24C-014 (8) - EXISTING ENTRY WAY
KITCHEN
LIVING AREA
_-�- 4 / _ 2 „ ..�
8 , - 0
I 3' -10"
n
PRPOSED BATHROOM
TOM POPPALAEDO 254 PROSPECT ST, NORHAMPTON, MA
BONDE CONSTRUCTION, EASTHAMPTON, MA 529 -2176
VDAC
RE WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S6OUB -0241 N89 -1 -09 )
CLASSIFICATION SCHEDULE:
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM
SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S)
SIC - CODE: 1751
STANDARD
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 1570
PREMIUM DISCOUNT NONE
0900 -20 EXPENSE CONSTANT 338
TERRORISM 6
TOTAL ESTIMATED PREMIUM 1914
TAXES AND SURCHARGES 96
DEPOSIT AMOUNT DUE 2010MP
A/R (WCIP) #
Minimum Premium: $ 500 EMPLOYERS LIABILITY MINIMUM: $ 50
ST ASSIGN: MA
DATE OF ISSUE: 02-06 -09 CL
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: FINCK & PERRAS INS AGCY 28NOK
VDAC
Th.z.
ILItaportD WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6560US-0241N89-1 )
RENEWAL OF (6560UB-6139827-7-08 )
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
NCCI CO CODE: 80411
1.
INSURED: PRODUCER:
BONDE , MARK 5 DE3A. SONDE FINCK & PERRAS INS AGCY
CONSTRUCTION 6 CAMPUS L.N
205 PARK STREET EASTHAMPTON MA 01027
EASTHAMPTON MA 01027
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period Is from 03-13-09 to 03_13_10 12:01 A.M. at the insurecl's 'nailing address,
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
13. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
Item 3.A. The limits of our liability under Part Two are:
WT. WM
Bodily Injury by Accident: $ 500000 Each Accident
~IMP Bodily Injury by Disease: $ 500000 Policy Limit
===
Bodify injury by Disease: $ 500000 Each Employee
11111110111Z
wi=211111I C. OTHER STATES INSURANCE: Part Three a the policy applies to the states, If any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
D. This policy Includes these endorsements and schedules;
Jg SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
--vs=
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
2--1-2 Plans. All required information is subject to verification and change by audit to be made ANNUALLY .
DATE OF ISSUE: 02-06-09 CL ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: FINCK & PERRAS INS AGCY 28NJK
ocs ors s=111 ear
Construction Qasign
Mark Bonde Policy No# (Liability) MP020651 Finck & Perras Ins Agcy.
Policy No# (Wk's Comp) UB- 8139B27 -7 -07 527 -5520
General Liability Dates 8 -15 -2008 To 8 -15 -2009
Workers Comp 3 -13 -2009 To 3 -13 -2010
Gary L Kostek Policy No# (Liability) MP064863 Finck & Perras Ins Agcy.
Plumbing Policy No# (Wk's Comp) WC064863 527 -5520
General Liability Dates 6 -27 -2009 To 6 -27 -2010
Workers Comp 6 -27 -2009 To 6 -27 -2010
NRB Exteriors Inc Policy No# (Liability) CP49710701 Chaffee Helliwell Ins Agcy.
Policy No# (Wk's Comp) WC8738203 536 -0751
General Liability Dates 6 -07 -2009 To 6 -07 -2010
Workers Comp 3 -19 -2009 To 3 -19 -2010
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance - with state building -- codes - and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, whichincitrde foundatiun /fuotinns (before baekfill).
sonotube holes (before pour), a rough building inspection (before work is
concealed). insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until tfie wo� r cane iispectei
Tithe homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
J .'
The Commonwealth of Massachusetts
-= : 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): ''tStuiDE CO no 14 tj _
Address: 2105 a2,k b
City /State /Zip: fid k,,, t[s►i fl 610Zone #: q 52.9 -717b
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. El New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. (1].- R'ismodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9. [1] Building addition
No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing- all -wark officers have exercised their 11.7 Plumbing repairs or additions
myself. [1\T o workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance 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.
*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. lithe 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: T4P \ —
Policy # or Self -ins. Lic. #: ( j (, rj (.0 I t dt " '
_; v -C) 1 Expiration Date: 3 r 3 (Z
Job Site Address: 2. 01 c- i" City /State /Zip: kiLea P i f1. 01 066
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 andior -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
Iuvestieations of the DIA for insurance coverage verification.
I do hereby certify u d the pains alties of perjury that the information provided above is true and correct.
S ignature: Awk- 0-14447 Date: _74,6 •O
Phone #: �'jf 3 5 P.9- 2J 76.
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. Bo ar- ti-o-f- Health ?— BulldIng Depar- intern( 3. Ci tyin, w u Cleik_ _4. r:lect ical Ins ector 5. Plumbinc* Ins • ector
6. Other
Contact Person: Phone #:
/
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : _ 1 fJVe --t9---7--5-S________
License Number
70 s _ !- 2. -
Address Expiration Date
Ac km vTi a 1,. H is, 6 i 27
Signature Telepone '
G _ 601■10•(,__
Z - 21
9 Register Home +;Improvernent :, ' Not Applicable ❑
• Ce7, - 7,2vC -1 e4 154% % 39
Company Name Registration Number
Z05 'A < - 1
Address Expiration Date
L `
.�6-1- 1 b N , his, 0ta7Telephone 52cf - 217 L
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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 111-- No ❑
I lK ''Y a v 4 er E ffipt
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 1083.5.1.
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 -ef the-work- for - which- this- permit-is- issuer
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-LawsAnnotated.
Homeowner Signature
.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 12 Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [0 Siding [O] Other [o]
Brief Description of Proposed
Work: A x l St .• - �.•
Alteration of existing bedroom Yes L.--- Adding new bedroom Yes 1/-No
Attached Narrative Renovating unfinished basement Yes _ --No
Plans Attached Roll - Sheet
sa If New .: house- - andotadditionlo existin0 housing', comptete.: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, " ''t 0 OW I „ffi.. O 1- ffitriA 1 [`h , as Owner of the subject
property
- hereby . hori -ze 411111g ' .i EP ®ND g.
to act on y behalf, in Ili s rela ' e to work t `rize..y this building permit application.
x Ir 1 "1 ®L ®f f `' 4 `
Signature _'Owner r Date
I, fall 9 04itii1990 .4 5n&A : il l , 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 Namililli '
1, 1� / �r �> >
Signature ."Owner /Agent 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 -- 3
Frontage
Setbacks Front
Side
5 r ,
Rear
Building Height
Bldg. Square Footage 6-6-S ;'•
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 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO c:0 DONT KNOW 0 YES 0
IF YES: enter Book ; Page and/or Document #
fr
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 0 Obtained
0
, Date Issued:
C. Do any signs exist on the property? YES 0 NO 1. 4
41110.
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 4
46.
IF YES, describe size, type and location: ;
E. Will the construction activity disturb (clearing, grading, ex avation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 4
410.
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
Department use onty
city of Northampton 5 tat of Pert t# N
, Building Department Curbttt�tewayt'em11t
12 Main Street ew
2 Sewer�SepticjA`kall"atiiity .-� � d
Zapg Room 100 Watel'IWeli Auailabitity°
PUS 1 Ngrtha pton, MA 01060 TWO sets ot`Structprat P3ans
phone 240 Fax 413 - 587 - 1272
Other Speay
AIPLICATION 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
2 ostcT' I • Map Lot Unit
-Zone Overlay District
EIm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
1n _ -l4 '_ A - -- ^ ata 1.4 -- - - 29 . 1 T 577
Nam ' (Print Current Mailing Address:
''II
Sig =tune " F
A Telephone ' 2P 44 2 IS 7 $5
2.2 Authorized A ent:
� aP duDF 2_05 RA-11-1< 0i
Name (Pant) Current Mailing Address:
Z erktd-g 4.13 535-9
Signatur Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (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 = (1 + 2 + 3 + 4 + 5) � �('� Check Number
_._ 7111S Se`ctiiin -FO O1'ficiat'U`se Only
_
Date
Building Permit Number: Issued:
Signature:
Building- Commissioner /Inspector of Buildings Date
File # BP- 2010 -0163
APPLICANT /CONTACT PERSON MARK BONDE
ADDRESS/PHONE 205 PARK ST EASTHAMPTON (413) 535 -9529 0
PROPERTY LOCATION 254 PROSPECT ST
MAP 24C PARCEL 014 001 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 6 -e 0:s,�
Fee Paid
Typeof Construction: ADD 1ST FLOOR BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owne o r Lic 067758
3 se of Plans / Plot Plan
THE F LOWING r/ Statement ACTION ense HAS BEE TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
TI HE
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
,.._.---- ® / 200
Signature of Buil ing 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.
254 PROSPECT ST BP- 2010 -0163
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 014 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 -0163
Project # JS- 2010 - 000198
Est. cost .$8800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK BONDE 067758
Lot Size(sq. ft.): 5793.48 Owner: PAPPALARDO THOMAS J & SARAH E SMITH
Zoning :U Ri3JOQ L dpplicant BONDE
A1.: ,2b4
Applicant Address: Phone: Insurance:
205 PARK ST (413) 535 -9529 () WC
EASTHAMPTONMA01027 ISSUED ON :8/13/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK:ADD 1ST FLOOR BATHROOM
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: +,- `r1�„,Rongh; fGi�7/ 9 House # Foundation:
i � Driveway Final:
Final: ! _� ,� 7 /} Final: /A1 1/
�J
� ! L Rough Frame:
- aH
Gas: Fire Department Fireplace /Chimney: r
Rough: Oil: Insulation:
Final: Smoke: Final: d / 4; 7‘
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy . ..2_Signature:
FeeTvpe: Date aid: Amount :
Building 8/13/2009 0 :00 :00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo