24C-009 (2) co CERTIFICATE OF LIABILITY INSURANCE DP ID SF DATE (MMIIDD/YYYYj
CONSA50 07/15/09
PROOUCEIt THIS CERTIFICATE IS ISSUED AS *MATTER OF INFORMATION
IRM Insurance Agency, Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Barry M. Stephens, CPCII HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
75 North Main St. -P 0 Box 564 ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
East Longmeadow MA 01028
Phone: 413- 759 -0010 Fax: 413 -159 -0017 INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Central snsuranos Companies 20230
INSURER
CQQ &
36 s tru A ociaateeQs,, Inc. INSURER
Nor ton MA 01O6U INSURER D:
INSURER E
COVERAGES
THE POUCIES 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, EXcLusio S AND CONDITIONS OF SUCH
POUCIES. AGGREGATE UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NOM TYPE OF INSURANCE POUCY NIMASER p 'f p
NAM
E i LMeB
ormenALUA LITY - ' EACH.OcGURRENCE $ 500000
A X' commeRG CLP7834317 07/01/09 07/01/10 Ir:nleu
i��•.TE
S(Eeaowalcel s100000
CLAMS MADE n OCCUR MED E> P (Any one person) $ 5000
PERSONAL & Acv INJURv 8500000
GENERAL AGGREGATE $ 1000000
GENT_ MIT APPLIES PPLIES PER: PRODUCTS - COMP/ OP AGG $ 1000000
X I a n LOC
AUTOMOBLEUABNJTN - SINGLE UMIT
A
ANY Au BAP8614614 07/01/09 07/01/10 $ 1000000
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Far Psalm)
X HIRED AUTOS ( I
LY INJURY
X NON-OWNED AUTOS S
PROPERW DAMAGE $
(
GARAGE LIABILITY • AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHERITHAN EA ACC $
AUTO CALY: AGG $
EXCESS / UMBRELLA UABYJTY EACH O CCURRENCE $ 1000000
A X OCCUR CLAMS MADE CXS 07/01/09 07/01/10 AGGREGATE s 1000000
$ •
DEDUCTIBLE $
X RETENTION S O $
wowed COMPENSATION IT Y UAMITS I I ER
AND EMPLOYERS' LYIBLITY
A ANY PROPRIETORIPARTNE YIN WC783431819 07/01/09 07/01/10 E.LEACHAcooerT $ 500000
OFFICERAAEMBER EXCLUDE
(MSRddoryInNH) E.L. EMPLOYEE DISEASE- EA $ 500000
If s
SPCI AL. PROVISIONSbelow E.L DISEASE - POLICY UMIT 8500000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS
CERTIFICATE HOLDER y CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POEMS BE CANCELLED BEFORE THE EXPIRATION
PROOF00 DATE THEREOF, THE ISSUING INSURER BILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTIOE TO THE CERTIFICATE H0LDEt RAINED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE MO OBLIGATION OR UABLITY OF ANY IOND UPON THE INSURER, ITS AGENTS OR
Proof of Coverage REI1RESENTATIVES.
AUTHORED REPRESENTATIVE
IRM Insurance Agency Inc..
ACORD 26 (2009101) 0198S-2009 ACORD CORPORATION. AA rights reserved.
The ACORD name and logo are registered marks of ACORD
�4
_ q A Mom ,.
«. R `v` : ..�,P4y tr A1� �" =rz.,re h b
8.1 Licensed Construction Supervisor: _ Not Applicable ❑
Name of License Holder : s L a? .L , ? b s 5 79 / , 0
License Number
S'ervice.Onl-er Rd. IllorNhcrn,cb 1,/ �Io /,d
04 10
Address Expiration Date
Signature Telephone
.... �,.. Not Applicable ❑
Si -ephen �. ess C�-ener41 eon for 150847
Company Name Registration Number
J4, .1- erviee eetikp- irTatnplvn1,u ply 05 /0q /Qua
Address L /, Expiration Date
Telephone 4/i -6D / /
COMPENSATION 1NS0RAN rA DAVIT Mat.. c, 452.4 gr
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 DwelliHEs 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 accessoty 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 buildins 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 $tate 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) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [0] Other [l
Brief Description of Proposed —�
Work: / ,,, e,.., /1 C - A - r14 -
Alteration of existing bedroom Yes £/ No Adding new bedroom Yes N o
Attached Narrative Renovating unfinished basement Yes v No
Plans Attached Roll - Sheet
sa., If New:houseknd`or addition to existing housings, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: ,.� Number of Bathrooms
c. there - •arage attached? -°`
d. Proposed Squa ; footage of new construction ` Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. nergy Co.; - ation 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, 1 o_ e- y S k & u , as Owner of the subject
property /
hereby authorize . i. V�
to act on my behalf, in all ers relative to work authorized by this building permit application.
6,7
e. z G0
Signature of Owner Date 11
I, 57
7 ■-t t t- rC O 35' , as Owner /Authorized
Agent her y 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 ains and penalties of perjury.
4 ,,p
Print Na
7 �5-- 6
J
ature . owner/Agent Date
y -C' Ill i7l d-14 � .
Ai, 4 , __ 41 ( i
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 R:
Rear ,
Building Height
Bldg. Square Footage '7 % .
Open Space Foot
(Lot area minus b & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Spec' Permit /Variance /Finding ever been issued for /on the site?
NO DON'T KNOW 0 YES
IF YES, date issued:,
IF YES: Was th ermit recorded at the Registry of Deeds?
NO DONT KNOW 0 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 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ,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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav n, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
De partm en t use or iy
City of Northampton StatusofPermit,
I ' iB"uilding Department Curb C uf/Drsvew y P ermit ,
212 Main Street Sewer /Se4tio Availetdir
Room 100 Wa to ti Ayailabitity „ "2,*
c EN Northampton, MA 01060 TwaS t f8trucitiral
phone 413- 587 -1240 Fax 413 - 587 -1272 Pet e P ns
Cher 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
d ! Map Lot Unit
Zone Overlay District
0/660
Eim St. CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
ft Al y 57 e' 5- e L�
Name (Print) Current Mailing Address:
Telephone
Signature \ � ' 3 6 7` 35° 4
2.2 Authorized Agent: c 61 57-z c
Na (Print) Current Mailin Address:
711"` tieo0
igna . e Telephone �q / .
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building / G c' (a) Building Permit Fee
2. Electrical L� r� (b) Estimated Total Cost of
Construction from (6)
3. Plumbing LS !�a :, s• " Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) /57 ' Check Number j O It / 0
This Section For Official Use Only
Building Permit Number: Date
g Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -1192
APPLICANT /CONTACT PERSON STEPHEN D ROSS
ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413) 584 -1224 ()
PROPERTY LOCATION 17 ADARE PL
MAP 24C PARCEL 009 001 ZONE URB(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 3eb 090 r
Tvpeof Construction: REMODEL BATH
New Construction
Non Structural interior renovations
Addition to Existing
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
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
(.7/0-,--- A......."6--..---13 Signature of Building O icial Date 6/ / Ci 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.
17 ADARE PL BP- 2010 -1192
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Biock: 24C - 009 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 -1192
Project # JS- 2010- 001726
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq. ft.): 11848.32 Owner: STOUT NANCY J TRUSTEE
Zoning: URB(100)/ Applicant: STEPHEN D ROSS
111. 17 AO ARE ^L
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584 -1224 () WC
NORTHAMPTONMA01060 ISSUED ON :6/28/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REMODEL BATH
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground : ervice: Meter:
j �
g && lY g Footings:
Rou h: � � ' �� Rough: House # Foundation:
Driveway Final:
Final: 8 1 g� (" � inal:
Rough Frame: OK ? 19-16 0 l
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: OK g / g'- /6 CNn.,,
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REG I N
• A i t raw.40 4 .
Certificate of Occupancy (..--signature:
FeeType: Date P . id: Amount:
Building 6/28/2010 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo