17C-223 (8) 04i29,01 FRI 1,1-49 FAX 4135867973 BORAWSKI INSURANiE [ j002
AR WCTP -r J
ISSUING OFFICE 354 it ' Workers Compensation and
T.WORMATiON PAGE Employers Liability Policy
�WACCOUNTNO' SUB ACC£NO, Liberty Mawal lasumee Group/Roston
1-317111 1 0000 LIDERTYMUTUAL MURViCE Ca tow
POLICY NO- TA,`Cb SA:3.ES OFFICE CODE(SALES REPRESENTATIVE COI) N/R ST YEAR
WC1-31S-317111.010 X7f X STWOOD 101 ASSIGNED 3000 a 1999
Rom 1.Name of PREVENT INC
Iiswed FEIN 04.3686301
Address 38D HIGH ST
RISK ID (1104183Y
HOLYOI+:,MA 01040
Status 03 CO"ORA,TION
Other workplaces Dot shown above; SEE ITEM 4
Mo. DW yew Ma PW Yeor
Item 2.Policy Period:From 09-02-00 to 09-02-01
12:01 AM standard time at the address of the insured as stated he-rein.
Item 3.Coverage
A. Workers Compensation lnsuraacc: Part One of the policy applies to tic Workers Compensation Law of the
states listed bare:
MA
B. Employers Liability lusurance:Part Two of the policy appliesto work in each state listed in item 3A.The limits
of our liability under Part Two are:
Bodily Injury by Accident 100,000 eacli accident
,Bodily Injury by Disease 5D0,000 policy limit
Bodily Injury by Disease 100,000 each employee
C. OtherStatcs Insurance:Part Three of the policy applies to the states, if any,listed here-
SEE END WC 20 03 06A
D. This policy iacudes these endorsements and sr�hedules: SEE EXTENSION OF INFORMATION PAGE
Item 4.Premium - The prcmi=for this policy will be determinod by our Manuals of Rules, Classificatiow, hates and
Rating Plans All information required below is subject to wi-diication and change by audit- _
PremiarpHesis Reeea LINE 110
,r Eseime:cd PerS100 F�itimatPd ��
Cade TOtWAPnvoi Or Re• AUUW
CW3111cations NO ttc67usmueo muerati- Premiums
SEE EXTENSION OF INFORMATION PAGE
Minimum Premium S 272 ( MA) Total Estimated Annual Premiulu S 1,41a
Interim adjustmout of premium shall be made: ANNUAL
This policy,including all endorsements issued thcrewiti,is hereby countersigned by SEE ATTACHED FORM 1710
AulhorizEa Reprexotsti+e Date oY-12-M
T li7e.iv>c Term Opsr. Audit Basis Pe,iodkPayment R.41fngl3oAx -Pvl_H.ii. Homesuft Dividend RENEWAL OF; _
a9-1a-00 i�_Nit MA WCI-31S-317111.019
GP04030 R1 Gupyfigtd 1987 National Council on Cornpematlon 1nswarnee WCDD 0001 A
fflobeR Gory
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1�..g11� _�It_/ p Pr.:t,4pp,;cab3d G
N of i_Gense Mp9der 41.3_---_.__.
/_leer se Number
::x .ratio Date
Signature T of ephoae
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v o l Not ApGlicab!e tC2
Com an N me Regi,ttAlcr. Nurra er
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A.darc�'a Expiratiar Gate
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1Norr:c:rs Compensation !nsurance affidavit must be ccmpleted and submitted with this F pplication. Failure tc pr'nvide th s jyf davit
in the genial of the issuance cf the b jildi^.g pS2'm,t.
No...... FJ
The current exomption for"homeowners"was extended to iie:lude Owne Q_Wgllinos of one(1) or two(2),fartil'es
and to allety such homeowner to engage an individual for hire who does not possess a liceirse,provided that the owner acts
as supervisor.CMR 780, 5ixfh FdRion Section 108.3.5.1.
Definition of Homeowner.Person(s)who ovem a.parcel of land on which lae,"She resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling attar hed or detached structures accesson-:o such use and/or farm
structures.A person who constructs more than one horse in a two-Year period shall not be considered a hvraeowner.
Such"homeowner"shall submit to the Building Offlciai,or a fonn aeceptabie to the Buildine Official that he/she shat;be
responsible for all such work performed under the buildin2 permit.
As actuig Construction up_�.ri isor your presence on the!ob site will be,r eou;xed from tune to tv2ae,during and ut"or,
completion of the work for which this permit is issued.
biro be advised that with reference to wlurpter 152(Wcrkers'Compensalion) and Chapter 15'4(Lia'nihty of Employes to
Employees for injuries not resulting in Death)of the Massa& setts General Laws Annotated,yo!L maLbu liable for persoa.(s)
you hire to perform work for you under this permit.
T:lie undersigned"homeowner"certifies and assumes responsibility for compliance with 6c State Building Code,Cit}'of
Northampton Ordinances,State and Local Zoning Laws and State of'Massachuseas General laws Annotated.
Homeowner Signature
P• 0
Rpr 20 01 09:20a
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mscsyy, 61d .'S "4. {S#g'. ....°` 'w' 7 517- F
New House CZ Addition Q Replacement Windows Alteration(s)❑ RooT fing
dr Doors ❑
Accessory Bldg- C 1,•Demolition❑ New Signs [ ] Decks l Siding[ J Other[ J
Brief Jescf;ption ofProwosed'JJ:Jrk: ZI
Alteration o*existing bedroom Yes No Adding new bedroom Yes NO
Attached Narrative Renovating unfinished basement Iles _ __Ne i
?ians Attached Roll 0-Sheet n
a. Jse of bui'ding:One Family-_ Two Family;- —Other
b. Yu, ,ber of rooms in eeen fang.iiJy unit: _ Number of Bath,Z)C1 MS.
.�,�
c. Is there a garage attached?
d. Pro osed Square foota e of new con ?ruction
p q g � �� Dimensions_.— i
e. Number of stories,'— _ -___ ^�—J 2.
t, tJet'nod of heating? /�L-/ate f=ireplaces or Alocdstoves Number of each
f
} g E,ergy Ccnservation Ccrnpfiance._ _ Mascheck Energy Compliance form attached? _
l
Type of construction._4�O-vl{ /s�lK�:
i.
is co nstru ticn within 1100 ft.of wet'ands? Yes "f io. Is constrtfct'on within 104 yr. floodplain_ Yes .__N-_,
Depth cf basement or cellar floor below finished grade • ��__
k Will building conform to the Building and Zor*ig reguiaticns7 ._Yes No .
ee Dtic Tank City Sewer_ Private well, City water Supply
yEGI iiN`�rw AvrRlzA rarur § o
� ri� sz �x{ ol�T Asp pa
as Qwne-of the subjec- prcperty
re b authorize __ to act on
l y b_half, in a a .ers re Iti au e by this building permit application.
Signature of Owe ate
C3. I U V g_'E� ____ as+dwnew Aa �era
hereby declare that he statements and iriforr atlas on the foregoing application are true and accurate,to the best of my
kriowledge and bell f.
Sigr.ed under the pairs and penalties of;perjury.
4Pµ#A.%
Print i m
Signature
Apr 20 01 09: 19a P. 2
Vk!.
Section 4.
ALL LNFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENM',D DUE TO LACK. OF INFORMATION
— Existing Proposed Required by Zoning
This column to be filled in by
$uildiug Department
Lot Size
Frontage _
Setbaeks Front
Side L: 1K: L: }?:
hear ---- --__— /'
Building Height
Bldg.Sgua:•e Footage
rOpen Space Footage --- °j
(Lot area minus Eldg&paved
of Parkino Spaces —
Fill:
rbo'.::mec'~ f_oeation)
A. Has a Special Permit/Variance/Fired` g ever beer, issGed for/on the site?
NO DON'T KNOW_ YES
IF YES, date issued:�/�
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW _ YES ___--
IF YES: enter Book _ Page _ and/or Document#
B Does the site contain a brook, body of water or wetlands? NO GON'T 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 sigrs exist on the property? YES NO ✓ _
IF YES, describe size, type and location: _
D. Are here any proposed changes to or additions of signs intended for the property
No
IF YES, describe size, type and location:—_" _�_ _
P.
RPr 20 01 09: 18a
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City of Northampton
Building Department.
212 Main Street
Room 100
Northampton, MA 010650
j phone 41S-587.1240 Fax 413.587-,272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWULINu
S'-C7f!3N 1 SITE INFORMATION
z.7 Pr ert Addre s !� Thls secilao toe com (eted by at#scP
QI? Y_____�
lyl a �,R iY I.OUF—
5
SECTION 2- PROPEKTY OWNERSHIP/AUTHORIZED AGENT
_-
.1 Ow er_of Record.:
f _�_ ��l� lr�.�ect'_��!�-v�5`7`___— �17_J��d�►� a.e� _��f'_o3._.Ps�`"
1Tsa,° Pint) �. r.�i� Meiling A dl6
J1_ m ¢f• T IF !Ian
2.2 authorized Agee '
Name(Print) (_urrent(vaiiln„Address.
--
} ,gnat;.re i e.faphona
SECT!GN 3 -,EST I NIATFD CONSTRUCTION COSTS
i Il sn ES'.irra� 3
Cost I:,bh Cfficial Lase=Only
cor let�-.d b}�-nermit azpllcart _
1- Sul d r� � (a)B dairg Permit Fee
2. Ele lrival M Estimated Total C,�St of
___ �__ f ----- — -- __-- Corlstructicn.fr6m 6i'
Plttr°bing i Building=P=ermit Fee
k
J+ �
5- Fire Protection
6. Totat =(1 +2+3 +C, t F C r1�Qf}11lt [beCn � a }.: r .f''• ;�
,SAC#! n Far iyfr #� cta1��lSsef�nw t _xsti't �x a -
t e XMIN
$f UrlibG' `� Date i SUP P;'rbr I �
7 S r X I ,'E je �e e.• z-^-+c'-:-'� b^-+^�:.x^^'^ i �. u - + >a A� � i`�'L",�y" [ sy r._'---�--
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BP-2001-0820
GIS#: COMMONWEALTH OF MASSACHUSETTS
1 .: CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0820
Project# JS-2001-1544
Est.Cost: $2400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GLEN MORIN 071903
Lot Size(sg.ft.): 49222.80 Owner., SHEA TIMOTHY E TRUSTEE OF
Zoning: GB Applicant: GLEN M O R I N
AT: 76 MAPLE ST
Applicant Address: Phone: Insurance:
190 CHESTNUT ST (413) 493-1478 Workers
Compensation
HOLYOKEMA01040 ISSUED ON:4120101 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP, PLY & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/20/010:00:00 5765 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo