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15-024 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS 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 certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) ACORD, CERTIFICATE OF LIABILITY INSURANCE /27/AA/DD/YYYY) 6/27/2008 PRODUCER Phone: 413-538-7444 Fax: 413-536-6020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION James J. Dowd & Sons ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 14 Bobala Road HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 10300 Holyoke MA 01041 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Commerce Ins. 34754 Associated Building Wreckers, Inc. INSURER B: 352 Albany Street INSURER C: Springfield MA 01105 INSURER D: INSURER E: 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 CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I NS R DD' POLICY EFFECTIVE POLICY EXPIRAN LTR N R POLICY NUMBER YY M Y TIO LIMITS GENERAL LIABILITY EACH OCCURRENCE $ A A COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $ CLAIMS MADE [--]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'LAGGREGATE LI MIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC A AUTOMOBILE LIABILITY 07MMZP4610 4/22/2008 4/22/2009 COMBINED SINGLE LIMIT $1,000, 000 ANY AUTO (Ea accident) ALLOWNEDAUTOS BODILYINJURY $ X SCHEDULEDAUTOS (Per person) X HIREDAUTOS BODILYINJURY $ X NON-OWNEDAUTOS (Per accident) PROPERTYDAMAGE $ (Per accident) GARAGELIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTOONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FI CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WC STATU- OTH- WORKERS COMPENSATION AND 13 TRY LIMITS I I ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ It yes,describe under E.L.DISEASE-POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate Holder is named as additional insured per written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER Ed Jazab WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE 9 Shepherds Hollow Rd CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO Leeds MA 01060 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATI ACORD 25(2001/08) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS 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 certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S(2001/08) 2 of 2 #S43859/M41411 Client#:27633 ASSBUI DATE ACORUM CERTIFICATE OF LIABILITY INSURANCE 06/27/2008YYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Chittenden Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 1391 Main Street,3rd Floor ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Springfield,MA 01101 413 781-6871 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Steadfast Insurance Co Associated Building Wreckers,INC INSURER B: American International 352 Albany ST INSURER C: Springfield, MA 01105 INSURER D: INSURER E: 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 CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MM/DDhY DATE MM/DD/YY A GENERAL LIABILITY GLO586686403 03/15/08 03/15/09 EACH OCCURRENCE $1,000,000 To COMMERCIAL GENERAL LIABILITY DAMAGES( RENTED $100000 E.CLAIMS MADE 51 OCCUR MED EXP(Any one person) s5,000 X PD Ded:10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY X PRO JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY SE0903618301 03/15/08 03/15/09 EACH OCCURRENCE s5,000,000 OCCUR X❑CLAIMS MADE AGGREGATE $5,000,000 RDEDUCTIBLE $ X RETENTION $10000 $ TATUS1 FA OTHER WORKERS COMPENSATION AND 6986797 02/01/08 02/01/09 TWO C SLIMIT X DER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 Pollution CPL903860901 03/15/08 03/15/09 $1,000,000 occurrence $2,000,000 aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Job Site:9 Shepherds Hollow RD, Leeds,MA Certificate Holder is named as additional insured under general liability as required by written contract for work performed by insured subject to terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Ed Jazab DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 'An_ DAYS WRITTEN 9 Shepherds Hollow RD NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Leeds,MA 01053 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S43859/M41411 JMG © ACORD CORPORATION 1988 Massachusetts Department of Environmental Protection m.____ ■ Bureau of Waste Prevention • Air Quality 100073985 i BWP AQ 06 Decal Number Notification Prior to Construction or Demolition C. General Construction or Demolition Description (cont.) 6. a. If this is a demolition project,were the structure(s)surveyed for the presence of asbestos containing material (ACM)? 0 Yes 0 No If yes,who conducted the survey? N/A c.Division of Occupational Safety Certification Number 07/07/2008 �� 09/02/2008 _ 7. Construction Or Demolition: a.Start Date(mm/dd/yyyy) b.End Date(mm/dd/yyyy) 8. a. For demolition and construction projects, indicate dust suppression techniques to be used: [� seeding paving b. If other, please specify: �✓ wetting shrouding ® covering other 9. For Emergency Demolition Operations,who is the DEP official who evaluated the emergency? a.Name of DEP Official b.Title c.Date mm/dd/ of Authorization d.DEP Waiver Number D. Certification co I certify that I have examined the JOHANNA SAVAGE �O above and that to the best of my a.Print Name s0 knowledge it is true and complete. The signature below subjects the b.Authorized signature N signer to the general statutes DEMO COOR o regarding a false and misleading c. osi ion i e o statement(s). ASSOCIATED BUILDING WRECKER, INC. � ffdR resentin °cD e.Date(mm/dd/yyyy) A O �Q � ag06.doc•10/02 BWP AQ 06•Page 3 of 3 ti Massachusetts Department of Environmental Protection ,,. Bureau of Waste Prevention . Air Quality 100073985 BWP AQ 06 Decal Number Notification Prior to Construction or Demolition General Statement:If B. General Project Description Cont. asbestos is found during a Construction or 4. General Contractor: —•-�- Demolition ASSOCIATED BUILDING WRECKER, INC. operation,all responsible parties a.Name must comply with 352 ALBANY STREET 310 CMR 7.00, b.Address - 7.09,7.15,and SPRINGFIELD 01105 Chapter 21 E of the MA�� General Laws of c.Cijeh wn d.State e.Zi Code the Commonwealth. (412-3179 This would include, f.Tene Number but would not be limited to,filing an ANW MIRKIN _,_„_ asbestos removal h.On-site Manager Name notification with the Department and/or a notice of release/threat of C. General Construction or Demolition Description release of a hazardous substance to the 1. Construction or demolition contractor: Department,if --- �� applicable. ASSOCIATED BUILDING WRECKER, INC. - a.Name - 352 ALBANY STREET b.Address SPRINGFIELD [MA � 01105 �� c.Cit /Town d.State e.Zip C� ode E(43 732 732-3179 f.Tele hone Number area code and extension .E-mail Address o tional ANDREW MIRKIN n-site Manager Name 2. On-Site Supervisor: FRED VANDERHOOF On-Site Supervisor Name 3. Is the entire facility to be demolished? ✓] Yes El No N —-0 4. Describe the area(s)to be demolished: 0 ENTIRE EXISTING FIRE DAMAGED STRUCTURE. �N �O 0 5. If this is a construction project, describe the building(s)or addition(s)to be constructed: N/A ( E O _....-..,,,.___.�.� _ _._......-�.... _ e� -Q � ag06.doc•10/02 BWP AQ 06•Page 2 of 3 Massachusetts Department of Environmental Protection Bureau of Waste Prevention . Air Quality 100073985 l Decal Number BWP AQ 06 Notification Prior to Construction or Demolition Important: A. Applicability When filling out pp y forms on the computer,use only the tab key A Construction or Demolition operation of an industrial, commercial, or institutional building, or to move your residential building with 20 or more units is regulated by the Department of Environmental Protection cursor-do not use the return (DEP), Bureau of Waste Prevention-Air Quality Control Regulations 310 CMR 7.09. Notification of key. Construction or Demolition operations is required under 310 CMR 7.09 (2)ten (10)days prior to any work being performed. The following information is required pursuant to 310 CMR 7.09. B. General Project Description 1. a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied Instructions residence of four units or less?2 Yes [:] No 1.All sections of b. Provide blanket decal number if applicable: Blanket Decal Number this form must be completed in order to comply with the 2• Facility Information: Department of Environmental RESIDENTIAL STRUCTURE °-- Protection a.Name notification 9 SHEPHERDS HOLLOW RD. „_ requirements of b.Address 310 CMR 7.09 MA 01053 Palmer � c. it /Town d.State e.Zi Code f.T le hone Number area code and extension E-mail Address o tional 3,036 � h.Size of Facility in Square Feet i.Number of Floors j. Was the facility built prior to 1980? Yes No k. Describe the current or prior use of the facility: FIRE DAMAGED RESIDENTIAL STRUCTURE I. Is the facility a residential facility? Z✓ Yes E] No o m. If yes, how many units? Number of Units —0 3. Facility Owner: �N ED JAZAB 10 a.Name 0 9 SHEPHERDS HOLLOW RD. b.Address LEEDS MA 01053 co ff(978) wn tate _ i d 486-9253 _ I o f.T I h n Nor ¢gr(area c�dP and PxtPnsinnl q.E-mail A�1rgS ti nal _mod ED JAZAB _, �Q h.Onsite Manager Name � ag06.doc•10/02 BWP AQ 06•Page 1 of 3 07/0312008 08:49 4137883143 VERIZON PAGE 01 Y I tJ L um n V L 1 I I U N 3.3JN-27-2008 08;12 F'ron: 413734G224 To:41373413123 A m-aftW: 392,A,Tbiny Ss.,6prkV5c1d,MA 01145 m /r��}` Tcl:(413)732-3179/(809)4¢ -2822 �r�+ � r� Fax;(413)734-6224 DA'Z'E: ,curie 277 2008 TO: SERVICE DM. . FAX # 413-734-5123 OF: V£I iZON PHONE # 413-750--3501 k'I.E,ASE CUT AU SERVICE AT THE LOCATION OF 9 Shepherds Hollow Rand, heeds, MA,AS IT IS BEING SCHEDULED rOR DWOLITION. ONCE DISCONNECTION HAS BEEN CQ 1 ETED,YOU MAY EITHER SIGN EEI OW C AND FAX IT TO ME AT 413-734-6224 OR YOU MAY FAX ME NO'F1FZWION ON YOUR COMPANY LF,1'IERHEAv THANK YOU MY MUCH FOR YOUR ASSISTANCE. SNNCEREC.Y, ASSOCIKMI) BUILDING h£KS,INC. i )OAME SAVAGE DEMOLITION COORDINATOR SERVICES AT: 9 Shepherds Hallow Road,Leeds,A4A HAVE BEEN DISCONNECTED AS OF F'R NT NAME: SIGNATURE: REMARKS,IF ANY: ciicz r '� f *W TQTgL FADE.01 07/08/2008 08:07 27681 rvMAMt-IUN IYIGIGI[ --nationalgrid July 8,2008 ,Associated Building Wreckers 352 Albany St. Springfield,MA To Whom It May Concern, This is to verify that National Grid has removed the electric service and meter #7$557051 at 9 Sheperds Hollow Rd., Leeds, Massachusetts, effective July 7,2008 and is safe for Building Demolition. Sincerely, im Nichols Supervisor Distribution Design JN/ekp 548 HaOerA file Road,I_eods,MA C1053_■ wwanationalgddmm Bay State Gas Company June 27, 2008 Associated Building 352 Albany St Springfield, Ma 01101 Dear Associated Building, The address listed below has had the gas service(a) disconnected and is now ready for demolition. ADDRESS: 9 Shepherds Hollow Rd TOWN : Leeds STATE : Massachusetts Sincerely 'Perri Hiner Workforce Planning 2026 RooseveR Avenue P,O.Box 2025 Springfield,MA 01102.2025 413.781.9200 Fax:413.781.9222 DIG SAFE SYSTEM, INC. - Dig Location Page 1 of I Request Number 20082600732 Date 06/23/2008 Time 08:35:56 Start Date 06/27/2008 Start Time 10:00 Location Info. MASSACHUSETTS NORTHAMPTON 9 SHEPHERDS HOLLOW ROAD Member Utility List Code Abbreviation Name MC MASSEL MASS ELECTRIC COMPANY SP VERIZN VERIZON TV COMCAS COMCAST WG BSTGAS BAY STATE GAS ON ONTARG ON TARGET LOCATING RJ IDM INNOVATIVE DATA MANAGEMENT • There may be non-member utilities in the area that you need to notify. • Electric and other companies may not mark lines they don't own or maintain. You may want to contact them for more information. • The excavator is responsible to maintain markings placed by member utilities... DIG SAFE ENCOURAGES A COPY OF THIS ELECTRONIC TICKET ON SITE AT ALL TIMES. Create New [ Create From Existing Return To Menu Return To Home http://digsafeform.digsafe.00m/cgi-bin/dlcgi.exe 06/23/2008 L,,O,L , IN 352 Albany Street, Springfield, Massachusetts 01105 Tel: (413)732-3179/ (800)448-2822 Fax: (413)734-6224 May 30,2008 Ed Jazab 9 Shepherds Hollow Road Leeds,Massachusetts 01053-9707 Thank you for the award of this contract. For the sum of and salvage rights,we agree to demolish the fire damaged house and garage located at 9 Shepherds Hollow Road,Leeds,Massachusetts. Associated Building Wreckers work includes: 1) Demolition of the house and garage and removal of all non-hazardous debris to an approved facility,leaving the concrete foundations and slabs in place. 2) Notifying Dig Safe and arranging for the disconnection of services. 3) Taking out the demolition permit and furnishing a certificate for demolition general liability and workers compensation insurance,upon request. 4) Using water for dust control,as needed. Ed Jacobs (insured) will be responsible for: 1) Any service disconnection charges,if any. 2) Obtaining any historical permits or special notifications,if required. 3) Any repair to driveway,landscaping,concrete and/or septic system damaged during demolition in the work area. 4) Any damage to underground services that Dig Safe and/or Ed Jacobs has not made us aware of(including,but not limited to,underground sprinklers,roof drains and septic systems). 5) An asbestos survey,as required (cost is approximately$800.00-$1,000.00). 6) Cost associated with any hazardous materials found at the site. 7) Marking out-septic tank and/or well with stakes prior to demolition,if applicable. 8) Marking the property for Dig Safe. 9) Making the job accessible to work by clearing debris from in front of the house. Leaving access roads to back yard clear. 10) Arranging for Travelers of Massachusetts to make direct payment to Associated Building Wreckers,Inc.,in full,upon completion within twenty (2 1) days. Option #1: While on site,if the chimney needs to be removed add$600.00 to our price. Ed Jazab acknowledges that he is the owner of the property and is not in bankruptcy or petitioning for bankruptcy. Any balance that becomes past due for any reason will be charged a service charge of 1.5%per month, 18%annually. If it should become necessary to turn this account over for collection,the billed party agrees to pay all collection costs plus reasonable attorney's fees incurred. Ed Jazab is unaware of any hazardous materials or wastes on the property and knows of no legal reason,regulation,or other circumstances,which might prevent or in any way interfere with the right or ability of Associated Building Wreckers,Inc. to perform the above work if any hidden conditions do exist on this job,they are the owner's responsibility. Sincerely, Associat uilding Itrs,Inc. Agreed and Acce ted: /t By: X01812006 Steven Hill,Estimator Ed Jazab, er Date Option#1 Agre an Accepted: By. , a L�-8 Ed Jazab,O ner Date P:\Msword\DEMO_CTRTS_2008\9_Shepards_Hollow_Rd_Leeds_MA.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 Worker's Compensation Insurance Affidavit uas•• Name: Location: City Phone# ❑I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity Ni R F .pi rr""a' 4. •� .�S j' Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1500.00 and/or one years'imprisonment as well as civil penalties in the form.of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I Do hereby certify under the pains a fn7d penalties of perjury that the information providedJ above is true and correct. Signature 's ,( V� Date 1 Print Name f' okma) ,�Cw Phone# '7 j) Official use only do not write in this area to be completed by city or town official City or Town: —Permit/License# ❑ Building Department ❑ Licensing Board ❑ check if immediate response is required ❑ Selectmen's Office ❑ Health Department Contact Person: Phone# ❑ Other (revised 3/95 P/A) SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: No t Applicable ❑ Name of License Holder: ��[I C rY 4 4 1,(Il I n Pr J0(�� License Numb pr qij �j 'G1lcc,r Ld c)(tlill 11 A 11flOf� ID/,3!��� � dr ss Expiration Date Signature Telepl o me 9.Reaistered Home Improvement Contractor: Not Applicable Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(i)77 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 build' g permit. Signed Affidavit Attached Yes....... IV No...... ❑ 11. - Home:Owner Exemption The current exemption for"homeov..mers"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�o 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 ur:der 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) D Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition New Signs [❑] Decks [❑ Siding[[3] Other[❑] Brief Descriptionof Description Proposed Work: ! C� ors c�i�//n"/IMa Lmulaz?�i f1/ �fyrr� c�' fir /« ff�b'lrr�l�lc�l��'f 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 houstha, 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(ItIP 174f/IL i. Is construction within 100 ft. of wetlands? Yes `V 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 V/ City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS ,�AGENT JOR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �(�.?�: 1� as Owner of the subject property �i hereby authorize )QUO h11V MJ _.71?c• to act on my behalf, in all matters relative to w authorized by this building permit application. Sigr ature of Owner Date I, l yltr y/I/(lfft Pl� d'd A55 �/C (� (���(!�/��%�O ��L)�k,C as Awrzer/Authorized rl Agent hereby declare ttfat the statements and information on the ftrregoing application are true and accurate,to the best of my knowledge and belief. X ned under the pains and penalties of perjure. l nt am p� Signature of Owner/Agent Date r • 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 Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW ® YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW Q YES Q IF YES: enter Book Pagej, and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, typf-:and location: D. Are there any proposed cha.yges 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,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? (ES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. A R 3y '2 T.k City of Northampton Building Department 212 Main Street Room 100 A Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 �� � �� u ' r APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: �q '�_{Q l "d This section to be completed by office �(s: T� tU h A �LI-5 V l.0 ill. Map Lot O Unit cu ;l nCS j k1 Zone Overlay District I- ILC Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: fC1`�CCzGh q t5h j f'5 /-I-,/ Giv° f. ,CUCLs 14 01G7 . Name 7(,Print) r�_( (� I {�/a/l Current M fling Address: j/ 1/I I l�. 1 l I Q I�1 I lr t �n I o 1 id 1 �I 1/ �/l r Telephone "j S nature / / ,` 7 2.2 Authorized Ascent: 45SOCI(�(��,�//!('/117 VY�(Aet5,1�(., 1���'/�!/'/sl �_3 .�i ,� S 1/ra Na (Pri t) 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 (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=0 +2+3+4+5) Check Number ' This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2009-0033 �y APPLICANT/CONTACT PERSON Associated Building Wreckers Inc ADDRESS/PHONE 352 ALBANY ST SPRINGFIELD (413)732-3179 PROPERTY LOCATION 9 SHEPARDS HOLLOW-CHESTERFIELD RD MAP 15 PARCEL 024 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction:_DEMOLISH FIRE DAMAGED STRUCTURE,LEAVING SLAB&FOUNDATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 062382 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO"ATION 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 -o -C rr-t,t. 7 n 4 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. Old RT }° BP-2009 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-2009-0033 Project# JS-2009-000044 Est.Cost: Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Associated Building Wreckers Inc 062382 Lot Size(sq. ft.): 43560.00 Owner: JAZAB EDMOND A&BARBARA M Zoning:URA Applicant: Associated Building Wreckers Inc AT. 9 SHEPARDS HOLLOW - CHESTERFIELD RD Applicant Address: Phone: Insurance: 352 ALBANY ST (413) 732-3179 Workers Compensation SPRINGFIELDMA01105 ISSUED ON.71912008 0:00:00 TO PERFORM THE FOLLOWING WORK.-DEMOLISH FIRE DAMAGED STRUCTURE,LEAVING SLAB & FOUNDATION 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 VIOLAT ON OF ANY OF ITS RULES AND REGULATIONS. - C_p 1 , Certificate of Occupancy Signature: - FeeType• Date Paid: Amount: Building 7/9/2008 0:00:00 $35.00301536 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo