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42-102 262 WEST FARMS RD BP-2011-0279 GIs #: I COMMONWEALTH OF MASSACHUSETTS Map-Bloc 42 - 102 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-2011-0279 Project # JS- 2011- 000464 Est. Cost: $2535.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MICHAEL MCKENNA 057009 Lot Size(sq. ft.): 23130.36 Owner: DURYEE CHARLES C & VIRGINIA E Zoning: SR(100) //WSP II Applicant: MICHAEL MCKENNA AT. 262 WEST FARMS RD Applicant Address: Phone: Insurance: 209 POMEROY MEADOW RD (413 ) 527 -1266 SOUTHAMPTONMA01073 ISSUED ON. 9/27/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK: R E PA I R CH I M N E 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 9/27/2010 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0279 APPLICANT /CONTACT PERSON MICHAEL MCKENNA ADDRESS/PHONE 209 POMEROY MEADOW RD SOUTHAMPTON (413) 527 -1266 PROPERTY LOCATION 262 WEST FARMS RD MAP 42 PARCEL 102 001 ZONE SR(100 )//WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out 2 -1 04 Fee Paid Typeof Construction: REPAIR CHIMNEY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 057009 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 9 Signature of wilding 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. City of Northampton Building Department t 212 Main Street 1 Room 100 2 210 Nort ampton, MA 01060 SEQ phone 413-587-1240 Fax 413 - 587 -1272 z. 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 p Lac 1�J Ma Uiait zone: ovea�rDisct 55 frri St `DistHct " CS District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record AR lea pu Ky e. e, a W J ►4r(V&5 2 Name rin Current Mailing Address: Telephone Signature 2.2 Authorized Accent: yo nq z� 1�t� ✓hLnvy i'►'Ie� d acrit 2 [J SQif ►n Name (Print) Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only com feted 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 = (1 + 2 + 3 + 4 + 5) 2 S 3 $" Check Number This Section For Of iicial!Use Onl Building Permit Number: IIsssued: Signature: Building Commissioner /Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size __ s Frontage Setbacks Front F Side L: } R £ � ' L: R: Rear - -. -$ Building Height i ---- I Bldg. Square Footage % �– Open Space Footage % (Lot area minus bldg & paved u p arkin g) # of Parking Spaces ? – Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES 0 IF YES, date issued:` IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT K NOW 0 YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q 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 Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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? YES 0 NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aaalicable) _T New House ❑ Addition ❑ Replacement Windows Alteration(s) E] Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [o] Other [ �I] Brief Description of Proposed Work: k � t Ci I V► l :.l Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa :'1#�euirioust�Ia"�r�n:�E �stnct��sina csmrile " #ott: 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 as Owner of the subject Property G hereby authorize to 77n behalf, in ma rs r a ve to ork authorized by this building permit appli tion. I' l X Signature of ner Date An 911 awbiv 00) 1n / /J t 4 Z /'f /t a as Owner /Authorized Agent hereby de are that the stateme is nd 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. rn!G`jAc� .�.�'��>`hh4 Print Name n V Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION "SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ t Name of License Holder : M I L k Y}fJ �� ✓I C( 5 License Number X �e ►'1 -'►�R � <� L-6 /U Address Expiration Date r12X— 0/U 7 3 r Signature`�'69L� / Telephone S.' Reaisterecl °CamrIrttor ©arrrenti:or�racf6r; p; Not Applicable ❑ �LhA� 1 I M L / Je wt,,r(,. /32 01 Company Name Registration Number a61 �o ;�� ,�o 11-- 61 , 4a Ad dress � Expiration Date SEA' A^'00 ) 1*4 ®icon Telephone 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....... 5d No...... ❑ ��i�pt�Q 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 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 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 The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston, MA 02111 ,v www mass gov/dia -Workers' Compensation Insurance Affidavit:.Builders/ Contractors /Electricians/Plumb.ers Applicant Information Please Print Legibly Name ( Business /OrgmAzauoarmdividual): Yll i (.-fit 6 e I 5- 1'► (- l4e wra Address: o3 � q ✓ A Nll t,/ RI City /Sta&Lp: 5a-Vi1 o^41V j M,4 010'l Phone. #: - :4?`� Are you an employer?. Check the appropriate'bog: Type of project (required):. L ❑ I 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 2.1 I ani a sole proprietor or partner - listed on the attached. sheet. 7. ❑ Remodeling ship an have no em-oployees These sub- contractors.have. .8. ❑ Demolition working for me any capacity e2aplgyecs and Kaye workers' 9 - � a�dion [No workers- comp. msurance - 10. Electrical airs or additions required] 5. ❑ We are a corporation and its 0 Electrical 3.0 I am a homeowner doing all work officers haveexercised their 1 L❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL I2: 0.Roof repairs f c. 152, §1(4), and we have no insurance requacd] employees. [No workers' 13. ® Ot3�er �H comp. insurance required). *Any applicant that checks box #1 must also fill out the section below showing dicirwad='- 'on policy information. t Homeowners who submit this a$davit.indicating they are doing alt work and then hire outside contractors must submit anew affidavit indicating smrh. ( Contractors that check this box must.attached an additional shed showing the name of the sub -com act= and state wheel= or not those entities have employees. If the sub-contractrn have employers, they mustprrnnde their workers' comp..policy number. I am an employer that isprovik&6- workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Z OII & H Policy # or Self ins. Lic. # {o Z U " q70 S L 79 U Expiration Date: q- � 3 40 Job Site Address: _ % City/Stafe/Ztp. lo 4L Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date Failtn-e . to secure coverage :as required under Section 25A fMGLc 152 can kad'to flie imposition of crimmail penalties of a fine up to $1,500.00 and/or one- year imprisonment, as well as civil penalties in the form of 4 STOP WORK ORDER and- a fine of up to $250.00 a -day against the -violator. advised that a copy of this statement may be forwarded to the Offico of _ Iavestisations of the DIA for insurance` cove r&Me verification I do hereby,certify under thepains ofperjury that "the reformation�rovid abovE_s�rue_andsarrect -___ 4; Qnzture e �Lu' Date: % r�V' / U Phone # Official use only. Do not write in this area, tb be completed by city or town offrciaL City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector S. PIumbinp Inspector 6. Other t- Contact Person: Phone #: VDAC ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB- 9703L79 -0 -10) RENEWAL OF (6ZZUB 9703L79 -0 -09) INSURER: AMERICAN ZURICH INSURANCE COMPANY 1, NCCI CO CODE: 80012 INSURED: PRODUCER: MCKENNA, MICHAEL 0 KSK INSURANCE AGENCY INC 209 POMEROY MEADOW ROAD PO BOX 597 SOUTHAMPTON MA 01073 EASTHAMPTON MA 01027 Insured IS AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 09 -23 -10 t0 09 -23 -11 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA U7 B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: a Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit 0 Bodily Injury by Disease: $ 100000 Each Employee ,r— C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A 0 D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 09 -13 -10 WC ST ASSIGN: MA OFFICE: ZURICH -ORLAN 809 PRODUCER: KSK INSURANCE AGENCY INC 26DKN 004775