23A-296 JUL /09/2012/M01 09.19 AM FAX N . F. /
00
ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MMroD+YYW)
07/09/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS I
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES !
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. i
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policyties) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Webber & Grinnell Ins. Agency, Inc. PHONE 1 413.586.0111 I FAX 413.586.648 !NC No Eat): I (NC, No):
8 North King Street h4 AIL ADDRESS: J
Northampton, MA 01060 PRODUC ID /: 00020678 —
IH3URERIS) AFFORDING COVERAGE RAC a I
IN SURE O NSURER A Peerless Insurance I
Leonard Buck & David Fortier INSURERS:
DBA: Buck Brothers Concrete Service & Dave Fort
INSuRERC : _
PO Box 416 NSU —1,
INSURER C . _
Hadley, MA 01035 INSURE
INSURER F: l I
COVERAGES CERTIFICATE NUMBER: Exp 2012 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, 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, I
7p� TYPE OF INSURANCE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
-- - ADOLSL ERI ' POLICY EFF POLICY tRP I
L INSR YWOi POLICY NUNIBER (101IDDM'W; 04VODNYN 1 LIMITS
GENERAL LIABILITY I I
EACH OCCURRENCE I $
H nP.M AG TO RE!v7En __— I _ —�
COMNEFC AL GENERAL LIABILITY I PREMISES lib cecurrenc.: 4 $ — I
1 CLAIMS -MADE L OCCUR I MED EXP (An e person) , $
' I , PERSONAL & Ar.i, IP JLRY i $
1----- 1 GENERAL AGGREGATE ' $
SEN'_ AGGREGATE LIMIT A °PLIES P= R PRODUCTS - COMP /O' AGO I JI
�$ $ 1
�' PRO -
{ I
POLICY 1 I JECT LPL,
AUTOMOBILE LIABILTY j 1 COMEINED SINGLE LIMIT $ 1
(Ea accident!
I
ANY AUTO ECCILY INJURY (Ear,erson) I $
1 .ALL 04A+tNED AUTOS
ECEDLY IWUP` (P ;Leid•n) 1 $
I SCHEDULE: AUTO: PROPER_N DAMAGE
T H
n A UTOS (Per;�;IOe .' ;
�_
a
1 _ i UMBRELLA LIAB h I OCCUR i I EACH OCCURFENCE I$
I ' EXCESS LAB i I CLi- '.f.1S -?,FS E ,AGGRED,RTE $
,--
:OOJCTIOLE 1 $ --I 1--j RETENTION: $ t I I I I 1$ 1
WORKERS COMPENSATION • ''C STATJ- 1 DTH- I
WC850399109105120 1 09!0512012 X TORY LIMITS , ER I
I AND EMPLOYERS' LIABILITY Y f n --- ■ . NIPROP , °.IETOR /RARTVERI=:KECUTIVE — I EL EACH ACCIDENT $ 100,D
A !! OH: CEP /MEMBER E.{CU_CED: N I NIA t —
1 ;Mandatory In NH) [E.}. DISEASE - EA EMFLOYEEI $ _ 100 , 000
■ f V,s descr "re urnier ! ---
DESCRIPTION OF CPERA'iONS oe E L DISEASE - POLICY LIMIT I $ 500,000
I
DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (Attach ACORD 101, AddiSonal Remarks Schedule, if more space Is required)
CERTIFICATE HOLDER CANCELLATION
I FAX: 413.586.8965 I !.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Northampton
City Hall AUTHORIZED REPRESENTATIVE
Main Street
Northampton, MA 01060 Barbara Grynkiewicz/BARBG
% 1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
City of Northampton
e
f NC H..' ,..- »,�,
�� Massachusetts'
Ishit il NI DEPARTMENT OF BUILDING INSPECTIONS �
", -� ,1 212 Main Street • Municipal Building �b ■
if " Northampton, MA 01060 ' 3,
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
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): �C ? �}.'. ,),t it ? 1 1. 423
Address: . 2 ZA-U,z T.
City /State /Zip: if)��a� iq ,w ‘t f1 , c't C) CAE/ Phone #: to( _. 6- 6
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a employer with 3 4. I am a general contractor and I
employees (full and /or part- time).* have hired the sub - contractors 6. ❑New construction
listed on the attached sheet. 7. 0 Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have g. Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.0 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 13.0 Other {Li'i Ai.tr ✓: ^, c w
employees. [No workers'
comp. insurance required.] Si 06i
*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. ---
Company Name: t C)
Policy # or Self -ins. Lic. #: IN (y S 3 c i9 I Expiration Date:
Job Site Address: 1‘7 City/State /Zip: t - 1 t 1,4;4' i Ci 0 #(6'
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.
Ido hereby certi under the pains and penalties of perjury that the information provided above is true and correct
Signature: 1. )1 �✓ l D ate: Cl/ I '
Phone #: -1 C 3 6-`t c
- 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 Applicable ❑
Name of License Holder : (-) 1 r ' J (`L e 5 t)4 : 9 6.0A4
License Number
Address Expiration ate
Signature Telephone
9:YRegisfe7ed Home lmprovemen#',°Contiactor n V-27r:2ZaW4 -r , Not Applicable ❑
I OS
Company Name Registration Number
Op,.) t g
CLo
Address , G Expiration ate
3 1-7 � � � I A�I Iuf" 1 TelephoneVi
SECTION X10- 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 ❑
...y lome,, weer xelnp on
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
•
J
SECTION 5 DESCRIPTION OF PROPOSED WORK..(check all' applicable) .,,., 0 . ,
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing n
—1 Or Doors tW
1
Accessory Bldg. I i Demolition ❑ New Signs [O] Decks [0 Siding 011 Other [p]
Brief Description of Proposed
Work: ISirtAcet. iii, ) i frJ 2ca,» <. ' 3�) l c.F
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa, l ew liouse;Zti or addit n.to existing. housing ompiete:theafoliowing:
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 7O' BE COMPLETED WHEN
OWNERS AGENT OR CONT.RAGTOR:APPLIES FORBUILDING PERMIT
1, �v I 'v ,Q o hi2e. , as Owner of the subject
property
Dif
here• authorize i1 ; 4' 17 er
to : •n my b;,, alf, in - matte joio -ti - to work authorized by this building permit a lication.
2401 _ At .� _ f i--,;72())
Sill ture of Owner Date
I L/ V) '-- Cf I,v� 1 t , as Own r /Author
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best nowledge
and belief.
Signed under the pains and penalties of perjury.
O J ��
A) 1 d .i rAi
Print Name r r
A
Signature of Owner /Agent I ate ,
• . . .
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Toning
This column to be filled in by
Building Department e,
'114
1 i i i 1
Lot Size , ... .
....._____
Frontage
Setbacks Front
Side L: . R: L: i R::
Rear = i
■
Building Height
"-
Bldg. Square Footage ---
. %
Open Space Footage %
, ____,
(Lot area minus bldg & paved
parking)
l i - ; !
# of Parking Spaces L . _ _. 1
Fill: Ii,
1 '
(volume & Location) , !
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
I
IF YES: enter Book , I Page i i and/or Document it;
,
B. Does the site contain a brook, body of water or wetlands? NO 0 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
, Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 0
IF YES, describe size, type and location: I
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
D. ®art raettt.u$eto y.
City of Northampton Statue p.
�Pe It
REC _ Building Department C •, I, e P t
212 Main Street Sewer -
Room 100 Wat We Aya�labil ���
JUL - 9 2012 North mpton, MA 01060 S t� -
phone 413 -58. -1240 Fax 413- 587 -1272
CFBUI
Der:. MA0 06 Otkrb�,Specify .
NCRTHAV r
APPLICATION 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: E
' Ma . i t gr " Lot' ' 6 a' ' xr tint- f'
Zone
Overlay District,
"Elm St : D istnct '` CB`D strict °'''
SECTI 2 - PROPERTY. OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of - ecord: C,,(id /c ; s-7-7 �r!
C - eit -me (Print) Curre t i Addres l , ,! i
, � ' Gds 7,
,� AA (_, 1(s� Telephone
Sig "tture
Authorized Agent:
,jt I ll LAv e c, (i(. c,_ t
Name (Print) Current Mailing Address:
A
VL- IL 3 1 1 1 _ 7no - c t_ '4ri"
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS' :.
Item Estimated Cost (Dollars) to be Official Use Only .
completed by permit applicant
1. Building g6--666 (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 •
•'This Section For Official Use Only:- - - •
`.BuiIding • Permit: Number I
Signature
Building-Commissioner/Inspector of Buildings Date
172 NONOTUCK ST BP- 2013 -0028
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 296 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2013 -0028
Project # JS- 2013- 000044
Est. Cost: $35000.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID FORTIER 008026
Lot Size(sq. ft.): 15028.20 Owner: RHOADES JOHN C & LISA M
Zoning: URB(100)/ Applicant: DAVID FORTIER
AT: 172 NONOTUCK ST
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586 -8965 WC
NORTHAMPTONMA01060 ISSUED ON: 7/9/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE WINDOWS & SIDING
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 7/9/2012 0:00:00 $70.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner