29-066 �111UI�llI �I�Illflll(IIIIIIII�I �� illllillC �I � �� Gl II ;: _ l , i1 a 111 1111(11I11RII IMEHl, ; ' 1 1 ,1,'JIl
HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE
ERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED
;Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN
HE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
MPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION
S WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement
•n this certificate does not confer rights to the certificate holder in lieu of such endorsement.
PRODUCER
White- JublmIlle Ins. Agency Inc.
Pa Box 789
South Hadley. MA 1075
COMPANIES AFFORDING INSURANCE
COMPANY A GRANITE STATE INSURANCE COMPANY
INSURED
Selkirks Family Chimney Cleaning Lic,
272 Newton Street
South Hadley, MA 01075-0000
■
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR
THE POLICY PERIOD INDICATED. NOT WITHSTANDING 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 THE
POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN
MAY HAVE BEEN REDUCED BY PAID CLAIMS.
co
LTR TYPE OF INSURANCE POLICY RUNNER PCuCY EFFECTIVE DATE POLICY EXPIRATION DAM
A WORKERS COMPENSATION
AND EMPLOYERS' L ABILITY
LIMITS
THE PROPRIETOR/
PARTNERS/EXECUTIVE
OFFICERS ARE
INCL 0 EXCL ❑ 1660620 1/24/2011 1/24/2012 STATUTORY LIMITS
OTHER
Comma Applies to MA Operations Only
. EACH ACCIDENT $ 100,000
DISEASE POLICY LIMIT $ 500,000
DISEASE-EACH EMPLOYEE $ 100,000
DESCRIPTION OF OPERAT1ONSJVEHICLES/SPEGIAL ITEMS
RE: NO PARTNERS ARE COVERED BY THE WORKERS COMPENSATION POLICY.
CERTIFICATE HOLDER CANCELLATION
AMHERST INSPECTION SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
ATTN: BETTY EXPRATION DATE THEREOF. NOTICE WLL BE DELIVERED VS ACCORDANCE
4 BOLTWOOD AVE MITE THE POLICY PROVISIONS
AMHERST, MA 01002
AUTHORIZED REPRESENTATIVE
1
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors D
Accessory Bldg. El Demolition ❑ New Signs [0] Decks [(_] Siding [0] Other [0]
Brief Description Rf Proposed
Work: 4/00V S c v` /4,f7 4 L (- y''r".2r1 o-v T C i'. '&S /Z e.S AC a TC b,ci t rjy
TA ir'u
Alteration of existing bedroom Yes No Adding new bedroom Yes No S•yc c
Attached Narrative Renovating unfinished basement Yes No L- A., rfl
Plans Attached Roll - Sheet
ea=; ft Netst • US - and oi a ,• •." ion to existln • house. • . , corn . • lete the followin • :
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: 2 Number of Bathrooms
c. Is there a garage attached? ? ,
d. Proposed Square footage of new construction. Ai A Dimensions
e. Number of stories? `
f. Method of heating? 0) ,- Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction ' ns \. \ \. W v ,Ys ka.ii / /�
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, -- S - CSSI.(✓' p vek ",e-1 , as Owner of the subject
property I
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, __.). SS L ,, c ,L.e.... , as Owner /Authorized
Agent hereby declare that the statements and infor on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penaltie of perjury.
1sSv i, ok )'.-J
Print Name
,� i ( ► l ea
S of Owner /Ag t N Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
�r J �l Not Applicable ❑
Name of License Holder : W //l/ C .) ,c; cc u ( a. 14 772- g 7 vv , , /
0075 License Number
2 72 NC 'To' ST ; So Hmdi c-/ pig . ' 5 1 Lc/ E 0 / e-..
Address Expiration Date
Cr46 /5SY� 6 c
Signa re Telephone
+rL ✓ i / 3 5J E vL G (
i
'fti .'Y - it'. HO e ' *:udtr( i., tit - oritractor Not Applicable ❑
J c L 44 , 71 ix rf7. , t/ r H(,--7 iv e
Company Name Registration Number
Trl ?7 ` /t `/ C 3 e _ c 6 fz 1 z_ c s 5 't ?2 r z
Address ,�/ 5 Expiration Date
7 ) / Y L 17 -G�2V ' Telephone 532 Yee j 2 // { k/ l e 0 / 4 �7
_...
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 ❑ No ❑
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
9/...,1
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 tilled in by
Building Department
Lot Size
Frontage
Setbacks Front " '"'
Side L.. V.�C'3 R : ../ `1 •s� L. R:._. ..
Rear 10 ! - t ,';y
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DON'T KNOW YES Q
IF YES, date issued:
YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained lQ Obtained Q , Date Issued
C. Do any signs exist on the property? YES Q NO
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 Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
RECEIVED City of Northampton f ��� , �� � �:.
Building Department ��
2012
I
JAN 212 Main Street _ a _ . ' ��
Room 100 r ,'
Northampton MA 0106
DEP OF BUILDING INSPECT' m 1 9
��,� NORTHAMPTON, MA 01060 on 413- 587 -1240 Fax 413- 587 -1272 s �
' , , s�Xt x ' y
.,v'>,a+ sa`? "�'.'�" -.� a k r�,& °;:';
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be compieted by office
1.1 Property Address: , 5 (.1.,1 r ct, r �
tY rc. ce.
Map Lot Unit
Zone O verlay Dietri±
Elm St. District CB D
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: , `� (�/
T Qs _S, n - e (X c�� G`,r_... 1 � - r r cam. J'1orc,. MA
Name (Print) Current Mailing Addr�s,s 7
ti. V Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building L.) V / ' 7 G (a) Building Permit Fee
S Tb d'C,
2. Electrical (b) E of
Construction stimated Total from Cost (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number C "l.�
This Section For Official Use Only
Date
Building Permit Number: Issued
Signature:
Building Commissioner /Inspector of Buildings Date
v
15 GILRAIN TER BP- 2012 -0658
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 066 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2012 -0658
Project # JS- 2012- 001128
Est. Cost: $1318.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WAYNE SELKIRK 99212
Lot Size(sq. ft.): 8494.20 Owner: RODNEY JESSLYN
Zoning: URA(100) //WSP Applicant: RODNEY JESSLYN
AT: 15 GILRAIN TER
Applicant Address: Phone: Insurance:
15 GILRAIN TERR (413) 475 -0803 () Workers Compensation
FLOREN CEMA01062 ISSUED ON:1/13/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VERMONT CASTINGS WOODSTOVE
W /STEEL LINER
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 1/13/2012 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner