29-180 (7) •
• • . . • • AFFIDAVIT , • •
• As a result of the provisions of MGL c 40, S54, I acknowledge that as a condition of Building Permit
.. . Number all debris resulting from the construction activity governed by this
• Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL
c 111, S 150A_
I certify that I will notify the Building Official by •
. (Two months maximum) of the location of the solid waste disposal facility where_the debris •resulting from • ,
. the. said construction activity shall be disposed of, and I shall submit the .appropriate form . for attachment
to the Building Permit. ' ' : •
. • • •
`� 7-1.i .� . • . . • Date • • _r Signature of Permit Applicant
•
•
• (Print or type the following information) • • . '
•
•. . . . ' i Pi . * bh ('
. J ' :: ..) ..... . _ _
, .,
. •
N me of Permit Applicant
•
•
• ( 2 ) ?
• Firm Name, if any •
• . J •
• • . • Address
•
' :..Tht.:: :debris':`wili, be:: d 4osd :•••o :f•. ;:_:•.,. �• : : >: ...... .. ...
---:, Vir) . 0 I j . eel
(Location of Facility) 1 J _
• •
7 b C' L 7 S
•
•
•
_ Office of C Affairs and usiness Regulation
=- == - 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement C2r1tractor Registration
_= = " " " "' -' =- • - =__= Registration: 100001
Type: Private Corporation
- - - - Expiration: 6/8/2012 Tr# 297762
The Jubb Company, Inc.
Larry Jubb -
P. O. Box 429
Greenfield, MA 01302
r
er -� \ c
\' /, c� , Update Address and return card. Mark reason for change.
` � I . ) ,• 0 Address 0 Renewal iLi Employment 0 Lost Card
DPS -CA1 0 50M- 04/04- G101216
+.. Massachusetts - Department or Public sarct,
Board or Budding Itt•tul:ttiun.. anti Slumlords
Construction Sutn'rvt scar I
License: CS 55333
Restricted to: 00 ?r` ,
a t
' ,
LAWRENCE A JUBB JR f t � J "'j y SSS2 ?
PO BOX 429 ',Y;;;;
GREENFIELD, MA 01302
•
Expiration: 5/21/2012
'mnni•Ai,ni•t• TO: 24599
U., LLI LC111 IL. :JO 4.I.Otib..1'Jt Dlii AH K1ST INSURANCE PAGE U1 /01
„. „..mos. I
A D CERTIFICA 1 E OF LIABILITY INSURANCE _ _ E(MM o11 Y)
THIS CERTIFICATE IS ISSUED AS A MATTER OF II'FORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR N= ATlVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED EY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DO:;- NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERT .ICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIe: AL INSURED, the poiley(Ies) must be endorsed. If SUBROGATION IS WAIVED, subJect to
the terms and conditions of the policy, certain pollcl}, • may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s). -
PRODUCER t. CONTACT '1'rac y KvklewiC
PM M _ Fax -- .
A.H. Riot: Insurance Agency, Inc. _(A/C „No,ExtlL (413)863 - I_(A/C.� (4123a - R65a
159 Avenue A e•MArL
ADDRESS:
P.O. Box 391 i PRODUCER 00002625
...CI1.S.tO M E R, ID a:
Turners Falls to 01376 i _fNSURERU AFFORDIN COVERAGE_ NAIC 11_
INSURED I INSURER Insurance ... Company 24198
INSURER fat _.. . _
!The Jubb Company, Inc, 1 INSURER ,c, t
: P.O. BCOX 429 I
INSURER D : _._... ,.._
INSURER E : __
GR'EENFIELD 1•1F'. 01302 —
INSURER P :
COVERAGES CERTIFICATE NUII,- cER :CL111300070 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, T: M OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE II SURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMI 1' SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR i "� ADDL SUER i 1. POLICY EPP 7C kley E:XP I — — _..._
- I TYPE OF INSURANCE . -: ,AR POLICY NUMBER (�j�tiIYVYYE__ YYY) I LIMITS
GENERAL LIABILITY (' ■ T EACH OCCURRENCE $ 1,000,000
I---1 I 6AMAGE TO RENTED —_
1 X COMMERCIAL LIABILITY I 1 ' ka351)1)y8E,B_(EAocourren_oj $ 100,000
A I j CLAIMS -MADE ; OCCUR ICHT+B. 1749 $/3/20 .0 5/3/2011 h9 °D EXP (An one pereor) ; ,e _ _ 1.5 , 000
I ( PERSONAL & AU” INJURY I $ 1,000,000
I I, I GENERAL AGGRIG,ATE 1s 2,000,000
1
GEN'L AGGRE G ATE LIMIT APPLIES PER: I PROCUCTS - COkiP /O AGG f $ 2,000,000
PRO- L ..., 1 S
_ POLICY . J`r I . LOC _
1 AUTOMOBILE LIABILITY j I I: COM G
BINSD SINE LIMIT I P
. I (Ea accident)
I ANY AUTO i— ._.... RASE -2A7 5I3 /2010 5/3/2011
I e t
I BODILY INJURY ( or pnrron, $ 1 , 000 , 000
� � - • - - - - -
A 1 ALL OWNED AUTOS j BODILY INJURY ( necidrnij I. S ], , 000 , 000
� , I SC AUTOS I � •
PROPF,P,TY DAMAGE
IX I HIRED AUTOS (Per =olden() a `1�OD0,000
X 1 NON -OWNED AUTOS I PIP-BEs!c S 8,000
I I Uninkurad motorise BI split limit 5 20 , 000
UMBRELLA LIAR I j OCCUR L, EACH CCGURr?[NCE a
EXCESS LIAR 1 CLAIMS•MADE f I AGGREGATE 1 A.
_... ,...,. i i
DEDUCTIBLE _._,- .... --
I �.
,S
RETENTION g 000 I we STATU 0-
TH
WORKERS COMPENSATION
A I I is I , 7QRY_LIMJZEJ_ . .
I_ER...
AND EMPLOYERS' LIABILITY
■ ANY PROPRIETORIPARTNERIFXECUTIVE I 1 N I E,1., EACH ACCIDENT T S _ -- , 100,000
WC86 947 /3/2010
OFFicLR/MEM9ER EXCI,UDcD1 I 'h N / A I I„ /3/20 100
(Mandatory In NH) r • J : 157.7 Et, DISEASE ;FJ, EMPLOYE S
D$ 100
(Mandatory
If yen describe under
G OF OPERATIONS below F.L. DISEASE - POLICY LIMIT $ -. 500,000
DESCRIPTION OP OPERATIONS !LOCATIONS / VEHICLES (Attach ACORD I +1, AddlEonnl Remarks Schedule, IF more spate le required)
C],aCai ieiation: Siding Xnata1lation
C ERTIFICATE HOLDER , CANCELLATION
(4 ".:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED G_ °PC1Si?
THE EXPIRATION PATE THEREOF, NOTICE Wu_ el n x
. ACCORDANCE WITH THE POLICY PR V?S :.?N3.
fJ i
i Tria.cay Kula inri e /TM :. _ /- --_ $ r•'� – .. ..r S
o:,. I, !4) - 1909=Z00n ACORD CI All f ...- .. r , .
firs �. _ . 3_; f. , . .
The Commonwealth of Massachusetts
Department of Industrial Accidents
h _►:� Office of
__�: �- _• 600 Washington Street
Boston, MA 02111
W► VW. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): I I l �� L ► I � I �Qi ti 1���1 / ► C
Address: 0. go, a9
City /State /Zip: C c H Phone #: a .7
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees (full and/or part - time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. x ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. 0 We arc a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12.0 Roof repairs
insurance required:] t employees. I No workers' 13.0 Other
comp. insurance required.'
Any applicant that checks box ill must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
1 Contraclors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: , ) C r)
Policy # or Self -ins. Lic. #: (/ Expiration Date: 5 l 3 /)
Job Site Address: City /State /Zip:
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 under the pains and penalties of perjury that the information provided above is true and correct.
Smnature: — � Date:
Phone #: 7 - 7.2- Co a_f 7
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction / Supervisor. j Not Applicable ❑
Name of License Holder : L t � (,v a - e %I ( L _ v h )i) '7 ' 6
License umber
if () / 9( V C ( ' 2 6 7 ,6 16 -jr1 /
.k. ; ) 1. ,,, _
Address .. Expiration Date
�1
S ignature_. Telephony 1
9. Retlistered Home InaproyefnentContractor Not Applicable ❑
J C(jO f
Company Name Registration Number ,
CL
Address Expiration Date
) �, s f S C L/ (:✓ al / 11 ( 1
�c"Telephone —7 ? J _ . 2 / ?
C
-
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M_G.L. c. 152, § 25C(8)) I
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....
II No ❑
11. - Horne Owner Exemption
The current exemption for "homeowners" was extended to include Ow - 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) [J Roofing
Or Doors (]
Accessory Bldg. ❑ Demolition ❑ New Signs [l] Decks [p Siding [0] Other [0]
Brief Description of Proposed ` ( j
Work: j I 1 � \ .� V ��� ii i (�i l "� ( AI . C.P `t &Cv%(2
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea. If New house and or addition to existing housing, Complete 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 oonstruction. 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
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I , 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
Signature of 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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
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 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES; Was the permit recorded at the Registry 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 0 DONT KNOW 0 YES Q
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 0
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 0
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 0 NO ()
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t L ft 910
Department use only
t *T 01- 4, City of Northampton Status of Permit
Building Department Curb Cutll�ivew�ay Permits
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
�? nlel►�sr_ n 13 -587 -1240 Fax 413 -587 -1272 Plot/Site Plans
• , ' Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELUNG
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
' �'C_ Map Lot Unit
V/ ( l _,l!(J -1c(c L
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
4 IIIfoil
Name (Print) Current Mailing Addr
- .- Telephone
Signature j _;
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1
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) 0 '1 L no Check Number jd/ 90 - k
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
194 BROOKSIDE CIR BP- 2011 -0817
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 180 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2011 -0817
Project # JS- 2011- 001341
Est. Cost: $7700.00
Fee: $77.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THE JUBB CO INC 055333
Lot Size(sq. ft.): 19950.48 Owner: MORIARTY HOWARD J & AUDREY M & K T TOBIN & L M MORIARTY
Zoning: URA(100) //WSP /WSP II Applicant: THE JUBB CO INC
AT: 194 BROOKSIDE CIR
Applicant Address: - Phone: Insurance:
P O Box 429 (413) 772 -6217 Workers
Compensation
GREENFIELDMA01302 ISSUED ON:4/11/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE MAIN HOUSE,REAR PORCH &
GARAGE
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 4/11/2011 0:00:00 $77.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner