI 1, _— STATF,: r--A 7_IP:=,i 11 EMAtt,ADDRESS: L� N 1 - _` {�01.t ck M -----_--_----- cEI_L SPECIFICATIONS M,LLL_6AF VXIcGCz1S, Ah) --CA 1 Sr�G 6A 6l S fl lnrzec E"M_�_TE �5 _u_.v_'D ei-6 A t1M E'.yT--- -- �t/s 7-1 G F_moo B2A.--�e�r o_ nrT_A Loves 2 r S. Ir �r �tJSTAGC. GAP T�t� i_ ”AtF.L! z � •o L stf��2cT A Fo l� Cez�2 d l,y74 7-ry E�j1i2 E CI-LO_� -__------ ------ --- A"-1w-Au�; A bb�/L 6,4l Est.Start: 0 t L- -_,_F,st.Comp,: E�_ T � /�Secority Interest: ❑YES [1 NO In Consideration1of the labor and materials supplied by the Contractor,the Owacr(s)agrce(s)to pity to the Contractau the sum of: s� Lire `M..e,..dD-v�� L-t'J�I.�—= • _6 0,0 UAWS—/ �j O O• ©O v Payable:$ T I �O < 7" �/EA�EC T- ( L}Bai�u� q �r l� —�[� on completion. THE OWNER SHALL PAY FOR THE WORK BY THE.FOLLOWING IN CASH 1 1 I/3 DEPOSIT, 1/3 HALE COMPLETED, 1/3 ON D SATISFACTORY COMPLETION. [ 1 BY BANK MOERNIZATION IRAN TO THE OWNER: It shall be the obligation of the Home Improvement Contractor to obtain such permits as the Owner's Agcnt.The Owner(s)who secure their own construction related permits,or deal with unregistered C'ontractors will be excluded from the guaranty fund provisions of MGLC. 142A. All Home Improvement Contractors and Subcoatraciors shall be registered by the Director and that any inquiries about a Contractor or Subcontractor relating to a registration should be directed to: Director Homc lntprovcmcot Contractors Registration One Ashburton Place.Room 1301 Roston,MA 02108/Tel.:(617)727-8598 FULL INSURANCE COVERAGE If the Owner refuses to permit NORTHEAST to proceed with the wort:herein,or in the event of any breach of the Owner of this agreement for any reason whatsoever shall cause the Owner to pay NORTHEAST a sum of money equal to thirty-three and one third percent of the price agreed to be paid,as fixed,liquidated and ascertain damages,and not as a penalty without Further proof of loss or damage. This Contract represents that entire agreement between the Owner and NORTI IEAST and no representative or warranty shall be binding upon either party,untess included herein. Homeowner agrees to pay for all work set forth herein. If the Homeowner defaults, Homeowner agrees to pay all costs of collection including reasonable attorney's fees in addition to other damages incurred by Contractor.All 189,per month service charge will be assessed for Lill payments made after 10 days of clue date per the schedule above. In the event of default the Contractor may seek to place a uniform commercial code lien, Mechanic's lien,or other lien on the Homeowner's property in order to secure any amounts due to the Contractor. You are entitled to a copy of the Contract at the time you sign.Keep it to protect your legal rights.We,the aforesaid Owners,certify that immediately after the signing of the aforesaid agreement,a copy was furnished to us. BUYERS'RIGITT'ro CANCEL You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the separate Notice of Caucellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IT THERE ART NY BLANK SPACES. N WITNESS WHEREOF,the parties have hereunto signed[heir names thisy � day of A" Marketing Representative Accepted by _ _Sigrid Authorized Signature Owner NORTHEAST Massachusetts -Department of Public Safety Board of Building Regulations and Standards y Construction Supen isor Specialty -� License: CSSL-099195 RICHARD T PRU$M 115 SYCAMOREM HOLDEN MA Of520 .q. -` \ i 111�J Expiration Commissioner 06/2212015 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 106353 Type: Private Corporation Expiration: 7/22/2016 Tr# 254758 NORTHEAST HOME & ENERGY, INC. Richard Prunier 21 N. Main Street N. Grafton, MA 01536 Update Address and return card.Mark reason for change. Address 0 Renewal [ Employment ❑ Lost Card SCA 1 w 2OM-05/11 &.1/eanimo�aurea!l�a��laasactccselts Office of Consumer Affairs&Business Regulation return License or registration valid for indi u use only before the expiration date. If found to: ME IMPROVEMENT CONTRACTOR gistration• -0$353 Type: Office of Consumer Affairs and Business Regulation xpiration: -Z/2212616., Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 NORTHEAST HOME 8 1`IV RGY INC. I I Richard Prunier i 21 N.Main Street N.Grafton,MA 01536 Undersecretary Not valid without signature SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: R' 1G1=�AlV� �R nl t� GSSL - 09 9 1 4S License Number 1 S $yCa4r,--or^e- hp;.j g , 16L,DENI MA o f 5ZO 1 2-2Z 1Zo!„- Address Expiration Date ,,.�,� n11 2�f C So 0 g 3 9 - 70 d I Signs re Telephone $.Resflstered Home llmorm ment Contractor: Not Applicable ❑ NO2TtrEA S'r tiO lM E e (-OEgA" , ZN C• 1010 35l� Company Name Registration Number 21 N . MA li 0 SUR-EEC '7122. 1-24110 Address Expiration bate N , �1Q.14 Pro N , M A o 1 S 3 6 Telephone6P� q' 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....... IN( 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[13] Other[dj Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes 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 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 t e 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. undkth gins and pe; Ities rjury. ` l T Signature of ner/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 arkin #of Parking Spaces Fill: volume&Location) ......... . A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES Q IF YES: enter Book ' Page; and/or Document#, B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES i 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 Q NO IF YES, describe size, type and location: AA D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO _ ----------- b 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. L a t-') City of Northampton Building Department 212 Main Street 2014 Room 100 orthampton, MA 01060&G`.ti Us t�emr4 3-587-1240 Fax 413-587-1272 A O1 60 � 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'f8 14(-Ky F 1Q, k4A.6 Map Lot Unit F LA i4.E N CE 0 1 0(o 2' Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 5`rCv-E Ao b- rc.M; St" H i lle-C { Me Ryt. =q A; 11 ".1 rIzreri a o 1 o 6 2, Name(Print) C rrent Mailing Address: 413- 56to •1233q or yi3 . 32.0 •Z939 Telephone Signature 2.2 Authorize ent: /) ( 0 N int) Current Mailing Address: r� \ z �© cG. � : O , 7 on If Signaturer I L Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. B ' ' g I -z— j�Q (a)Building Permit Fee 2. Electrical �— (b)Estimated Total Cost of Construction from 6 3. Plumbing 6- Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+.4+5) Z Check Number Wal 1 W315 This Section For Official Use Only Building Permit Number: Date a Issued: Signature: Building Commissioner/Inspector of Buildings Date 348 ROCKY HILL RD BP-2015-0260 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:44-022 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2015-0260 Project# JS-2015-000495 Est. Cost: $12500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD PRUNIER 099195 Lot Size(sy. ft.): 79279.20 Owner: SCHIRCH TAMI& STEVEN zonin : Applicant. RICHARD PRUNIER AT. 348 ROCKY HILL RD Applicant Address: Phone: Insurance: 21 N MAIN ST (508) 839-7001 WC NORTH GRAFTONMA01536 ISSUED ON:91812014 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 9/8/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner