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8/9/2011 2:01 PM FROM: King Cushman Insur King _Cushman Insur TO: 14135290006 PAGE: 001 OF 002 Client#: 9759 NEWEN6 ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE ( o ° � YY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION • King & Cushman, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE King & Finn Streets HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR • ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. P.O. Box 447 • Northampton, MA 01061 INSURERS AFFORDING COVERAGE NAIC# • INSURED INSURER A: Safety Insurance Company New England Remodeling INSURER B: AIM Mutual Insurance Company General Contractors, Inc. INSURER C: 67 Division Street INSURER D: Easthampton, MA 01027 INSURER E: 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. h N POLICY TE ( MMID DATE ( M4NDD/YYj TR INSND RC TYPE OF INSURANCE POLICY NUMBER LIMITS A . GENERAL LIABILITY CP00000302 09/23/10 09/23/11 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY P F I.SFGOjFs RENTED Rj na+l 5100,000 CLAIMS MADE © OCCUR MED EXP (My one person) $10,000 PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 - .. • GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 7 POLICY n ref n LOC • A AUTOMOBILE LIABILITY 2395873 03/09/11 03/09/12 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ _ ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $250 HIRED AUTOS BODILY INJURY $500 NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $100,000 (Per accident) • GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ •, R ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESSNMBRELLAUABILITY EACH OCCURRENCE _ $ OCCUR n CLAIMS MADE AGGREGATE $ _R DEDUCTIBLE $ • RETENTION $ $ B WORKERS COMPENSATION AND WCC5006015012011 09/04/11 09/04/12 X 1 TORY 1 MRS {` I IOFR EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $100,000 . ANY PROPRIETOR/PARTNERIEXECUTVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $1 00,000 Ifyes desaibeUnder SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $500,000 • - OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRBED POLICIES BE CANCELLED BEFORE THE EXPIRATION • DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAL in DAYS WRITTEN NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FALURE TO DO SD SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR . REPRESENTATIVES. A �� E ATIVE ACORD 25 (2001/08) 1 of 2 #10447 SMF o ACORD CORPORATION 1988 New England Remodeling General Contractors Inc. www.neremodeling.net Proposal /Contract No.: 15023 Thomas M. Bacis Date: 07/10/11 67 Division Street Easthampton, MA 01027 MA Lic. #: 070061 (413)529 -0801 MA Reg. #: 149948 TO: Kevin Krumppholz PROJECT: Ryan Rd. 395 Ryan Rd. Job Description Price Remove damaged sheet rock and insulation from 2 front bedrooms and living room. Install new sheetrock, tape and sand. Replace any misplaced insulation. Dispose of all material. Includes permit fees and disposal fees. TOTAL: $7,680.00 - A 1 1/2% monthly service charge shall be applied to any balance over 30 days. - Above prices good for 21 days. - Any additional work or changes will be priced at the rate of $55.00/hr. plus material. '1 Customer Signature: Cu r K r vtve hal z- Q Date: U `0 - It Customer Signature: Date: J Contractor Signature: — / Date: `-/ C v V City of Northampton /;t.0$7, Massachusetts .e �r DEPARTMENT OF BUILDING INSPECTIONS � I x: 212 Main Street • Municipal Building 5 " � Northampton, MA 01060 t� INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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, which include foundation /footings (before backfill), 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 the work can be inspected. If the 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 • The Commonwealth of Massachusetts Department of Industrial Accidents iremmes 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): �&k' s f e I'h OdeLit- Address: G V) , ,/i St di) S 1, City /State /Zip: � � S "� p r Q �n 11" Phone #: Sd- 9 - o c t Are you an employer? Check the appropriate box: Type of project (required): 1. FA I am a employer with 2_. 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- ors have listed on the attached sheet. 7. Remodeling These sub- contract h ship and have no employees 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ 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. ❑ 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. ❑ 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: 5-56C, G 1 ?d Chr1 p/i y e is T CC Policy # or Self -ins. Lic. #: (n6 6 01 _c o/ .. � G to Expiration Date: seer, 7 0 .26 1/ Job Site Address: c xG/, d . City/State /Zip:,/( r rhari p tdrl / I Q . 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 perjuly that the information provided above is true and correct. Signature: . Date: - 1/ - i l Phone #: ( It 7 Shy - 0& D 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: Not ❑ j Name of License Holder : L 1 v ?av6 1 License Number 0 1 V 1 S 7 7 -6 -13 Address Expiration Date y 5 u8 c Signature Telephone e*Uistered Home mprovemen' Contra or� ; ; - , a�i „ . , •` Not Applicable ❑ 4 C O - egA-tos el, -, _ C , i ce, Icfaq 9 y ompanv Name Registration Number n ,1\/ $ �;,, s 7, 12- Address Expiration Date f at, r h akl p ,26t, , Telephone ¶d- —0 (F01 _ h Y 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 ❑ a .0 8 eA3WilertEXCITiPtiOii 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 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) n Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[:::] Siding [0] Other [ Brief Description of Proposed rc.c L e t / / WI f 7 Q /C (,.iCtlr f roo Work: '(L f – p s h C � � cc � � g f w,og Alteration of existing bedroom Yes V No Adding new bedroom Yes V No Attached Narrative Renovating unfinished basement Yes t/ No Plans Attached Roll - Sheet ;E;a l mew l uservand.or.¢addif an to,.ezis#ir g c wsinq comple #e 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 OWNERAUTHORIZATION -TO BE COMPLETED WHEN OWNERSAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT`' I, , 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, IJri� S as Owner/ uthorized ge ereby declare that the statements and information on the foregoing application are true and accurate, to the best of edge a belief. Signed under the pains and penalties of perjury. 7e v" g �� 1 Print Name /40 ` — Jb -' f Signature of Owner /Agent Date Section 4. ZONING • 1 Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information • Existing Proposed Required by ' liming ROI This column to be filled in by Building Department . t! Lot Size I , ' i I e S Frontage i , Setbacks Front I € € I Side L:` i R I R:1 { 1 Rear Building Height i I i E Bldg. Square Footage I 1 ➢ % 1 Open Space Footage - , r � ; (Lot area minus bldg & paved , I r € parking) # of Parking Spaces 1 l Fill: # _ - (volume & Location) i 1 € i t A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW '� I YES 0 IF YES, date issued:! } IF YES: Was the permit recorded at the R gistry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page; and /or Document #1 B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO ip IF YES, describe size, type and location: 1 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, cavation, 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. r r f ," I �. �.� 3 9 x � � ®.d rtrneot os i0 'l: s" a $ ' eCity of Northampton 5tat s °o I?ert L c a,� Z i i , wilding Department Cu •� - y 1 -- � , ,_- . 212 Main Street S a ® ab1t Room 100 IabFt S ty 11 1 i i,o p a i r BUILDING ar Northampton, FIX 01060 T ® ®Str «u a . - pFione 413 -587 -1240 413 587 -1272 ®� - Fa ° Of pecl . -- APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING S ECTION 1- SITE INFORMATION Th s to be completed by o h 1.1 Property Address � , E � , T,' %,, ' '. , A * . ne g �'. -* . '�u °- , ' - :- ` "" x x ' k e 'n. _ `' ' / ) Map I., >.Lot, '• '' -: ' U n i t 3� r V.. yon C psi' 4,A 21 - a •. a" ., �E ri ,. r c .gy -� 04.^, 5 -v- *- o ne ~ �`; zi i4 , - Overlay D 5 „x ' - , } . ' i k, •. .R lAit r.F �,} k " y s D istri t ,s., . E1mSt District CB D istract SECTION.2 .PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: / k�"'I1 k ��'�' z— lqs� l'‘/64/1 led Name (Print) Current Mailing Address: CO N 1 �A �T Telephone G� y 4(1° Telephon Signature 2.2 Authorized Anent: --- Name (Print) J Current Mailing Address: �--�,,4..� S 0 �c) / Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated C (Dollars) to be . Official Use Only , completed by permit applicant °' . 1. Building / p '— (a) Building Permit Fee D 2. Electrical �- -� (b) Estimated : Total _` "Construr Li on f rom (6) ost of m . - . _ . r 3. Plumbing �_ Build P Fee 4. Mechanical (HVAC)� 5. Fire Protection �_ 6. Total= (1 +2 +3 +4 +5) g G� (/d Check Nu This Section F Official Use On - - Buildi P ermi t N Issued. jiiirwoo, Signatu ; Building Commissioner /Inspector of Buildings Date • 395 RYAN RD BP- 2012 -0167 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 553 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -0167 Project # JS- 2012- 000251 Est. Cost: $7680.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS BACIS 070061 Lot Size(sq. ft.): 20124.72 Owner: KRUMPHOLZ KEVIN J & BRENDA L Zoning: URA(100) //WSP Applicant: THOMAS BACIS AT: 395 RYAN RD Applicant Address: Phone: Insurance: 67 DIVISION ST (413) 529 -0801 WC EASTHAMPTONMAO1027 ISSUED ON:8/11/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR WATER DAMAGE SHEETROCK CEILINGS & WALLS 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 8/11/2011 0:00:00 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner City of Northampton, MA Basic View Page 3 of 3 Search 'Contents' Index Terms of Service F.A.Q. Privacy Policy Font size: Smaller Bigger http: / /ecode360.cQm/ecode3- back / getSimple Jsp ?custId= NO2226 &guid= 11957486 8/11/2010 v\\9LA • C D r v5 1 -) N-S 4- S,?)6.7 j 0 ISra )ND X51 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 constructron 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, which include foundation /footings (before backfill), 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 the work can be inspected. If the 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 i3sermits 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 _ understand the above. (Home owner /resident's si_ • ature r questing exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date � IZ((O Address of work � � V �, PAfr O106 location y l(cJ • -- . , ' ' • The Commonwealth of Massachusetts Department of Indus Accidents Office of Investigations 600 Washington Street Boston, MA 02111 - www.mass.govidia _,. - Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly , Name (Business/Organizationandivirinal): Y--ev‘, A 3 • K tkkvvtA. Address: 3q's City/State/Zip: RA MO Ce AAA- 0i0 6 2.- Phone #: S13 b - I tiq ( 0 t - Are you an employer? Check the appropriate box: Type of project (required): //' 1. 0 I am a employer with 4.. Q I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet 7. 0 Remodeling 2.0 I am a sole proprietor or partner- ship p These sub-contractors have nri have no ,Dloyees 8• 0 Demolon employees and have workers' working for me in any capacity. 9 EIBuilding addition t [No ' corr. insurance al reers mI am a homeowner doing all work officers havetrercised their 5. 0 We are a corporation and its i 100 Electrical repairs or additions 3. iza; 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roo .j.ni , insurance required.] l' c. 152, §1(4), and we have no 13.0' l'Ir S 14 C ill (1.1 employees. [No workers' 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. tContractors 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 nmnber. Jam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: 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 ofMGL c 152 can lead to the itopOsitiOn of criminal penalties of a fine up to 81,500.00 and/or one-year iminisonment, as well as civil penalties in the form of a STOP WORIC 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 Ofifee of _ _ , ._. , ThrfiSlieiticuis the DIA for insurance cove:raze verification. ./thi hereby certi under the pains and penalties ofperjury that the information pro above.ktrue_aid_correct S - _ ignature: • ( ( to i , . Phone it: . . . Official use only Do not write in this area, to be completed by city or town officiaL City or Town: Per' mit/License # Issuing Authority (circle one): "- 1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone S: Regis' Cords. hn lthlbro4 rnnhit WntfPetor "° < bIP i 1 Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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 • tate of Massachusetts General Laws Annotated. Homeowner Signature ! . , ski A �� affr SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House i Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ED Or Doors CI Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [IA 5 Brief Description of Proposed � Work: S '� l(7 C7 *C_ P 1C ( S14Cd Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes c/No Plans Attached Roll - Sheet Asa, If e.w h`o .sea 1d ulr Sri tit is to a cisti q . roiustnt�; >ript+ .th c�itorlir'rna: 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 , 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, 6/k � vt/tw l , as Owner /Authorized Agent hereby declare that the statements Ald 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. vkthvi\ANI Print Na e I . 0 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 Sizeileae- a , I , E Frontage ` 1 Setbacks Front 7 Side L: i R:I i f L R:' � Rear I (Sr OFC f V°ir 1 Building Height t I I W i Bldg. Square oo ge 1 I % i I Open Space Footage % , (Lot area minus bldg & paved L I L.. I I parking) # of Parking Spaces ..._ } n 0 ■' Wig► C / CO Fill: I .,_ ._.� ...,.. �,_. �.._..._..�._. 1 (volume & Location) �V A. Has a Speci ermit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 0 1 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I Pagel I and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q 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 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 Q NO 0,--- . IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavati , r 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. City of Northampton ,Statusri � � t fr ,( \\) Building Department s� g �a 212\lylain Street m g ff 3 ' 'oom 100 Northampton, MA 01060 LIA phone 413- 587 -1240 Fax 413- 587 -1272 ° n ttsi�M�2`' 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 3C T-4 Map Lot Unit ( Oa Ce 0 6 Zane Overlay District l 1 Elm St: District " CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: a s vVk -vv1 t (Z S.15 1Zyow,1 . . CO t Ce 01062- Name (Print) JJ ,, Current Mailing A ess: _ .... 0..�l, Telephone J V i7 Lie) l/ 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 I(1 s t ked ft i 8 00 (a) Building Permit Fee 2. Electrical J __ __._— (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 1101 016 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0151 APPLICANT /CONTACT PERSON KRUMPHOLZ KEVIN J & BRENDA L ADDRESS/PHONE 395 RYAN RD FLORENCE (413) 586 -4910 Q PROPERTY LOCATION 395 RYAN RD MAP 29 PARCEL 553 001 ZONE URA(100) / /WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �/�sr Fee Paid �"� Typeof Construction: ERECT 8 X 12 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 (1/ 0 Signature of Building • fficial 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. 395 RYAN RD BP-2011-0151 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 553 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- 2011 -0151 Project # JS- 2011- 000247 Est. Cost: $1800.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 20124.72 Owner: KRUMPHOLZ KEVIN J & BRENDA L Zoning: URA(l00) / /WSP Applicant: KRUMPHOLZ KEVIN J & BRENDA L AT: 395 RYAN RD Applicant Address: Phone: Insurance: 395 RYAN RD (413) 586 -4910 O FLORENCEMA01062 ISSUED ON:8/27/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: ERECT 8 X 12 SHED 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 8/27/2010 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner