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37-070 (2) General Liability Dates 6 -02 -2012 To 6 -02 -2013 Workers Comp 11 -28 -2012 To 11 -28 -2013 Bergeron Policy No# (Liability) Ross Ins. Agcy. Inc. Sheetrock Policy No# (Wk's Comp) 413 536 -8380 General Liability Dates 1 -16 -2013 To 1 -16 -2014 Workers Comp 1 -15 -2013 To 1 -15 -2014 B &G Tree and Landscape Policy No (Liability) Banas Ins. Agcy.. Landscape Policy No# (Wk's Comp) 413 447 -7376 General Liability Dates 9 -30 -2012 To 9 -30 -2013 Workers Comp 5 -03 -2012 To 5 -03 -2013 Andre Senecal & Son Policy No# (Liability) Finck & Perras Ins Agcy Masonry Policy No# (Wk's Comp) 413 527 -5520 General Liability Dates 6 -14 -2012 To 6 -14 -2013 Workers Comp 6 -14 -2012 To 6 -14 -2013 BONDE CONSTRUCTION: SUB - CONTRACTOR WORKERS COMP. INFO. ✓ Mark Bonde Policy No# (Liability) MP020651 Finck & Perras Ins Agcy. Gen. Contractor Policy No# (Wk's Comp) UB- 8139B27 -7 -07 413 527 -5520 General Liability Dates 8 -15 -2012 To 8 -15 -2013 Workers Comp 3 -13 -2013 To 3 -13 -2014 ►Gary L Kostek Policy No# (Liability) MP064863 Finck & Perras Ins Agcy. Plumbing Policy No# (Wk's Comp) WC064863 413 527 -5520 General Liability Dates 6 -27 -2012 To 6 -27 -2013 Workers Comp 6 -27 -2012 To 6 -27 -2013 t— Casinhino Painting Policy No# (Liability) 6806630n336 Finck & Parras Ins,. Agcy. Policy No# (Wk's Comp 413 527 -5520 General Liability Dates 1 -16 -2013 To 1 -16 -2014 Workers Comp 1 -15 -2013 To 1 -15 -2014 NRB Exteriors Inc Policy No# (Liability) CP49710701 Chaffee Helliwell Ins. Roofing Policy No# (Wk's Comp) WC8738203 413 536 -0751 General Liability Dates 6 -07 -2012 To 6 -07 -2013 Workers Comp 3 -19 -2012 To 3 -19 -2013 Urban and Sons Insulation Co. Inc. Insulation Policy No# (Liability) CPA018807913 McClure Ins Agcy. Inc. Policy No# (Wk's Comp) WC8738203 413 536 -0751 General Liability Dates 6 -07 -2012 To 6 -07 -2013 Workers Comp 3 -19 -2013 To 3 -19 -2014 Aaron Morin Policy No# (Liability) 2008X0180 Meyer Agcy. Heating & A/C Policy No (Wk's Comp) 2008W6194 413 582 -0332 General Liability Dates 1 -19 -2013 To 1 -19 -2014 Workers Comp 3 -23 -2012 To 3 -23 -2013 ✓'Kurt Mengel Policy No# (Liability) Ross Ins. Agcy. Inc. Electrician Policy No# (Wk's Comp) WC20 -20- 001319 -01 413 536 -8380 om` l ne a.arrtrrurrsweusart UJ lrAta.JUaa *- Department of Industrial Accidents ; =::,3017-== Office of Investigations E = 8e>ill-- "0 600 Washington Street =Mgr... p+ it N. ' Boston, MA 02111 ".AZI www.mass gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Narne ( Business/ Organization/Individual):)tJ�l' (" utr - Address: '2„,,,p s ---1,2_C •i, • City /State/Zip: _ _Jj. . ► . . . a r m . _ _ Phone .# : 4 t 57. - Z.1'71 Are you an employer? Check the appropriate box: Type of project (required): L,h I , 1 ara a employer with 1 4. Yam a general contractor and I 6. ❑New construction employees (full and/or part - time)." have hired the sub- contractors 2, Q I am a sole proprietor or partner- listed on the attached sheet. 7. ©'Ii emodeling ship and have no employees These sub - contractors have g. Q Demolition working for me in any capacity. employees and have workers' Y P t3' t 9. Q Building addition [No workers' comp. insurance comp. insurance. required ] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 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 - contactors have employees, they must provide their workers' comp. policy number. 1 am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: g",j ELt 2 S .. ....134S, (t0 . — Policy # or Self -ins. Lic. #: 2, g S 3 9 8 UE, Expiration Date: ?j — 1 - 5 y s q -1-o ( ' L • Ci c.5% o coo Job Site Address: ty /StateiZip: 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 , enalties ofperjury that the information provided above is true and correct. Si _nature: Af/ LA—J. ,ft.tt.4.__. i Date: — S " _ Phone #: L4 4l2 5� - 2 - 7 (o 1 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� tZ 3 c ij ( 6 7 5 License Number Address Expiration Date c-1 Y1 ►� -11 3 57P Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable 0 u'4E Cc3► .��� — i.k�t 10 t■J' Company Name Registration Number d O ` 67, T, Cp ? - A dress 11 A 9V -- 11 Expiration Date - F 1 . � , � t-1 A I L\ t (()2 ;7 Telephone 4 3 v7 2 1, 7 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 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) ❑ Roofing J Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [Ell Decks [❑ Siding OM] Other la Brief Description of Propose Work: ' V 3`r -trx F -k -Z.LY71'4 ; ?:Ft%-kl)l) r NA.– . 1 " - i 1 17C --- - RA/ F (1t3/ I0eUt.-J Alteration of existing bedroom Yes -' No Adding new bedroom Yes — No Attached Narrative Renovating unfinished basement Yes fr --- -- 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 e" r CJ,Q,i. . ( l _ _L -L , as OwneLpf the subject prop hereby authorize ' e° 1p t.17—' k_ i " > x, l'i to act on my behalf, in al matters relative to work authorized by this building permit application. � ' , . - -` C�.Qa.�.�, 3 - a6 - l3 4i' re of Owner Date I, 4 -,ip,. z..\ 7"7"t..1 N C= , 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. PASS :. �?jOL) Print Na ilj S 511/4—k)- ignature o wner /Agent ate 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW ® YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ® YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , 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 O NO ©c 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? YEE O NO ®' IF YES, then a Northampton Storm Water Management Permit from the DPW is required. C ���� t Department use only R� V City of Northampton Building Department Status of Permit: Curb Cut/Driveway Permit wti L. 6 2013 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability 0 ���� N GINSPO C 71 0 , tthampton, 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 6 `-j -i tai= N L Map �� Lot 1 P Unit e. (\k iIN., Zone Overlay District Elm St. District . CB District /: SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: i P LVEV Rt=_t)Y (L Ar ?..t- VI vla L1~ v ck- t r�." 69,u1 i---uq N(F .. .c1 i R") V E LK ,"1 Name (Print) Current Mailing Address: ..) 4 t , c,4 -- 2 ;4 A • • (Ji L ' ,, ,.4...;./..; / ,f__:___ Telephone ./ gnature el 2.2 Authorized Agent: t`-Akre \c `- ,3b V 2i . ?A z';7". IA 5 11 -l14 iNx Name (Print) Current Mailing Address: A A L 413 - -;2J -i `I t, Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (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 O 6. Total = (1 + 2 + 3 + 4 + 5) i 1 /4 r 0 0 Check Number loD� v h This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0873 APPLICANT /CONTACT PERSON MARK BONDE ADDRESS/PHONE 205 PARK ST EASTHAMPTON (413) 535 -9529 Q PROPERTY LOCATION 689 FLORENCE RD MAP 37 PARCEL 070 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ! p�� � Fee Paid (O Q 1 7 Typeof Construction: REMODEL BATHROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 67758 3 sets of Plans / Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 . ' ion P - Signature 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. 689 FLORENCE RD BP- 2013 -0873 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37 - 070 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- 2013 -0873 Project # JS- 2013- 001495 Est. Cost: $14030.00 Fee: $84.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK BONDE 67758 Lot Size(sq. ft.): 56628.00 Owner: L'HEUREUX GERARD A & CLAIRE A WHEELER Zoning: Applicant: MARK BONDE AT: 689 FLORENCE RD Applicant Address: Phone: Insurance: 205 PARK ST (413) 535 -9529 O WC EASTHAMPTONMAO1027 ISSUED ON:3/29/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM 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 3/29/2013 0:00:00 $84.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner