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42-146 �— 915 WESTHAMPTON RD BP- 2010 -0264 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 42 - 146 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) B UILDING UILDING PERMIT Permit # BP- 2010 -0264 Project # JS- 2010- 000339 Est. Cost: $6800.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WESTWOOD GENERAL CONTRACTING SERVICES 99530 Lot Size(sq. 1): 36459.72 Owner WHITLOCK ELAINE R Zoning_ SR(100) //WSP II Applicant: WESTWOOD GENERAL CONTRACTING SERVICES AT.• 915 WESTHAMPTON RD Applicant Address: Phone: Insurance: 417 SPRINGFIELD ST SUITE 176 (413) 433 -1300 WC AGAWAMMA01001 ISSUED ON.- 911712009 0 :00 :00 TO PERFORM THE FOLLOWING WORK. SKYLIGHT, CHIMNEY REPAIR & 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: 4 K q - a g 0(7 THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy i nature FeeType: " Date Paid: Amount: Building 9/17/20090:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo $� t r File # BP- 2010 -0264 APPLICANT /CONTACT PERSON WESTWOOD GENERAL CONTRACTING SERVICES ADDRESS /PHONE 417 SPRIMIFIELD ST SUITE 176 AGAWAM (413) 433 -1300 PROPERTY LOCATION 915 WESTHAMPTON RD MAP 42 PARCEL 146 001 ZONE SR(100)//WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 44 oecz -A Fee Paid Typeof Construction: REPLACE SKYLIGHT, CHIMNEY REPAIR & STRIP & SHINGLE ROOF New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 99530 3 sets of Plans / Plot Plan THE FO OWING 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 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. City of Northamptono€ Building Departmentt 212 Main Street Room 100 �LUV9 Northampton, MA 01060 we► stns cStrarE P SE? phone 41,3 -587 -1240 Fax 413 -587 -1272 Odw Sp,� . ;APPLICATION TO CONS fRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This secon tl�' be completed ffce 1.1 Property Addre ti ,: � ted of Map Lot Unit {— L u f t .ti e. I" A ° G 10 Zone Overlay ©lstriq am St. ce vistrid SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record f� T L i; Y . 5 �� r?d Z - y C Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Aaent: J. n z t cp vc 5. tG yl� �' .5 .��� 17L > A W1G} d i 6e / Na Current Mailing Address Y/ - 4'33-)"3od Signature Telephone SECTION 3 - ESTKA_TEQ COpTRUCTIOtj 2Q TS Item Estimated Cost (Dollars) to be Official Use Only completed by rmit applicant 1. Building c+e7 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing BeRIIrig Permlt Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2+3+4+5) l;) CJ Check Number Ae This Section For Of 111" Use 9 rilly Building Permit Number. Data Issued 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage _ (Lot area minus bldg & paved p arkin g) # ofParking Spaces Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page, and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 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 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 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 O NO E) IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SLCTION Y DESCRIPTION Of PRgJMD INM Mect an aonticaWel New House ❑ Addition ❑ Replacement Windows Alteration(s) a Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [CT] Decks [0 Siding [p] Other [O] Brief De ptionq� Propose �} 1 Work �,o. �a. ;, C�-,A� `1 )cam ` ` WIAe� tj sky � d - �C'QRir ' T o r n Alteration of existing bedroom - Yes , - No Adding new bedroom Yes No \ OC�c'� r Attached Narrative Renovating unfinished basement Yes _&,-- No Plans Attached Roll - Sheet Ow New 110USC and for a4 t hM 0 exisft1� h�nl� `cctt�* the ft►lib na 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. fktodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject properly hereby authorize to act on my behalf, in all matters relative tD work authorized by this building permit application. Signature of Owner Date 1, 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 Signature of Owner/Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not / Not Appficable ❑ Name of License Holder i' /� � 1 - (,%A 2-LA L oC-J ` Z 2 d License Number I ZI rD cre Goo S ?c,:nc c e� Dr - 7,5 - Zvi 2.. .i 6 1 Expiration Date 13 tau Signature Telephone 9, RecdsteMd IiOM CnnAMdor, Not Applicable ❑ �`TGt?v�p C e,v cc�a l. Cv:.sdna.c }�.,,t few - vices tC ) G ) V Company Name Registration Number 1 � 6 N I &> / , V/ Z- ci C Address Expiration Date QA s,a A Mil 0 I y!) 1 Telephone r/ y 3 l3 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L c, 152, 9 23C(8)) 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 buil ong permit. Signed Affidavit Attached Yes....... No...... 0 1 - H -1 QOyfter livgl�s 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 180, Sixth Edition Section 108 15.1 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 -vear 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 Gable 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 Massackusetts Department of Industrial Accidents Office of Investigations H:. 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Buil ders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization /Individual): ( AJ 7 ;I - G e -e A L � ,� � C A C "� �,v C � VC s (LG Address: City/State/Zip: w a k A o IvQ i Phone #: c it 3 - 3 3- , 3 t3 0 Are you an employer? beck th propriate box: Type of project (required): 1.P I am a employer with 4. E] I am a general contractor and I employees (full and/or part-time).* have hired the sub- contractors 6 . ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These subcontractors have g_ ❑ Demolition working for me in any capacity. employees and have workers' 9 Building ddition [No workers' comp. insurance comp. insurance. g required.] 5.0 We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner do" all work officers have exercised their I L Plumb' doing ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 Roof repairs insuran 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. tContractors 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 t►ee policy and job site information. Insurance Company Name: ]..l p n 4 P c � n y ni s cx a. a c1(� Policy # or Self -ins. Lic. #: (,� L' C C 0 3 2 11 U Expiration Date: o / /a i // U Job Site Address: 9/s L� � i '1 H x1 »� ��► o h l 12-0 City /State /Zip: "re tic e ryl A u 1 v 6 L 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 insuranc coverage verification. I do hereb the and penaties of perjury that the information provided above is true and correct Si erti C Date: �, L Eyr/v Phone #: , /3 V.3 Y- r t t1 U 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 #• From:M.J, LaPlante FaxID: Date:08 /28/09 01:46 PM Page: 2 of 3 AC CERTIFICATE OF LIABILITY INSURANCE OP ID MP DATE(MMIDD/YYYY) WESTG-2 08/28/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE J.M. Glover Agency /Holyoke HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1548 Northampton Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Holyoke MA 01040 Phone: 413- 534 -1500 Fax:413- 534 -1599 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A. Hartford Insurance Grou NSURER B: Hanover Insurance Compan Westwood General Contracting Services , LLC INSURER C: _ - -- - — 417 Springfield St, Ste 176 INSURER -- _ Agawam MA 01001 NSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REOUIREMENT, 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR OkDDL POLICY EFFECTIVE POLICY EXPIRATION LTR NSR1 TYPE OF INSURANCE POLICY NUMBER DATE (MM/DDNY) DATE (MMIDOMY) UMITS GENERAL LIABILITY EACH OCCURRENCE s 500000 A x COMMERCIAL GENERAL LIABILITY 31SBbiVQ2029 01/06/09 01/06/10 PREMISES(Eaocarence) $300000 CLAMS MADE [>�] OCCUR MED EXP(Any one person) $ 10000 PERSONAL BADV IN,AIRY $ 500000 GENERAL AGGREGATE E 1000000 GENL AGGREGATE LIMIT APPLIES PER PRODUCTS- COMP/0P AGG $ 1000000 POLICY ACT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 500000 B ANYAL/TO AWN2501338 01106109 01/06/10 (Eaaaident) ----.._--_----- -- ALL OWNED AU TO BODILY INJURY x SCHEDULEDALITOS (Per person) $ X HIRED AUTOS BODILY INJURY x NON -OWN ED AUTOS (Per accide(t) $ PROPERTY DAMAGE _ (Per accident) GA RA GE L IABIL ITY AUTO ONLY - EA ACCIDENT $ AN Y AU TO OTHER THAN E ACC $ AUTO ONLY AGG $ EXCESS/UMBRELLA LIABIUTY EACH OCCURRENCE $ OCCUR a CLAIMS MADE AGGREGATE y DEDUCTIBLE $ RETENTION b $ WORKERS COMPENSATION AND X TORYLI ER EMPLOYERS' LIABIUTY A ANY PROPRIETOR/PARTNER/EXECUTNE 31WECE03210 01/06/09 01/06/10 E.L. EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED? -- -- — - - - - -- If yes, describe under , EL.DISEASE - FAEMPLOYE $ 1000000 SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 1000000 OTHER DESCRIPTION OF OPERATIONS /LOCATIONS/ VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION l/ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION { DATE THEREOF, THE ISSUING INSURER VNLL ENDEAVOR TO MAIL 20 DAYS WRITTEN /-� NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Elaine Whitlock /-, IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 915 Westhampton Road 0) 0 6 1 REPRESENTATIVES. Florence MA 01062 �� AUT D RE yr E ACORD 25 (2001108) © ACORD CORPORATION 1 >- �la„achu,ctt Department of Public �'afet% Board of Builtlin. Rc,ulation, and standard. License: CS 9950 Restricted to: 00 PHILIP GUAZZALOCA t 121 WESTWOOD DRIVE WEST SPRINGFIELD, MA 0108 Expiration: 1/29/2012 l • uuni..i uur Tr#: 99530 Board of Building Regulations and Standards - ( HOME IMPROVEMENT CONTRACTOR Registration: 161334 �r Expiration: 10/14/2010 Tr# 276273 Type: LLC WESTWOOD GEN CONTRACTING SERVICES LLC. PHILIP GUAZZALCA 417 SPRINGFIELD ST STE 176 AGAWAM, MA 01001 :�dmiuistratur