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10D-028
URBAN & SONS INSULATION CO, INC. 385 LIBERTY STREET SPRINGFIELD, MA 01104 (413) 783-0701 • (413) 732-3922 FAX (413) 525-8116 r ustomer Name Address L � give permission to pull a permit for my City or Town home to do insulation work to be done by Urban & Sons Insulation Co. , of Springfield, Ma. Any questions please call me. 413-783-0701 7 Salesman for Urban & Sons Date �� .Tie �amn�onrueccl<<z o��.jjaxur�ufpl�t Bob of Building Regulations and Standards - - HOME IMPROVEMENT CONTRACTOR Registration: 100590 Expiration: 6/19/2010 Type: Supplement Card j URBAN 8 SONS INSULATION CO. ALAN URBAN 385 Liberty St Springfield, MA 01104 Administrator Massachusetts- Department of PUhlic S:lfct% Board of Building Regulations and Stantlartl. Construction Supervisor Specialty License License: CS SL 101878 Restricted to: IC ALAN URBAN 117 PIDGEON DRIVE SPRINGFIELD, MA 01119 Expiration: 8/18/2012 ( numi*+i mcr Tr#: 101878 Client#: 40154 URBAN DATE ACORD„ CERTIFICATE OF LIABILITY INSURANCE 3/30/2009 rrrY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Commercial Lines ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 103 Van Deene Avenue HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P - Box 339 Springfield, MA 01090-0339 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Acadia Insurance Urban 8r Sons Insulation Co., Inc. INSURERB: A.I.M. Mutual Insurance Co. 385 Liberty St. INSURER C: St. Paul Travelers Springfield, MA 01104 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISI ED BELOW HAVE BEEN ISSUED 10 1 HE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICAI ED.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 CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS D POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY LIMITS A GENERAL LIABILITY CPA018807912 08/01108 08/01/09 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $50 OOO ES(Ea occurrence) CLAIMS MADE �OCCUR VIED EXP(Any one person) $5.000 X BI/PD Ded:1,000 PERSONAL&ADV INJURY $110001000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY X PRO LOC JECT C AUTOMOBILE LIABILITY BA-718OW738-08-SEL 08/01/08 08/01109 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS - (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ X Drive Other Car ` PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG S A EXCESSIUMBRELLA LIABILITY CUA020840712 08/01/08 08/01/09 EACH OCCURRENCE S1 00O 000 X OCCUR CLAIMS MADE AGGREGATE $1,000,000 DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WMZ8005556012009 01/01109 01/01/10 WC LIMIT OR1- EMPLOYERS'LIABILITY ANY PROPRIEIORiPARTNER;EXECUTIVE E.L 000 .EACH ACCIDENT $500 OFFICERIMEMBER EXCLUDED? E L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Proof of coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL E!,OEAVOR TO MAIL _..30_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO TI 7 LEFT,BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND-JPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S42337/M42304 DMB © ACORD CORPORATION 1988 s ,. O HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state aef nes "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 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 workvanous s ages, w `c i rciade f°ouirdatiunffootin�sfbe#�re i3acl�fll), 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 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 fo sch6dule rid-Guildmg inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents ' Office bf Investig ado ns 600 Washington Street =;7_� Boston, MA 02111 , y[ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly --` Name(Business/Organizationdndividual): lT��0,V\_ S d h V-✓l�\,T f Q*7 v t Address: City/State/Zip: �� 14- Phone #: 7 Z` �a �, Z Are you an employer?Check the appropriate box: Type of project(required): 1.�am a employer with ( Z 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 8. ❑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.❑Electrical repairs or additions offic rs have exercised their -11_ Plumbing repairs or additions 3.❑ I am a homeowner-doin-a aH waFk ---- -- —e --- -- - ❑- 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. 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 employee's. 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 jab site information. �, Insurance Company Name: 1- VV\ Policy#or Self-ins.Lie.#: �� ✓�-S ( �1c�a�l Expiration Date (5 l/ l C) Job Site Address: r&� - Im t �'� S City/State/Zip: t- 'FF 1 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-$ well-as civil pen-a-1-ties-iii-the form of-a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided ubo ve is true and correct. Signature:�/ // -�- Date: Phone#: �> Z Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): - is-$card o>'-I-ealth--)mild#ng-Be¢ar-ttrtetit 3.Ci(yiTuwu Clerk.__4_Elf_ sical Inspector 5 Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES , 8.1 Licensed Construction SuII ervisor: Not Applicable ❑ Name of License Holder: 1 ci,�_ �J G r\ S L / 7 Y License Number 6 Address Expiratiorl Date Signature Telephone 9.'Re tistered.Home"-4murovemerif"d i cfor.. Not Applicable ❑ U T`�a,►•� �v S Company Name Registration Number Address Expiration D to Telephone�z 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...... ❑ 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 1-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-t-he-work-fer-whit-h-this-penni�i-&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 Taws annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors (] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[❑] Brief Description of Proposed Work: 6 -"t'C ��..5 3101 ��►'\ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa:`if New;douse-anti or"' d tit a t. ezistina=t,ous�ng,5.coriiAte#e._tfi61611owin- : 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 SECTION2 7a-OWNER AUTFIORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 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 CD Ct 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 0 DONT KNOW 0 YES 0 IF YES, date issued:? IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book F��_.._.._.�...�._.._ Page; M and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES 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 0 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 0 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 NO 0 IF YFS,then a Northampton Storm Water Management Permit from the DPW is required. � f �L3 �et use ter.. a �" �2, - `C',ity of Northampton tus �i �t wilding,Department " SK 212 Main Streete�nrerlSeptxcAvalTab rn r"r" Room`100 tar W 7I} atla tJ!' � �� ' Northampton, MA 01060 Tvu©Sets cif stcfri31 Plai �j'phone 413-587-f240 Fax 413-587-1272 PlottS tePlai s r APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -'SITE INFORMATION' This section to be completed by office. 1.1 Property Address: r J� ��`t �-i— Map Lot Unit =done Overlay District EftviSt.'District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Sig a ure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS' Item Estimated-Cost-(Dollars)-to-be Official Use Only completed by ermit applicant 1. Building �N)j v� - (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 Date Building Permit Number Issued Signature: Building!Commissioner/Inspector of Buildings- Date r � BP-2010-0029 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-2010-0029 P_roiect# JS-2010-000040 Est.Cost: $1623.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: URBAN & SONS INSULATION CO INC 100590 Lot Size(sq.ft.): 153331.20 Owner: GROUT ROBERT I&MARY L TRUSTEES Zoning:URA(100)//WP Applicant: URBAN & SONS INSULATION CO INC AT. 150 MAIN ST Applicant Address: Phone: Insurance: 385 LIBERTY ST (413) 732-3922 WC SPRINGFIELDMA01104 ISSUED ON.71812009 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION 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 7/8/2009 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo