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35-224 (4) Barron &Jacobs DESIGN . BUILD . REMODEL \l /\ /10 Dear Code Official, Enclosed please find an application and related documents and information for a requested building permit. Our client will be out of town. I am enclosing a self - addressed, stamped envelope for your convenience. Please mail the building permit to our office. Thank you. Sincerely, ecil Jacobs President A Tradition of Building Satisfaction 70 Old South Street, Northampton, Massachusetts 01060 413.586.8998 www.barronandjacobs.com r, V,,,.0111V, r uo, V, , ,,an rax,u. rage 1 CT Y ua:e:Dr 1r 1J1u 01:Of •NI rag e:1 OT 1 a" • Atc5Tib* CERTIFICATE OF LIABILITY INWRANCE OP ID SF DATE(MM!DDIYYY'Y) BARRJ50 06/21/10 PR•:DUCER THIS CER1 IFICATE IS ISSUED AS A MATTER OF INFORMATION IRM Insurance Agency, In , ONLY ANC CONFERS NO RIGHTS UPON THE CERTIFICATE Barry M. Stephens, CPCU HOLDER. "'HIS CERTIFICATE DOES NOT AMEND, EXTEND OR 75 North Main St. -P 0 Box 564 ALTER TH E COVERAGE AFFORDED BY THE POLICIES BELOW. East Longmeadow MA 01028 Phone: 413-759-0010 Fax:413- 759 -0017 INSURERS AFFORDING COVERAGE NAICr INSURED INS_RER A: Central Insurance Companies 20230 IMS_RER 6: • Barron & Jacobs Assoc. Inc. INS_RERC: . 70 Old South Street INS_RER0: Northampton MA 01060 I lelS_REP. E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEE\ ISSUED TO THE INBUPED NAMED ABOVE FOR T -E POLIO' PERIOD NCICArED NOTWIT- 6rP1IDING ANY REOU RET1c7 r, TERM OR CONDITICN OF ?N' CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICA E WAY BE ISSUED OR MAv PEP. - AIM, THE NSURANCE AFFORDED 3'f THE POL CIES 7ESCRIBED HEREIN IS SLBJE7,T TO AL_ THE TERMS, E XCLUSIONS AND CONDITIONS OF SUCH PCLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN P.E000!D BY PA D CLAIMS, INON KUL: C POLICY .1.1 CTIVE POLCY hXF1RATRO17 LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE (MLVDD,'YrYY) DATE (MMlDDITYYY) LIMITS GENERALLLaBILIIY EACH OCCJRRENCE 61000000 • A X COWM?RCIAL GENERAL LIA8ILITY CLP7933761 03/09/10 03/09/11 PRE6 %ES(Eaoocuene) 8 300000 CLA MADE © OCCUR MED EXP (My one parson: 8 5 0 0 0 - - -- PERSONAL 3 ?DV r4J_RY 1 1000000 _ X GL Plus Endorseme . GENERAL AGGREGATE 6 2000000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGo 1 3000000 POLICY n 22i n LO'- - — - AUTOMOBILE LIABILITY COMBINED= I'GL?_IWIT 81000000 A _ AN"' AUTO BAP8612961 06/22/10 06/22/11 (Eea•:oicent) ALL OWNED AUTOS • SC0 LY INJUP'' I SCHEDULED a1! - �Yo (Per persor) — X HIRED A_TOE BCD LY INJUR' 8 X NON -Cv' NED AUTOS (Per accriert) PROPERTY DAMAGE 8 (Par ecollert) GARAGE LIABILITY AUTO rj',t - EA ACCIDENT $ AN AUTO OTHER. T-AN EA ACC 6 AUTOO\L" AGG I • EXCESS i UABRELLAuABLITY EACHOCOJR;ENCE 8 1000000 A ] c 0JR 1 I CLAJWSMaDE CXS7933762 03/09/10 03/09/11 AGGREGATE 1 1 000000 _ — I DEDUCTIELE g X RETE•TION 6 0 8 WORKERS COMPENSATION WC S,AIU- C•I ri- • AND EMPLOYERS LIABILITY YI N TORY LIMITS ER _' ANY BF R ( PAR LUD EC 9 ECuT vE r WC837586817 03/01/10 03/01/11 EL.EAD-IACOIDE'T 1 500000 . (Mandator' In NH) EL.CIEEASE - EA EMPLOYEE 1 500000 If yes, des=ibe Lode( SPECIA_ PROvISIONS below E L.C'I -SEISE - POL CY_IWIT $500000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT I SPEC1?L PRO)/ MIONS . CERTIFICATE HOLDER CANCELLAT ON SHOULD ANY' C %THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EDIPLRATION PROOFOF DATE THEREOI . THE ISSUING INSURER WILL ENDEAVOR TO mAIL 10 DAYS WRITTEN NOTICE TO THI CERTIFICATE HOLDER NAMED To THE LEFT, BUT FAILURE TO Do 50 SHALL IMPOSE N•: oe .IGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS _R Proof of Coverage REPP.ESENTAT VES. AUTHORIZED RE'RESENTATNE IRM Insurance Agency Inc. I _ ACORD 25 (2009/01) ©1918.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks if ACORD e � The Commonwealth of Massachusetts --- Department of Industrial Accidents 1- = ii1 �/ 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): i?) cktrpv‘ J 0 S AS50C1C Address: 10 OLD 50 tt w City /State /Zip: NorAL u1, f'ay., A 01 06() (() Phone #: I3 6 4 56 -- gi' Are you an employer? Check the appropriate box: Type of project (required): 1. 53 I am a employer with 4. ❑ I am a general contractor and I 6. Q 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. t ? fg Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition working for me in any capacity. workers' comp. insurance. 9. 0 Building addition [No workers' comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.❑ 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. [No workers' comp. insurance required.] 13.0 Other 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 subcontractors and their workers' comp. policy information. /am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ( ( Insurance Company Name: C e N� l`c ok. S tA kyt ee C 0 M hvNI Q S Policy # or Self -ins. Lic. #: J C 315% 655 I ") Expiration Date: ) aU Job Site Address: L AC, l .0tAnS Viva( L-e) City/State /Zip: c \ rt tv ;VAN O \OG,L— 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 u er the pains and f Ities of pe • ry that the information provided above is true and correct Signature: � > .+ Date: t \ / ■ 1 l7 Phone #: V) Zy6 Official use only. Do not write 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 #: Office of Consumer Affairs and usiness Regulation c 110 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 100809 Type: Private Corporation Expiration: 6/23/2012 Tr# 296962 BARRON & JACOBS ASSOCIATES, INC. Cecil Jacobs - -- - -- - -- - - - -- - -- - - - - -- - 70 OLD SOUTH STREET — — NORTHAMPTON, MA 01060 -- -- -- - - Update Address and return card. Mark reason for change. Li Address tJ Renewal h Employment % Lost Card DPS -CA1 G 50M- 04104- G101216 272e 6 °"dman`cieald o/ /6.-LiackaetZt License or registration valid for individul use only Office of Consumer Affairs & Business Regulation $ • HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Reg l0pgpg Type: Office of Consumer Affairs and Business Regulation II =r Expiration: 6/232012 Private Corporation 10 Park Plaza - Suite 5170 � ' Boston, MA 02116 BARON & JACOBS ASSOCIATES, INC. Cecil Jacobs 70 OLD SOUTH STREET NORTHAMPTON, MA 01060 Undersecretary Not valid w' o signature \ia..achu.ctt. - Department of Public Safety Board of Builtlin, Rclulatinn. and 'taiitlartl. ,+ Construction Supervisor License License: CS 30739 Restricted to: 00 CECIL R JACOBS 70 OLD SOUTH STREET j ,; NORTHAMPTON, MA 01060 Expiration: 9/21/2011 ( nnmi.�i an r Tr=: 2429 SIGNATURES By signing below, you agree to items A, B and C. DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES. A. Alternative Dispute Settlement (Arbitration Clause): The Seller and the Buyer hereby mutually agree, in advance, that in the event of a dispute concerning this Agreement, the parties shall submit such dispute to a professional, state - approved arbitration service (cost, if any, to be paid by the submitter) prior to either party proceeding to legal action in the courts. B. By signing this agreement, you, as the owner of record, are hereby authorizing Barron & Jacobs Associates Inc. to act as your authorized agent in all matters pertaining to the building permit application. C. This is a binding Agreement. You may not cancel it except as stated. This Agreement covers and supersedes all conversations, statements and agreements, expressed or implied, between the parties, their agents or representatives. You, the Buyer, may cancel this / 0 `2- /10 transaction at any time prior to B Date midnight of the third business day after the date of this transaction. See the attached notice of cancellation Buyer Date form for an explanation of this right. Seller retains an equal right to cancel. j r j l� h7/ 1 Barr&i & Jacobs Repr'entative Date ************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Designer /Salespersons Registration Numbers ❑ Cecil R. Jacobs MA HIC 100809 ❑ Christopher R. Jacobs MA HIC 100809 CT HIC 0518617 CT HIS 0554397 El David J. Satkowski MA HIC 100809 ❑ William J. Bonini MA HIC 100809 CT HIS 0554600 CT HIS 0553918 Barron and Jacobs - Key Personnel Contact Information: Office Cell Home Office Manager: Sandy Scavotto 413.586.8998 Operations Manager: Bill Bonini 413.586.8998 413.672.1009 President: Cecil R. Jacobs (Jake) 413.586.8998 413.250.2357 413.584.4447 Purchase Agreement Page 16 of 16 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : C Qc \ ' - JC�C. y h C S 4- License Number .A O' � 1A , , \ M ik 0\ 0 bO 1 2A � Address Expiration Date Hi 3 iS Signature Telephone 9. Registered Ho e I provement Contractor: Not Applicable ❑ b(1\`00- \c c\OS - o c , ,AL t 0 `' l Company Name Registration Number • t 1. - • ►►' • •• 1 6/P7/ 12-- Address Expiration Date Telephone 91 " 3-0 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 ❑ 11. - Home Owner Exemption 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 buildine 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 n Addition ❑ Replacement Windows Alteration(s) If Roofing E Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [0] "5-4N \\ V SzCiit" fiv S t w st. l y% ti ttW bah � - �' ■- • Brief Description of Proposed J Work: 'vr\-0 5::c - wz wA tnSb: \\ Yew t 4vc,,;•X V. ANArodj. v144 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes c-' No Plans Attached Roll - Sheet 6a. 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 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 1, ' 3 Q b P (Qi i rnk 13 \ 6, Ch 0Ve.A.. , as Owner of the subject property J ��1��� ,, -- hereby authorize CJLl44)" '` i --flUS to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date \\ O Q` , ` � ��� , 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 Nat, \ „ / / L > � I ( nature r /Ages 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 " i c' cti Frontage Y CA- Setbacks Front sr1 ∎ w r� Side L: R: L: R: Rear Building Height INV_ Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved (\ (') C parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO e DON'T KNOW 0 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 O NO e IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO 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 ® NO el IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify 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 t / _ , ` \; v p 2 , Map Lot Unit \ �'k�{`u t" Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 60.-- -` 1 X- r 1 , S rr .1 ( -06,4 �1;. Ln , \o�fenu Name (Print) Current Mailing Aldress: r i e ,t `on `iSCI - "��� �t Z �, ) �(n C 1�(,�'�, Telephone Signature 2.2 Authorized Agent: \vrY &. V-. De:%.‘4 1r,. i"17 1c\ St y St , tic t gy p{ AnOtO, Name (P Current Mailing Address: t: — L rb Kcfl gnature Telephone SECTION 3 - E ATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building "j 1 ,I C1 L. (a) Building Permit Fee 1 2. Electrical 0 (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 0 6. Total = (1 + 2 + 3 + 4 + 5) i-VW 1 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0419 APPLICANT /CONTACT PERSON BARRON & JACOBS ADDRESS/PHONE 70 OLD SOUTH ST NORTHAMPTON (413) 586 -8998 PROPERTY LOCATION 46 LADYSLIPPER LN MAP 35 PARCEL 224 001 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 /� � ` � 1 � Fee Paid a2 c Tvpeof Construction: INSTALL VENTED SOFFIT & EXHAUST PIPE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 030739 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: pproved 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 Signature of Building 0 icia 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. *WOWS ` . lv BP-2011-0419 GIS #: COMMONWEALTH OF MASSACHUSETTS 3 •4 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 -0419 Project # JS- 2011- 000688 Est. Cost: $4964.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BARRON & JACOBS 030739 Lot Size(sq. ft.): 91040.40 Owner: HORNOR JOHN W Zoning: SR(100) //WSP II Applicant: BARRON & JACOBS AT: 46 LADYSLIPPER LN Applicant Address: Phone: Insurance: 70 OLD SOUTH ST (413) 586 -8998 Workers Compensation NORTHAMPTONMAO1060 ISSUED ON:11/4/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL VENTED SOFFIT & EXHAUST PIPE 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 11/4/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner