31A-153 ' MA/dp ,. ' ' City of Northampton 5 X11 16 2011
I r' ' e is a. k, � ?S� lik
°A Massachusetts `�
q :t !t 7 r' :';tl... id el '1W..:..! E DEPARTMENT OF BUILDING INSPECTIONS 1-
. s ": 212 Main Street • Municipal Building ti 4
' c . Northamp MA 01060 S NY 1
Property Address: G ' /l /44/ 'nom /` 0 A 7 ) , /10 /a.-7-7-1A-77-14 P - 1 141 - , A
Contractor
Name: /d LEA/- \// f!M -) 7jFzCo ->rL i - 00,—s -/n,,%- J a i Lcc
Address: 7 & /�4 - c;E o ,C--T "'33 •
City, State: R/o tezr71, -,-i; . -v , A -t A • 0 i o
Phone: L/ /3 Sa' 7^ 0/ 3 7
Property Owner
Name: C%.e is _i) 4 -mac s
Address: (// /-1Y-) te"'s •
City, State: " /ti,e-rat ~27 , ,c-r.d _ 0 / o C c.3
■
1, /=d n/ ✓d 7. Z_S- v ' I 4 (contractor) attest and affirm that the building I intend to
insulate does not have any open air (knob and tube) wiring in the spaces to be insulted and that I have
provided the property owner with a copy of this affidavit.
Contractor signature i_____,..„0 •).
Date /
& / (6120 1/
• VDAC
TRAVELERS
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (7PJUB- 0545N1 3 -1 -11 )
RENEWAL OF (7PJUB- 0545N13 -1 -10 )
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
1 NCCI CO CODE: 13579
INSURED: PRODUCER:
DE LONG CONSTRUCTION LLC WHALEN INS AGCY
76 BANCROFT ROAD 71 KING STREET
NORTHAMPTON MA 01060 NORTHAMPTON MA 01060
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05 - 26 - 11 to 05 - 26 - 12 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
d�■
oMMI■
B. 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:
Bodily Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease: $ 1000000 Policy Limit
Bodily Injury by Disease: $ 1000000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
O=
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
Os
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 04 -25 -11 WC ST ASSIGN: MA
OFFICE: DIRECT ASSIGNMENT 701
PRODUCER: WHALEN INS AGCY 28LKF
001404
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, act as their own constructionsupervisor, 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 backfll)
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
iermits 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 DLLAY 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
,a•
•
The Commonwealth o I
Department of Industrial ACciderzts
Office of InvestigationS
600 Washington Street
=,:m= Boston, MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2iblv •
Name (Businesi/Orgardiation/Individual): c . c
• Address: 7 73,4tAre,eorr
City/State/Zip: Afo l Phone.#: 41(3,- 3 _
Are you an employer? Check the appropriatehox: • • •Type of project (required):
• 1n I am a employer with 4. 0 I am a general contractor and I
6. 0 New coistruCticm
have hired the sub-contractors
employees (full and/or part-time).
2_ Ei I am a sole proprietor or partner- listed on theaftnrbed sheet 7. 0 emodeling
• ship and have no employees These sub-coniractors have 8 D Deinblition
epAera
working for me in any capacity. goy id.have workers'
[No workers' comp. insurance • - con - -
10.0 Electrical repairs or additions
5. 0 We are a corpora: tion and its
3. 0 I am a homeowner doing all work °fficen bvi4xereiset1 their . 11.n PluMbing repairs or additions
myself [No workers' comp. ri aexemPti°2i per MGL 12.1E Roof repairs' . •
insurance required..] t c 152, §1(4); and We have no • . . ,
employees: [No workers' 13 .0 Other /•"s
• comp. insurance reqUiated.1. •
*Any applic:ant that checks bOx #.1: must also fill out the section below showing their*orkess'-comixensation policy information;
Homeowners . who submit thii airtda;it.incHcatin they are doing all work and then hire outside contractors must submit anew affidavit indicating sigh
TContractms that check this box must attached tin width:mai sleet showing the name of the sub-contractors and Mite whether= notahose =aides have
einployees. If the stih-contractorshaVe employees; they mustpravide their warkets comp policy number
l am an employer that is providing workers' compensation insurance for my employees. Below i.s the poliCy ondjob site
information.
Insurance Company Name: Vi
Policy # of Self-ins Lic. #: 77) 3-u-a 5 " Saj - -// Expiration Date : - /..2 /4 12.
. _
Job Site Address: c- fl 0 City/StafriZip:* -""/ A-4/4 ^ 0 / 0
Attach a copy of the workers': compensation policy declaration page the policy "mintier andeapirition date).
Failure to secure coverage as reqUiredinickif 25A 152 . 6iii lead to the iiepoti�n ofefirintiaj iienalties of a
fine up to S1,500.00 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 oopyOftbis statement may be forwarded to ilie:OtteCe of
_
j1Jzeiebj ceLrftJ5i under thep azns -7- land pest eriit&i:oiiiijray that the inforraritiOnprOviiiri.ObOv&&t
Signatnre: T •
Phone 3 -6 ? VS 7 _ : • : • • " •
• Official use only. Do not write in this area, to be completed by city Or townOirzciaL
•
City or Town: '- Permit/License #
Issuing Authority (circle one):
:1. Beard of Health 2. Building Department 3. City/Town Clerk 4. ElectricalIzispector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : EdM ✓r✓ F�vv;i�4�, C - e-/Z
License Number
7(0 '2;'4 A..t4 • 46 72_0
Address Expiration Date
4 713 - c8 7- el 47
Signature Telephone
Registered. dnii lmitiioveimiaeaii iradttbr' . =g ._.m , tW . Z.,. i Not Applicable ❑
� �LG 4 �✓4 CU Div,! , c C / S/ &//
Company Name Registration Number
76 '3,4+✓(reo per . 6 / (5 - 2. o /
Address Expiration Date
/I/�r'TN �hW7,7d A AA - o / a6,3 Telephone '/13'S87_ 037
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
SECTION 5 DESCRIPTION OF PROPOSED WORK (check all applicable)
New House D Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [O] Other [f
Brief Description of Proposed
Work: /46--fora .S'rJ b tc r dk,.i- Re,G . ,r7:5 -' , "r1 / .4 i
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
4'4 ti`ivu til4h li additoR6 tstt ct iii l :%iipt a to fdlitikifa:
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, C /,e i5 -- 1),e 44Ateis , as Owner of the subject
property
hereby authorize fct z 6v4 , H , ,-J
to act on my behalf rs relative to work authorized by this building permit application.
C l' (,i,//2 b. 1 /
Signature of Owner Date
I £d ^44,4 4 T' L .F�u' i , as 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.
,'d 1 Jc{ '7 4 6# H.u.
Print Name
_ P ' , ,�--_ w //L /L 0 I/
Signature of.Q /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Requirediby Zoning
This column to be filled in by C
Building Department .t
Lot Size i ____ _.J i .__ I
_. y
A
. ,
Frontage '. ,._,_ . 1 # I
Setbacks Front 1 � ,
Side L: R: f L:i ' R: } E,
Rear E-- ---- l i r
Building Height r _ s
Bldg. Square Footage 1 1 1" % '" $ i ,..1._i
Open Space Footage , %
(Lot area minus bldg & paved i I
parking)
�ww
# of Parking Spaces
Fill: a �...._
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 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 Page and /or Document # v ._
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: r .
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: j
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
�t«'�'r &.gig i a q � • _
ity of Northampton ti '" ?
GG ilding Department a • '°
' x v
0 12 Main Street s� .
32 \\ Room 100
�-•rth- mpton, MA 01060
-1240 Fax 413- 587 -1272
- (CATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Oil /f AM , D . Map Lot U nit
lane OverlayAistrict
Etnr St° District ' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
CX,e 7 ��.sti %S -// ii,ry/.tae'D
Name (Print) ' „ Current Mailing Address:
Telephone 7 5/ 3
Signature
2.2 Authorized Agent:
Ed L 6,Jwi 1/ 76 - B4Art,eo C7 - /27. — ( A.
Name (Print) Current Mailing Address:
-- � . z/ �9S 36E
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building —4s 000 [- (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) 7g O Check Number i
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
# G
File # BP- 2011 -1039 -rQ 65(1t€
o
APPLICANT /CONTACT PERSON ED LENNIHAN - F �N
ADDRESS/PHONE 76 Bancroft Road Northampton 587 -0437 SA) (/
PROPERTY LOCATION 41 MAYNARD RD SA) ° Q E Cl fl
MAP 3IAPARCEL 153 001 ZONE URB(100)/ K� . i -(6 e
THIS SECTION FOR OFFICIAL USE ONLY: �� tJ 49E�t�"'
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 16079)- l5
Fee Paid
Typeof Construction: INSULATE ATTIC & INSTALL SNOW BELT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 042506
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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
e/(S
S ature of Building 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.
41 MAYNARD RD BP- 2011 -1039
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 153 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateory: INSULATION BUILDING PERMIT
Permit # BP- 2011 -1039
Project # JS -2011- 001677
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED LENNIHAN 042506
Lot Size(sq. ft.): 8015.04 Owner: DEFRANCIS CHRISTOPHER & JENNIFER GROSS
Zoning: URB(100)/ Applicant: ED LENNIHAN
AT: 41 MAYNARD RD
Applicant Address: Phone: Insurance:
76 Bancroft Road 587 -0437 WC
NorthamptonMA01060 ISSUED ON :6/16/2011 0:00:00
TO PERFORM THE FOLLOWING WORK :INSULATE ATTIC & INSTALL SNOW BELT
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: `l' -°2- 2 •'t " 4
Final: Smoke: Final :_ -4'3 • .2?_ �J-
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES • IONS.
AZ. Aro &ettoloC.4
Certificate of Occupancy's , Signature:
141t4
FeeType: Date Paid: Amount:
Building 6/16/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner