43-004 160 GREENLEAF DR BP-2010-1
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map-.Bloc 43 - 004 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 -1119
Project # JS- 2010- 001641
Est. Cost: $13000.00
Fee: $78.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq. ft.): 233481 Owner: KAZEMTHOSSEIN & MAHNAZ MAHDAVI
Zoning: SR(100) //WP/WSP II A STEPHEN D ROSS
AT_: 160 G_ RE_E_NLEAF DR
Applicant Address: y � ~ Phone: Insurance:
36 SERVICE CENTER RD (413) 584 -1224 O WC
NORTHAMPTON MAO 1060 ISSUED ON. 611012010 0 :00 :00
TO PERFORM THE FOLLOWING WORK.- REMODEL MASTER BATH
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:74 `�(� Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: (pk —�d
THIS PERMIT MAY BE REVOKED BY THE CITY OF RTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL IO 44 " wow &M 44
Certificate of Occupancy i nature:
FeeType: Date Paid: Amount:
Building 6/10/2010 0:00:00 $78.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
9
'T
File # BP- 2010 -1119
APPLICANT /CONTACT PERSON STEPHEN D ROSS
ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413) 584 -1224 O
PROPERTY LOCATION 160 GREENLEAF DR
MAP 43 PARCEL 004 001 ZONE SR(100)//WP/WSP 11
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: REMODEL MASTER BATH
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/ Statement or License 079160
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INYORMATION 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
/ -f,° B
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.
Department use only
City of Northampton Status of Permit
Building Department Cuts tut/Dttveway permit
212 Main Street Serer /SepticArreilab,l;ty
Room 100
' Watet /Vye11 Availability
Northampton, MA 01060 TWO Sets of Structural Plane
phone 413 -587 -1240 Fax 413 - 587 -1272 PlottSite Plans
Other Specify
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
/60 T> f i ✓ Map Lot Unit
44't 0 lee. Z Zone Overlay District
6V T Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
a <5 ,,, lei Z �, /' /G o 4 .sin. I'-t4g b V- v
Name Pri Current Mailing Address:
Telephone
Signature t� t _•�—. �-2
2.2 Authorized Agent:
&j=$,- l n -V _3 4 S-cv✓v
Name (Pr' t) Current Mailing Address:
'5�" d- L`- ---- LUe
S Telephone r Z Z
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building �jyc�O�J '� (a) Building Permit Fee
IJ J v r
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing y V"" Building Permit Fee
4. Mechanical (HVAC) '
5. Fire Protection
6. Total = 0 +2+3+4+5) d , Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
�/- 4, 1 IJ/ t'v 0 v/- k
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
arkin
# of�arkin S ces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding er been issued for /on the site?
NO 0 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regis try 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 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 , Date Issued:
C. Do any signs exist on the property? YES 0 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, exc ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) EE Roofing
Or Doors i]
Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [Q Siding [p] Other [CI]
Brief De / tion of Proposed / 6 � ��✓
Work: ' � .v(
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If N ew house and or addition to existing ho using, com plete 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
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
I, 116 SS{ P1 LC�4 2 -G M / as Owner of the subject
property
hereby authorize S� -+--�_ r �2 s S
to actpn 0 behalf, in all matJ6, r tive to work authorized by this building permit application.
gn caner Date
I, �� �'� �� as Owner /Authorized
Agent herebyl8eclare 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.
S� 4 --' . p. f�•s s
Print Nam
f�;� A
nature Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor ^ c' Not Applicable ❑
Name of License Holder ,S' .-e-,>� .�.�^ /./, ��d's! Q '? 1 16r
License Number
Address Expira on Date
Signature Telephone
1
6. Re stered Home -Improvement Contractor: Not Applicable ❑
Co any Name Registration Number
34 .S'e ,mot/, c� C- r,�.� -�✓ ! 2 S--/q // -Z
Address Expira ion Dfite
�� ✓� � �isy►- / i' c '� Telephone S �Z 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....... IN- No...... ❑
11, - Home Owner Exemption
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
� CERTIFICATE OF LIABILITY INSURANCE OP ID SF DATE(MMIDD/YYYY)
V ROSSS50 07/15/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
IRM Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Barry M. Stephens, CPCU HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
75 North Main St. -P 0 Box 564 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
East Longmeadow MA 01028
Phone: 413- 759 -0010 Fax: 413- 759 - 0017 INSURERS' AFFORDING COVERAGE NAIL NI:
INSURE) INSURER A: Central Inauretsae Coegni" 20230
INSURER B: -
g t hen Ross t INSURER C:
Northampton NA 0106v d 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 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.
LTR TYPE OF INSURANCE POLICYNUMBER DA LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1000
A X coMMERCIALGENERALLIABIuTV CLPS123544 07/01/09 07/01/10 PREwasEs Epocau s300000
CLAIMS. MADE. Fx-1 OCCUR MED EXP.Wj one person) s 5000
PERSONAL BADVINJURY $1000000
GENERAL AGGREGATE s 2000000
GEWL AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OPAGG s2000000
x POLICY F M LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE OMIT $
ANY AUTO (Ea -ddeM)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per Pereon)
HIRED AUTOS
BODILY {INJURY $
NON-OWNED AUTOS (Per accdent)
PROPERTY DAMAGE $
(Per accident)
GARAGE IJABLJTY AUTO ONLY - EA ACCIDENT E
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS I UM®RCiLA LIABLI TY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
S
DEDUCTIBLE $ --- —
RETENTION $ $
WORKERS COMPENSATION
AND EMPLOYERS' LNBLJTY x 'TORY LIMITS ER
A ANY PROPRIETOROPARTNERIEXECUTWEL] NC812355915 07/01/09 07/01/10 E.L. EACH ACCIDENT $100000
( e E �� L-1 E.LDISEASE- EAEMPLOYE0 S 100000
SPECIAL PROVISIONS below E.LDISEASE- POLICY LIMIT 1 $ 500000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIATION
CONS001 DATE THEREOF, THE ISSUNG INSURER WILL ENDEAVOR TO MAIL. 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Construct ANSSOCiates IMPOSE NO OBIJGATION OR LIABILITY OF AN KIN
Y D UPON THE IN ER, SUR ITS AGENTS OR
36 Service Center Road REPINrATNVES'
Northampton MA 01060 AUTHOR=RERZESENTATNE
IRM Insurance Agency Inc.
ACORD 25 (2008101) 0198 &2008 ACORD CORPORATION. All rights reserved.
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