29-079 10/19/2015 MON 11:29 FAX IM 001/001
ACC>R" CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDIYYYY)
10/19/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGlt?S 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(ies)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 House
NAME:
King & Cushman Inc. PHONE (413)584-5610 LAIC No;1413)584-9322
P.O. Box 447 E-MAIL
ADDRESS:
176 King Street INSURERS AFFORDING COVERAGE NAICN
Northampton MA 01061 INSURERAIOhio Security Insurance Co_____.___ 24082
INSURED INSURER B:
David Fortier Builders INSURERC:
32 Laurel St INSURER D:
INSURER E:
Northampton MA 01060 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL15101901156 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 ALI L 5UBR POLICY EFF POLICY EXP _ LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER
$ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
� DAMAGE TO RENTED 300,000
A CLAIMS-MADE OCCUR PREMI ES(Fa oncurrence-1 $ _ _
BKS55722835 12/2/2015 12/2/2016 MED EXP(Any one perscn) $ 15,000
PERSONAL&AOV.INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE_ $__2,000,000
S POLICY❑PRO- F j LOC PRODUCTS-COMP/OP AGG $ 2,000,000
JECT u — -- -- --
OTHER, Expense Mod Factor 1 $
AUTOMOStLF)148107..—._.
ANY AUTO BuuILY INJURY ti ar persona "
ALL OWNED SCHEDULED BODILY INJURY(Per amdent) $
AUTOS AUTOS
NON-OWNED .I PROPERTY DAMAGE $
HIRED AUTOS AUTOS - -$ - ------
UMBRELLA LIAB HOCCUR EACH OCCURRENCE $
EXCESS LIP B CLAIMS-MADE AGGREGATE _ $
DED RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY _t STATUTE__ F.A
ANY PROPRIETORMARTNERIEXECUTIVE Y/N NIA E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ _
If yes,describe under
DESCRIPTION OF OPERATIONS belay E.L.DISEASE-POLICY LIMIT $
I
DESCRIPTION OF OPtrtAT'tuNS t LUCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached U more space is requireo)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Northampton, MA 01060 ACCORDANCE WITH THE Y PRO IS[ 11"
KIN
AUTHORIZED REPRESENTATIVE
At
se d.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025(201401)
City of Northampton 212 Main Street, Northampton, MA 01 060
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: n Actzxao,,6ot,-_ .Q .
The debris will be transported by: OA uO �®,AC t 9-vL
The debris will be received by: C L_ 0
Building permit number:
r �
Name of Permit Applicant 01
Date Signature of Permit Applicant
S
City of Northampton
Massachusetts tis s,�ft'
DEPARTMENT OF BUILDING INSPECTIONS =, x
212 Main Street • Municipal Building w1 1
,. Northampton, MA 01060 ss�;•,_ L�afi,;
lY l Fi7.,
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
:.: . .......... .
F 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): 6z9bI1-? Fv/!'T(Q LIL,694t5
Address: -'�J t Q u ."06(_ S
City/State/Zip:b r �,A , 0 Phone#: I o� -+6-23
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. E] I am a general contractor and I 6. ❑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. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. E]Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. We are:a 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.k 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.
Insurance Company Name:
Policy#or Self-ins.Lie. #: VV)S 6 I� �3 Expiration Date: �tk_
Job Site Address: h',ACPIF- (,kits'!''•, City/State/Zip
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 ce
MY under ffiepains and penalties of perjury that the information provided above is true and correct.
Si ature: Date: r
Phone#: - a Ll
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: ,s,�A Not
tTApplicable £
Name of License Holder: () U (� f'h c L �/0 90 &�.Q
License Number
. L U P AL ��� kO ri AAAO dJ J 0 0U6
A dres Expira on Dat
II - a �3
Sig re Telephone
9 Registered:HomeImp�ovemenf Contractor �_ w Not Applicable £
i
Company Name Registration Number
Address —' Expirati n Dat
Telephone �'�
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..VF-£ 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,
i
j
4-
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other[0]
Brief Description of Proposed A n
Work: "�R(P dc� �41rs -tN6 Flf�t�r � ��� 1�Si,4�l, e&V)
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If New house and.or�additidn to ezlStlnq`.housinq, complete fhe 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 '30 as Owner of the subject
property
hereby authorize
to act on my beh in matt relative to work authorized by this building permit application.
1 h z-.
Signature o Owner Date
1 on u , ash/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.
Vl. ti
Print Name
Signature of6wner/Agent Date
- �
Section 4. ZONING At[Information Must Be Completed. Permit Can Be Denied Due To Incomplete Inf rmatr�'
Existing Proposed Required by ZoniPg -t-
TIiis column to be fiII6-d in 5by
Building Departmentl
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage "0
Open Space Footage %
(Lot area minus bldg&payed
#of Parking Spaces
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
-��
NO �~x~�� DONT KNOW �,� YES �~x~�
/
IF YES, dateissund.
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �
� � DO NT
�
IF YES: enter Book Pag and/or Document#
�� ��
B. Does the site contain a brook, body of water or*etiands7 NO �~��� DONT KNOW �~� YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission? �
Needstobeobtained �-
\ Obtained �-t Date
'
v�� �~� '
C. Do 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 0 NO 0
IF YES, describe size, type and kncation:
E Will the construction activity disturb(clearing, gradingexcavation, orfi|Kng)over 1 acre orisd part ofa common plan
' that will disturb over 1acre? YES NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required. /
/
-��� )
4
:-
I
City of Northampton Status of Permit �dl ` �1�' 1t f ° F
Building Department Ctlb culrEDrirteway Petrrt# ;
212 Main Street Sewer%SeptteAvaifa�Eltt}( '
Room 100 VIlater/VfetiA�atla6ility i �'{r li r
_ Northampton, MA 01060 17 wa,Se#`siof5#ructural Ptans'
pEpr OF eus..ntNe sNSPEC I IONS
AMP70N,Mn�+% 13-587-1240 Fax 413-587-1272 Plot/Slfe PIanV,L ' i ''j il Y j IY ; ,t'
No»m Other Specify�Y �'� i yY x�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 Property Address: This secfsorr to ... completed by office
3 G �pk b� Map 3 Lot I Urnt
Overlay Dsstrrct
1
' rt r _, '
nm
CB DIStnct
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT:
2.1 Owner of Record: s.
Name(Print) Cur nt ailin dre
q, y i �
Telephone
Signature
2.2 Authorized Agent: (� i
�U t 0 2 T �l' ,� LA U I t tl4yL� 4A` I d6
Name(P nt / Current Mailing Address:
( `It -1 J9_6 3 3 9�.
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 Fee
w
2. Electrical (b)Estimated Total'Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 0 0 r 0 0 Check Number
This Section For Official Use'Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings , Date
53 ACREBROOK DR BP-2016-0538
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-079 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa: ROOF BUILDING PERMIT
Permit# BP-2016-0538
Project# JS-2016-000895
Est. Cost: $6600.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID FORTIER 008026
Lot Size(sq.ft.): 14418.36 Owner: MORIN ANNA G
zonina: Applicant. DAVID FORTIER
AT. 53 ACREBROOK DR
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965 WC
NORTHAMPTONMA01060 ISSUED ON:1012012015 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 10/20/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner