35-192 (2) A' CORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY)
TM 04/12/2010
PRODUCER 413 . 586. 0111 FAX 413. 586.6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Webber & Grinnell Ins. Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
8 North Kin Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Northampton, MA 01060
INSURERS AFFORDING COVERAGE NAIC #
INSURED Integrity Development and Construction, Inc. INSURER A: A.I.M. Mutual
110 Pulpit Hill Road INSURER B:
Amherst, MA 01002 INSURER C:
INSURER D:
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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR INSRC DATE (MMIDDNYYY) DATE (MDD/YYYY)
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE I O RENIED
PREMISES (Ea occurrence) $
CLAIMS MADE OCCUR MED EXP (My one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $
— I POLICY jEa LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
ANY AUTO (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS Per person)
HIRED AUTOS
BODILY INJURY $
NON -OWNED AUTOS Per accident)
PROPERTY DAMAGE
Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN
AUTO ONLY AGG $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION WMZ80062242010 04/10/2010 04/10/2011 X TORY L M TS X °ER
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 500,000
A OFFICER /MEMBER EXCLUDED?
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500,000
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
For Information Purposes Onl y AUTHORIZED REPRESENTATIVE
Cynthia Henderson /CINDY
ACORD 25 (2009/01) ® 1988 - 2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Y 2. G {t1A} 1 p 7 . O
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4,, �� (L i � > m:t an t hn , * I _ — :;��
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taw °' DEPARTh4ENT OP EUILDP•ZG INSPEC IONS .-'
212 Main Street • ` Municipal. Building -=
' Northampton, Mass. 01060
• `NORTOR'S COMPENSATION fNSURANCE AFFIDAVIT
7 (licensee/pernitiee ) ! V
with a principal place of bt:.sinessiresideuce a;:
av
110 f l+ 11 &4L1 4 h(.4 f ) lloell ) ..f '9q
st ticityfsta zip)
do hereby certify, under the pains and penalties of perjury, that.
am an employer providing the following worker's compensation coverage for Tay
employees wor' ng on this job: 6L .
11-•T. �1i 'tL
. it L. luni zfo0( W3010 (i` I 1 i 0ll i (S
p.asuranx Ccmpa.n:) (Polley Number) (Expiration Date)
( ) 1 am a sole p: oprietor, general contractor or homeowner (circle one) and have hired
the contractors listed beiow who have the toiowiing worker's compensation policies:
(N<a_:ae of Contractor) (Ins Com}y ,Potivy :dumber) (a:cpirudoa Date)
(t I me of Coutrit;;<;or (.rsurano Comnuly /Policy Number) (ExpLrtioa Dale) ,
_
(Name of Cor.:zactor) ti {Th tirriac° CompatryffcLcy Ntunber) (Expiration Dale)
0: of Com 4:111.5 trap= CompanyNclicy Nunibei) (Expiration Date)
(attach sclarioaa! :Stet itnnzss ry to in�tu:3a irde malice. Deli ins to el (xoc><zectors)
f
am ( ) 1 a a sole proprietor and have no one w orking for me.
( ) S am a home owner perforrling all the work myself.
NO'rE: pletae be ewe to that while b .nwnets who cam ivy pos=e to do tetsace, crt..tttaioo cc repair wank ce a d'''':161 cf
hot more than t.-oo hers in which the Fxrxtecmces. fades er ea t:ae grrt:c,ds app:t'ttaam thereto an no( geoerally cyasidaea to be
employers uaai r the wcxi:=e1..c ss:icc Act (OL152, sal (5)). appLaea by a homeowais fx a titer= cc rrnait may nidrnx the
legal stattaaa of= employer under tho Worker's Coespao.atiou Act_
I aaadtrssand that n Dopy et this chat, axy bo ffr eaected to the Geputeseed ofl Acddeasse Moo of tastaraneo trot' the
mvenge Yerif Vellal'iIIG that failure to seam covcruo under section 2$A of M3L 151 cal lap lo tbd imposition of aim:taal %vanitic
oa sistag of a tae of up to S 1,So0A0 =Sec of tto to ore }tar and civil panttie is the fora of a Stop Work Or had a
`ma of SI,04.00 a day tgaitzst ne.
•
{ For uio oa1Y
. , At . ` Perttut Nu.mtxyr __
Y /(q /1 { M2j0 iAt y
Sipat • of Li:xesscJFenaittee I) 51 ! 1,..
E� �� 41 y :pNSt Ua T1
• 134 Licensed Construction Supervisor: m Holdup �-^ - Nct Applicable ❑
Name of Llcen� : � � y ( i I ( J ' ?&, e?"
License N ruiOer
Addres Expiration Date
r
Sign e . Telephone
vw� _ ��4�13�4lt °3 ?16' ,1 . ;illy ^.F fi f o_p 1 :,' Not Applicable ❑
r 1 t� i e / � j p t ' n , Q ti+ .1 1 1 tic 11).- / / 4 y /
Company me
gegistr� tion tion PJu;�ber
I /o1 1411 et)1 .. / / /� 6 1»
Add ess / �,l (� Expiration Data
a01ll V � Telephone 13.. /1. 7 1
: > Sri t 10 W ORkERS' COMPENSATION •IN,SVRANg AV 1DAVIT (M G:J. c: 152. § 25C(6))
Workers Compe.nsatior Insurance affidavit mast be com Dieted and submitted with this application. Failure tc provide this affidavit
will result in the denial of the issuance cf the build'rg permit.
{_Signed Affidavit Attached `'es.......
The current exemption,fQr "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families
and to allow suchhorne :oiyner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 760, 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 codtructs 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 he
responsible for all such work performed under the building. Permit.
As acting Construction Supervisor you: presence on the job site will be required from time to lime, 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 •
•
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, • .
: =` a y{+}a n r y . VL s 1"47,1.4%,,i;54..:!:: r ;z' i t"a 7 -u j`�-.. iii
s' �Yila �" �9+ ��€ L4 .'ii,p r • v �. ��� t V "
tX °.,0 n . + ' I x 2'e:_2` 5 =.. ' r /m7 m om 'F t. , �,... � r a`a xrm ;r4 . , � -
i'k a �s , e, 7 Y eG a � ' "+ r C17Ci_____ 2t, , k r c.� 77i- - 'n
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... _.s..rf -' di`�'.T€ct_.a4.,.�.i! .a,•,..uc, sa,fe�.� ` a ' d �"l�p ya�.xa,�u� +���,d�`ui
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing 0
Or Doors 0
Accessory Bldg. 0 1 DemolitionD New Signs [ 1 Decks V Siding [ ] Other [ 3
36E4 Description of Proposed Work: Co N ii // x
Alteration of existing bedroom V Yes No Adding new bedroom Yes No
Attached Narrative 0 5 ' b," Renovating unfinished basement _ Yes No
1 Plans Attached Roll ❑ • h ee:0
a
1 a. Use of building: One Family __ Two Family .Other • •
; b. Number of roams 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?
i f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Typo of construction
1 i. Is construction within 100 ft. of wetlarids? _ Ye's No. is construction within 100 yr. floodpla n _ Yes No
j. Depth of basement or cellar floor below fir.ished grade
k. Will building conform to the Building and Zoning regulations? Yes Nc . ,
1 I. Septic Tank City S .Wen, Private well . C ty water Supply
=S 6 "' r `!1 i Ottl z i0,0 iO. i EG �'1:1R0 Q YYH�N
° 0 , 1 ' 1:• t ; : * .o t 4T:oR l
, A# o . t S l:oq, •W ,P op?PERMI ` i; ;``q
1, ?.Q. .An �' ( as Owner . leo of the_sr.hjeci property
behalf, in ai m atters rletive to won
reby author " r' \Q•s..� (%� 0 1� '� l r�"t 'i �� to act oon
I y k authdrized by Shis buildin � fmit � pplication.
Signature f Ow;;:
w er Date
r .... _. _
I, t� t/ �S1 �3 _• as Owner /Authorized Agent
hereby declare that the statemehts and information on the foregoing application: are true and accurate, to the best of my
knowledge and belief.
Si ned under the pains and penalties cf perjury.
0 . scee i :
f Print N.
1 I/ • Ad . • _ -am 4 r 4 � / ( i � 0
Signat ty o n• A;�',,`1� Date
I
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing I Proposed ) Required by Zoning
This column to be filled in by
Building Department
Lot Size &r t. • r s� 0 •
Frontage _ 100 1 6 0 � •
Setbacks Front •aid; 3 c • 3
sick L: tZ (, "x: I1' L : 4ZV R: J 1' `"
Rear �, 3cf 3� ► 140
Building Height / 6 s / b �
Bldg. Square Footage • °lo 7, '
Open Space Footage
(Lot area minus bldg & paved C t b9 1
.arkin ! t
# of Parking Spaces .3 i Y
Fill:
(volume & Location) _
A. Has a Special Permit/Variance/Finding ever been issued for /on the site?
NO DON'T KNOW ✓ YES .
IF YES, date issued'
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES •
IF YES: enter Book, Page _ anc!or Document #
B. Does the site contain a brook, body of water or wetlands? NO Y DON'T KNOW
YES
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 NO Y
IF YES, describe size, type and location:
1). Are there any proposed changes to or additions of signs intended for the property ?YES _ .
No
IF YES, describe size, type and location:_____ _
. . $
v
_. ..., ''.1 Ft. 05/7;52j.TA14-5717:77
City of Northampton
APR 2 0 20'0 Building Department *,.‘ikAO,f,k.t4,!.4-.11,;t0ti.O.A,„0.1,1=:=;=!•...,=:-4.!;='-a.;,--i!,1,2-4I-i,
21 Ma :n Street C
1 _' Room 100
.. – , ; ,,,,,..,,t, j ,. , ..,J,,,, t-,, :
L . 1\tor•iham4on, MA 01 C60
phone 41-3-587 1240 Fax 413-587-1272 id'tkAy'it:
,......,...4:., D.„,..-,-, , V. ,■" it'l;
',.... --,, -.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I
SECTION 1. • SITE•INFORMATiON I
1.1 Propertv Address: - 4:t • ..i:: : :, • ,,,,:‘,:; • Jilis.•,, ( 9,1,10,:0"f,icc) ; rtIP. 1 ,0A0'04iAf9,..,P•' - .'
i 0206. Zoris R-1 & „..,,,„,,,,.,..„_,-..:..,,,,,p,,., .., ,,...,..„...„,...,..„ .._..
.1y1ap _:.:?,.. , -.: 4::■.1 fi...,,,,
I , .., .
.., ”' '. ' ,, ' ' , i ,,,, ,T , •,' j' :.: - ,. , •
krotaL, /44. 0101,
Zone ,!:-..5V.....,-,-, . : , ;: 1- '%)■ilry'f.DisliicETi .1 . :.• , .• ; ..
Elm St,'Diti:ICt • __...... _._ ....._ CB District._
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
r ' ......._
1 2.1 Owner of Record: •■•• ..
/44
*
4 Aote- it iniotzalAiiiiick Curr 4 Pni teow,e(oattce_
Na Nil P
s) ri .) Current tril4g4tia' i IS) i 0 101
■
111 i .., ' , kV PII■
4/
__. A .. Telephone
S grlb ture i t
. utho 1 ed Affelot;
// •
A
Naar- ' rInt; • ,
. ,
IP Current Mailie Address:
118 V7 '' ? 9 i
. . . . . . . . . ,
Sif ature ' II
Telepi-one
St6t1014 3 - ESTI NIATtti I'doliSTROCTION COST$
Rem -- 1- Estimated Cost (Doilars) to be . Official Use Only •
completed by pe rrn rt applicant 1: • . . .., .
•
_
1. Building
)
2 Ele,:tinal . F I b. 5-15o. I (a) auilding PerMit Fee
I . . . ....
1 (b) Estimated tot'al-Cost of
CcWruc-tic.l.frorn (6)
3. PLmbing Building Fee
__......
4\ Mechanical :..1-{VAC)
5. N r.: Protection
6. tal (1 —2+3+4- 5) . / 0 , ,,S C.,',1
, - ChecK.Number 7.0 6,5 - • This Section For Official Ose,Oniy • • .
. . . . • •
•
Bi riler: : . Date issue±— , • • . .
. .
' ' • •• . _____ . • .
. „....
. .
• .. • Signature: •• • - • •
. ...
• -B04Oirigcortimissioner/Inspettor of Buildings • ,. .,.,. Date • •
•
File # BP- 2010 -0925
APPLICANT /CONTACT PERSON INTEGRITY DEVELOPMENT & CONSTRUCTION INC
ADDRESS/PHONE 110 PULPIT HILL RD AMHERST (413) 549 -7919
PROPERTY LOCATION 1206 BURTS PIT RD
MAP 35 PARCEL 192 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �f *6,3-
Fee Paid // 0 _
Typeof Construction: CONSTRUCT 11 X 27 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 059672
3 sets of Plans / Plot Plan
TH FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
p proved 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
(9'■ 4—/AJ s sA/ d
i
Signature of Building Official 1 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.
?/.et LJ
t BUM PIT RD BP- 2010 -0925
GIS #: COMMONWEALTH OF MASSACHUSETTS
y ®• + k. 35-192 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 -0925
Project # JS- 2010- 001374
Est. Cost: $10500.00
Fee: $63.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: INTEGRITY DEVELOPMENT & CONSTRUCTION INC 059672
Lot Size(sq. ft.): 10497.96 Owner: WHITLOCK MICHAEL V & PENNY E BANISTER
Zoning: SR(100) //WSP II Applicant: INTEGRITY DEVELOPMENT & CONSTRUCTION INC
AT: 1206 BURTS PIT RD
Applicant Address: Phone: Insurance:
110 PULPIT HILL RD (413) 549 -7919 Workers
Compensation
AMHERSTMA01002 ISSUED ON:5/6/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 11 X 27 DECK
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 5/6/2010 0:00:00 $63.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo