24C-143 (6) IM Massachusetts -Department of Putttic Safety
Board of Building Regulations and Standards
Comtractiun Supen itinr SpccialtA
License CSSL-099931
KEITH W DEVIN ,.
3134 MOUNTAINROA
WEST SUFFIELS CT
Exp;ration
Commissioner 101/09/2016 =
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AGGRO 25(WON) The ACW noM and fto are d ACORD
' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)0 ill 61217111.1i
TMIIFICATE 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
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to the
terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsemen s.
PRODUCER CONTACT
NAME:
SOUTHWICK INS AGENCY INC PHONE FAX
PO BOX 100 (A/C,No,Ext): (A/C,No):
E-MAIL
SOUTHWICK,MA 01077 ADDRESS:
28TKC INSUREII AFFORDING COVERAGE NAIC#
INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
SAMBRICO LLC DBA VISTA HOME IMPROVEMENT INSURER B:
INSURER C:
INSURER D:
2003 RIVERDALE ST INSURER E:
WEST SPRINGFIELD,MA 01089 INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MMlDD1YYYY) (MMIDDIYYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
CLAIMS MADE F1 OCCUR. PREMISES(Ea occurrence)
ED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE is
POLICY [:D PROJECT F]LOC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
(Per accident)
NON-OWNEDAUTOS PROPERTY DAMAGE is
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE! $
EXCESS LIAB CLAIMS-MADE AGGREGATE Is
DEDUCTIBLE 1
$
RETENTION $
A WORKER'S COMPENSATION AND WC STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-2E072183-15 03/12/2015 03/12/2016 X LIMITS
ANY PROPERITOR/PARTNER/EXECUTIVE a NIA E.L.EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under E.L.DISEASE-POLICY LIMIT 1$ 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
TOWN OF WEST SPRINGFIELD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
26 CENTRAL STREET SUITE 4 IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENT VE
W.SPRINGFIELD,MA 010891^ '
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
City of Northampton
r Massachusetts
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DEPARTMENT OF BUILDING INSPECTIONS �:t =x•
212 Main Street • Municipal Building
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
1, 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/dis
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: G
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
I am a employer with k � 4. E] I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. El 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, F1 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. g• E]Building addition
required.] 5. EJ We area corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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.
$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. i
Insurance Company Name: �`i`��
Policy or Self-ins. Lic. #: U�3` �_ � ` 1 3 I�Z I
y � Expiration Date:_ 1
Job Site Address: t t Al�_ � 5' City/State/Zip:6 csyr+, w lYl•{�
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 penalties of perjury that the information provided above is true and correct.
Signature: Date:
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#:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: t 1 6'OV,-'tAWj
The debris will be transported by: v�
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder:
License Number
Address Expiration Date
signature Telephone
9 'Registered Home Imarovemertf Contractor _.i__„-. Not Applicable £
Company Name ( Registration Number
3 i,jez- c,t,� A
"resssss Expiration Date
Telephoned
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 �wner:Egemption
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 ❑
Or Doors �2
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [O] Other[[J]
Brief Description of Proposed �,. ��1 f ' 1N�� t 1 n �� . J(�E ioce" �
Work: '( 1C "t'�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If.New house and_or''addition to existing houstng,.cornpfete 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
I as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Age 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 penalti s of perjury.
&�4'
Print Name
Sig re 6f-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 7777
�
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage 01�0
Open Space Footage %
(Lot area minus bldg&pxved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Rmding ever been issued for/on the site?
�~� �~��� �.���
NO �� DONTKNO� YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �� DON7KNOYY YES
v��
IF YES: enter Book
Page and/or Document
�� ��
B. Does the site contain a brook, body ofvvaterorwetlands? NO �~��� DON7 KNOW «�� YES «�/
|F YES, has a permit been or need tobe obtained from the Conservation Commission?
Needs to be obtained .��~� Obtained �~�~�� Date� ' .
C. Do any signs exist on the pmperty �� ��� YES �,� NO »��
IF YES, describe size, type and Location:
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: � l
L-__ ---'------------------�
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orinit part nfa common plan
' that will disturb over 1acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
k- i .._.sn ,,Depattmen.t:USe or l i h ms r
City of Northampton Status ofPermtt' �� "1 u,�; k !
'Building Department CtrrB Cut/Drl...... Petmtt Y' "
JUNO 20� 12 Main Street
1 Sewerlse tlCAyaiiablrt
Room 100 Water/ feTAVa7i'aT�l
_Dort T
ampton, MA 01060 wa$etsfctf5truotuFalPfa€ts
Electric,Piumr mgI �f�, ,r 7-1240 Fax 413-587-1272 P[of/sitiPlans' '� 8
Northam tool, :' yrr=,,.
O�ier'S
- peGlfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 PropertyAddres, : Th'is sectwr�to be completed b-
........... office
i
( �1�"o Map Lot Unit
Zone Overlay District
-H Ewn-imi
_Elm$t;Distract CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pnn Current Mailin ddress:
A�— Telephone
Signature
2.2 Authorized Agent:
Name Print) Current Mailing Address:
a&o o
Signature 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 Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
11 ARLINGTON ST BP-2015-1274
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24C- 143 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:windows replaced BUILDING PERMIT
Permit# BP-2015-1274
Project# JS-2015-002337
Est. Cost: $7644.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 099931
Lot Size(sq. ft.): 10410.84 Owner: KURTZ JUSTIN
Zoning: URB(100)/ Applicant: VISTA HOME IMPROVEMENT
AT. 11 ARLINGTON ST
Applicant Address: Phone: Insurance:
2003 RIVERDALE ST (413) 382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON.611012015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 9 REPLACEMENT WINDOWS
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 6/10/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner