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46-058 (3) 503 MT TOM RD BP- 2010 -0837 GIS #: COMMONWEALTH OF MASSACHUSETTS Map-.Bloc 46 - 058 CITY OF NORTHAM$TON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Cate o : renovation BUILDING PERMIT Permit # BP- 2010 -0837 Proiect # JS- 2010- 000512 Est. Cost: $12000.00 Fee: $72.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CHARLES SEDER 94375 Lot Size(sq. ft.): 117612.00 Owner: GLAZEWSKI HELEN S & MARY Zoning: SC(100) / Applicant: CHARLES SEDER AT 503 TVI T T OM RD Applicant Address: Phone: Insurance: 117 MOUNT WARNER RD (413) 315 -0045 WC HADLEYMA01035 ISSUED ON :312512010 0:00:00 TO PERFORM THE FOLLOWING WORK .- REMODEL KITCHEN,REPLACEMENT WINDOWS /DOORS 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: ! U L!3 Rough Frame: OK V- Gas: Fire Deyartment 5 � Fireplace /Chimney: Hough: iJii• v° Final: Smoke: Final: 1,<1Trur-AQ 04CA.a.o THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. C�vwv'Q1�1� �'• Certificate of i c i t ,.a•�, ^ i nature: FeeType: Date Paid: Amount: - Building 3/25/2010 0:00:00 $72.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -0837 ' APPLICANT /CONTACT PERSON CHARLES SEDER ADDRESS /PHONE 117 MOUNT WARNER RD HADLEY (413) 315 -0045 PROPERTY LOCATION 503 MT TOM RD MAP 46 PARCEL 058 001 ZONE SC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tyueof Construction: REMODEL KITCHEN.REPLACEMENT WINDOWS/DOORS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 94375 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFgWMATION 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 r te- 3 2- 10 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 Curb Cut/Driveway Permit 212 Main Street Sewer /Septic; Availability Room 100 Water/Well Availabilit 2 L `��� Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site 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 . . 503 MOUNT TOM ROAD - NORTHAMPTON, MA Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record MARY G LAZEW S KI 503 MOUNT TOM ROAD - NORTHA Name (Print) Current Mailing Address: 413 - 744 -35 Telephone Signature 2.2 Authorized Agent: CHARLES SEDER (DBA SEDER & SON) CHARLES SEDER (DBA SEDER & SON) Name (Print) Current Mailing Address: 413- 315 -0045 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building 12,000 (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) 12,000 Check Number This Section For Official Use Onl Building Permit Number: Date 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 arking) # 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 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW YES 0 IF YES: enter Book Page, and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , 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 0 NO Q 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder CHARLES SEDER 94375 License Number 117 MQUNT WARNER ROAD 08/18/2011 Address Expiration Date 413- 315 -0045 Signat a Telephone 9. Reaistered Home Improvement Contractor: Not Applicable ❑ SEDER & SON 151088 Company Name Registration Number 117 MOUNT WARNER ROAD 05/16/2010 Address Expiration Date Telephone 413 - 315 -0045 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....... .0 No...... ❑ ON FILE FOR THIS ADDRESS WITH TOWN OF NORTHAMPTON 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 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 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 __ SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) ED Roofing ❑ Or Doors ED Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other [0] Brief Description of Proposed Work: COMPLETE KITCHEN REMODEL- NEW KITCHEN WINDOWS AND DOOR Alteration of existing bedroom Yes XX No Adding new bedroom Yes XX No Attached Narrative Renovating unfinished basement Yes xx No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building: One Family XX Two Family Other b. Number of rooms in each family unit: Number of Bathrooms 2 c. Is there a garage attached? Y ES d. Proposed Square footage of new construction. Dimensions e. Number of stories? 2.5 f. Method of heating? BBHW Fireplaces or Woodstoves NO NE Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction W OOD FRAME 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 MARY GLAZEWSKI as Owner of the subject property hereby authorize CHARLES SEDER to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date CHARLES SEDER 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 lo Signature of war /Agent Date The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations '° 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /Individual): CHARLES SEDER DBA SEDER & SON Address: 117 MOUNT WARNE R City /State /Zip: HADLEY , MA 01035 Phone #: 413 - 315 -0045 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑✓ I am a employer with 5 4. ❑ 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 sub - contractors have g. ❑ Demolition working or me in acit employees and have workers' g any capacity. y• 9. F - ] Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 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. * Contractors 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 the policy and job site information. Insurance Company Name: TRAVELERS INSURANCE COMPANY Policy # or Self -ins. Lic. #: UB- 3329M432 Expiration Date: 05 /10/2010 Job Site Address: 503 MOUNT TOM ROAD City /State /Zip: N IH 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 insurance coverage verification. I do hereby certify de a pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: 03/16/2010 Phone #: 413 - 315 -0045 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 #: L ACORQ CERTIFICATE OF LIABILITY INSURANCE 051 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Chase /Clarke /Stewart & Fontana HOLDER. THE IS C AFFORDED N OT Y THE POLLEES BELOW 101 State Street - PO BOX 9031 Springfield, Ma 01102 INSURERS AFFORDING COVERAGE INSURED INSURER A: Travelers Insuranc C Charles Seder DBA Seder & Son Contract Sery INSURFR8, 117 Mount Warner Road INSURER C, Hadley, MA 01035 INSURER D, INSURER F. 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. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ ✓ COMMERCIAL GENERAL LIABILITY NC540865 03/23/08 03/23/10 FIRF DAMAGE (Anyone fire) $ 50000 A CLAIMS MADE L] OCCUR MED EXP (Any ona pergpn ry/5J�000 PERSONAL & ADV INJURY $ 00000 GFNFRAL AGGRFGATF.._.___ t.___ _ 000.0.00. GENT AGGREGATE LIMIT APPLIES PER: P RODUC TS - COM PIOP AGG $ 2000000 Z policy Elproject IoC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHFDUI.FD AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ -- — (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ANY AUTO OTHER THAN y A A $ AUTO ONLY: AGG EXCESS LIABILITY EACH OCCURRENCE _ 1 UUUV OCCUR El CLAIMS MADE AGGREGATE i DEDUCTIBLE RETENTION $ WC STATU1 WORKERS COMPENSATION AND ✓ _TORY.LINILT1_- EMPLOYERS' LIABILITY /� A UB- 3329M432 05/10/08 05/10/10 F.L. EACH ACCIDENT $ 1 / 00 , 0 / 0 / 0 E.L. DISEASE - EA EMPLOYEE $ 10 F.L. DISEASE -POLICY LIMIT 500 OTHER F PERATIONSILOCATIONSIVEHICLESIEXCLUSIONS A DE T PE IA PROVISI CERTIFICATE HOLDER ADDITIONAL INSURED INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION FILE COPY DATE THEREOF, THE ISSUING INSURER WILL MAIL 32 DAYS W RITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Lisa M. Clewes AUTHORIZED REPRESENTATIVE ACORD 25 -S (7197) (DACORD CORPORATION 1988 L.