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38B-114 ' 9 .CITY OF NORTHAMPTON s, Construction Debris Affidavit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work. cover-ed=by-a-Building Permit shalt be disposed of in a-properly licensed.disposal facility, as defined by M.G.L. c.,I I T § 150A. . Address of Work: � li�?/ �� The-debris-Mll-be-transported by: �i -/.-- -2✓�r;l- ... The debris.will be received at:. -- :-- Signature of ermit✓1pPlicant ------ — - Gate Ruildint Permit Number: - T i nwisi CONSTRUCTIGNMM ,INC. Bryan Aloisi DATE: Friday, April 18, 2014 OWNER/CONTRACTOR: FRED PITZER JOB LOCATION: 45 MONROE STREET NORTHAMPTON, MA 01062 JOB DESCRIPTION: THE SAW CUTTING OF THE BRICK WALL IN THE EXISTING HOME TO INSTALL A NEW ANDERSON FRENCH DOOR. THE JOB INCLUDES ALL THE LABOR AND MATERIALS TO COMPLETE THE JOB AS DISCUSSED WITH THE OWNERS. ALL WORK SHALL BE PERFORMED TO PROTECT THE EXISTING BUILDING FROM AS MUCH CONSTRUCTION DEBRIS AND DUST AS POSSIBLE. ALL THE LABOR, MATERIALS, DUMP FEES AND INSURANCE CERTIFICATE SHALL BE PROVIDED. INCLUDES THE PAINTING AND TRIM WORK AS CLOSE AS POSSIBLE MATCH. DOES NOT INCLUDE A STEP ON DECK IF REQUIRED AFTER THE DOOR IS INSTALLED. TOTAL JOB COST: $5,100.00 CHECK PRICE OR CASH PRICE OF $4,780.00 PERMIT FEE NOT INCLUDED 107 Rocky Hill. Road • Hadley,...MA 01035 • (413) 549-5141 A`°R°® CERTIFICATE OF LIABILITY INSURANCE 9/4/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 Christine Sullivan NAME: Aquadro & Associates PHONE (413)586-7373 FAX NMv(413)584-0859 355 Bridge St., P. O. Box 357 MAIL INSURERS AFFORDING COVERAGE NAIC 8 Northampton MA 01061 INSURER A:NGM Insurance Company INSURED INSURER B.-Travelers Indemnity Co of Conn 25682 ALOISI CONSTRUCTION CO, INC INSURER C.National Grange Mutual 14788 107 ROCKY HILL RD INSURER D: INSURER E: HADLRY MA 01035-9772 INSURER F: COVERAGES CERTIFICATE NUMBER ICL139404939 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LTR POLICY NUMBER MM/D MM/D LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 500,000 PREMISES ffia occurrence)A CLAIMS-MADE ®OCCUR 14PTS253J /28/2013 /28/2014 MEDEXP(Any one arson $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 2. POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident B ANY AUTO BODILY INJURY(Per person) $ 50,000 ALL OWNED x SCHEDULED 2968A362 /26/2013 /26/2014 BODILY INJURY Peraccident $ AUTOS AUTOS ( ) 100,000 HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ JP.r AUTOS Uninsured motorist BI s lit limit $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION WC IMIT- I OTH- AND EMPLOYERS'LIABILITY Y/N TOR FIR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) CT5253J /28/2013 /28/2014 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN FOR INFORMATION PURPOSES ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C Sullivan/CMS ACORD 25 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INCn9ic,i,?mnn5)m Tiro Amnon nsmu..A Innn of Ar`non City of Northampton S`5 r Massachusetts mow`` f{{t r Y DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building w Northampton, MA 01060 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 Le ibl Name (Business/Organization/Individual): C/l�_11 Address: City/State/Zip: / ` e_: Phone Are you an employer? Check t appropriate box: Type of project(required): 1.[ ] I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ] Remodeling ship and have no employees These sub-contractors have g, �] Demolition working for me in any capacity. employees and have workers 9. ❑ Building addition [No workers' comp. insurance comp. insurance.T required.] 5. ❑ We are a corporation and its 10.[:1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.F-1 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 employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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. Insurance Company Name: 4 � e Policy#or Self-ins. Lic. #: iA/ C T �T2s- 3J Expiration Date: Job Site Address: 7J 1�1'17rezo_f City/State/Zip: VT Attach a copy of the workers' compensation policy declaration page (showing the policy number and xpirati n 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 ce ' under the pai and p nal ',F of periury that the information provided above is true and correct. Si ature: l� Date: 0� Phone#: 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: L Not Applicable £ Name of License Holder: 14r.4 G V License u be J X Ae, 4 �1Cf1s y ,�,,, A ess Expiratio Date Ar)KA ign ure f w Telephone 9 Re istered Home Im- `rovement Contactor Not Applicable £ �� w ,, ../....'• ......... tuber Com an Name Regis ation N I Al-6-1 #,// td- llziC116��l i A.4 ;-171�r ddress f Expiration D to Telephone��✓ X7/ 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. -.Ho-me Owner.E mptioA 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�indows Alteration(s) Roofing E]Or Doors Accessory Bldg. ❑ Demolition New Signs [O] Decks [M Siding[O] Other[O] Brief -Fegcript ionofProsed Work: 1 :A� � and....L k1/a,&2 e Y fiea) 4r e„ 4� Pe,f Alteration of existing bedroom Yes No Adding new bedroom Yes /` Nc�, Attached Narrative Renovating unfinished basement Yes /` No Plans Attached Roll -Sheet 6a..If Nevi►house and olr�addition to'existin%houslng; cornp`lete 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 / as Owner of the subject property / hereby authorize gio li 1c15� VSI `'�j �/'1✓L” �n 4e- to act my behalf,in m tter la've to work authorized by this building permit application. S' ature of Owner Date 9 A& as Owner/Authorized Agent here declare that fh&statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Si d under the pains and penalties of perjury. 4-14 Print N e kinatt.Ve of Owner/Agent Date � - Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Tliis column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage "'0 Open Space Footage % (Lot area minus bldg ZVayed #of Parking Spaces Fill: r IL A. Has a Special Permit/Vahnnce/R riding ever been issued for/on the site? N 0 u�% YES 0 IF YES, dateissued:| � IF YES: Was the permit recorded at the Registry ofDeeds? NO K j D �c ~~� KNOW — IF YES: enter Book L PagE and/or Document# D. Does the KNOW a brook, body water NO *A5"\ DONT KN� 0 YES IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tobpobtained �~� Dbta�ned �~� ' .Date �-� �_� C. Du any signs exist on the property? YES 0 NO 0 IF YES, describe size' type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES �-� NO 1 �~� IF YES, describe size' type and location: � E. Will the construction activity disturb(clearing,gradingexcavation,orfi|Ung)over 1 acre oris it part ofu common plan ' that will disturb over 1acre? YEGK��} WO �3> IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ^ 1` City of Northampton $tatusofPermtt f' T� z� r Building Department Ct)rb'Cut/I�li�ce4tvay�Perrrtt }� APR 2 8 204 212 Main Street SetWer/S�pticAyailab)Irty ] Room 100 ertVlteif �aila6 Northampton, MA 01060 TwaiStstofstFuctuialPlans{ Ele ric,Plumbing&Gas Ins ¢� Northamrton,MA 010S�T1� 413-587-1240 Fax 413-587-1272 Plolsite Piano` M _ „ �Y + i Other•�,S;peolf�'�51 +, ' ✓u vld i�,Ik d�li i+i' x{r i 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 G/✓ ✓'�j/ {t � S Fi Map Lot 15 Urnt Zone , Overlay District ' ` r Elm St District CB Dlstnct SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nam (Print) Current Mailing Address: / Telephone y// _ j w gnature 2.2 Authorized A ent: /Y4 G`f/ � e(Pfl nt) o Current Mailind Address: / !7'Z Signat a Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Feb 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official We'Only Date Building Permit Number: Issued: Signature: Building Commissionedinspector of Buildings Date File#BP-2014-1133 APPLICANT/CONTACT PERSON BRYAN ALOISI ADDRESS/PHONE 107 ROCKY HILL RD HADLEY (413)427-2457 Q PROPERTY LOCATION 45 MUNROE ST MAP 38B PARCEL 114 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid p�V eA Tyneof Construction: REPLACE WINDOW W/FRENCH DOOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 073513 3 sets of Plans/Plot Plan THE FOLL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOPMA TION 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 D olitio elay Signa re of Buildin icial 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. 45 MUNROE ST BP-2014-1133 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B- 114 CITY OF NORTHAMPTON Lot:-00 L PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2014-1133 Project# JS-2014-001926 Est.Cost: $51000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use GrouR BRYAN ALOISI 073513 Lot Size(sq.ft.): 7318.08 Owner: PITZER FREDERICK N&MARGARET Zoning: URB(100) Applicant: BRYAN ALOISI AT. 45 MUNROE ST Applicant Address: Phone: Insurance: 107 ROCKY HILL RD (413) 427-2457 O WC HADLEYMA01035 ISSUED ON.51512014 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE WINDOW W/FRENCH DOOR - header &jacks per code 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 5/5/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner