14-014 830 CHESTERFIELD RD BP-2016-1264
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 14-014 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: GARAGE BUILDING PERMIT
Permit# BP-2016-1264
Project# JS-2016-002173
Est.Cost: $35000.00
Fee: $270.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. 1): 354229.92 Owner: THIBAULT WAYNE G&FRANCES M
Zoning: Applicant: THIBAULT WAYNE G & FRANCES M
AT. 830 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
FLORENCEMA01062 ISSUED ON.51912016 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 30 X 45 DET GARAGE
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 5/9/2016 0:00:00 $270.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1264 �;6W
APPLICANT/CONTACT PERSON THIBAULT WAYNE G&FRANCES M
Y
ADDRESS/PHONE FLORENCE01062 ¢
PROPERTY LOCATION 830 CHESTERFIELD RD `
MAP 14 PARCEL 014 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyneof Construction: CONSTRUCT 30 X 45 DET GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included: �}
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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
Demolition Delay
Si re of Buil mg 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.
,, ,..,.... . . .
City of Northampton Status of Permit: Department use only
I APRzais
T Building Department Curb Cut/Driveway Permit
z
! 212 Main Street Sewer/Septic Availability,
Room 100 Watermell Availability
`S 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 O
SECTION 1 -SITE INFORMATION L
1.1 Property Address:/� /� ) This section to be completed by office
T3 O `�� �rCri G 1'� /c('/ lJ�nen� P Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ws.--t�nC ! ��"•✓► T. 1/11 G F[e.chC --
Name(Print) Current Mailing Address:
-^ 4 13 -- 5-,8(0 - V1"I I
�s Telephone
Signature
2.2 Authorized Agent: ! 7 /
Lfthrc+i1 vi/z'Z D✓to/1 isy �(�✓1Cas X�Jr 'Syf"-. Plon lir3l j IMC -��N.l�✓�
Name(Print) �o Current Mailing Address:
Signature ff Telephone
SECTION 3-ESTIMATED STRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by permit applicant
1. Building (a) Building Permit Fee
GOO
2. Electrical (b) Estimated Total Cost of
C C! D Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) d Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING Alt 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 ` '
i.�s
Side L: > R:!____.1 L:_ R•
Rear
Building Height -- ? 1
Bldg.Square Footage % '
L
Open Space Footage _ j---, %
(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 (!Df' DONT KNOW ® YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ® YES
IF YES: enter Book Page-[ and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO (2( DONT KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: F
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
IF YES, describe size, type and location:
E
E. Will the construction activity disturb(clearing,grading,excav on,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. [4 Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[0]
Brief Descriptipn of Proposed f ��+,
Work- Cola 54o, c,c� P0811 YrnYhP �✓e1�Tt�,' ,10�'fSoy1!a I ✓P._�,e.�C 546r'G�<;� —
Alteration of existing bedroom Yes No Adding new bedroom Yes No CUJ
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.-9f New house and or addition to existing housing;; complete the following:
a. Use of building : One Family Two Family Other X
b. Number of rooms in each family unit: Number of Bathrooms CA
c. Is there a garage attached?
d. Proposed Square footage of new construction. /G d Q Dimensions 30 ,g ys
e. Number of stories? 1
f. Method of heating? rlo,'IC Fireplaces or Woodstoves-/I A Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction VB
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 ei
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
Vie �h(�n as Owner of the subject
property
hereby authorize _lor-Fo►'+ � �'t]i�'hC�� , /'�C-
to act on my behalf, in all matters relative to work auth rized by this building permit application.
Signature of Owner Date
I, vvti:7r" ��" b r' 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.
rka
Print Name
Signature of wner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction' Supervisor: Not Applicable ❑
Name of License Holder: (r�-n �� C�Zg _-111-s_ tZq Q l'a
License Number
.�4-felv'V-44, 3 N AAA C.IJ Rd a,r,V%/.. �- C-1- a61��l 201-1
Address T Expir ion Dat
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
ivgy6 Li
CompanyName 1 R�,eggiistrattiion Number
1 "el 2
s PIC- P
Address (� Expi ation Date
K �►r�elephone
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 Exem don
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, oy u 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
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: X630 � .( r�'e.1c� Q�; f mvr%ae—
The debris will be transported by: �,^�p
The debris will be received by: SJt 3�►��� ��,,$ ..- s-�..�.,o.-, ✓��
Building permit number:
Name of Permit Applicant dc-ny' � k ,,j1 -
Date Signature of Permit Applicant
The Comnwnwealth of,Massachusetts
t;~ ;? Department of Industrial Accidents
I " i+. I Cott,ress Street,Suite 100
Boston,MA 02114-2017
wevw.mass.ti otldia
Workers'Compensation Insurance Affidavit: Builders/ContractorsiElectricianslPlumbers.
TO BE FILED WIT11 THE PERM11TING AUTHORITY.
Applicant Information Please Print i eQibly
Name(BusinessiOrganizltioaflndividttal):Morton Buildings, Inc.
Address:252 W.Adams
City/Statel7ip:Morton, IL 61550 Phone#:309-263-7474
Are you an employcr7 Check the appropriate box:
Type of project(required):
l.Q✓ I aa±a employer with 1664 employees("full an&or part-tune).' Q t
7. New construction
2f]1 am a sole proprietor or partnership and have no employees working for me in S. ❑Remodeling
any capacity 1No workers'corp.insurance required.]
3-a I am a hontcowner doing all work myself.INo workers-comp_insurance required.]* 9. ❑Demolition
4.n I am a homeowner and will be hiring contractors to conduct allwork on my property, 1 will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or arc sole I I.o Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.Q 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
'these sub-contractors have employees and have workers'comp.insurance.*- 13.❑Roof repairs
fi❑We are a corporation and its officers have exercised their right of exemption per MGL c 14.Q Other
152,§1(4),and we have no employees.[No workers'comp,insurance required.]
'Any applicant that checks box-fl t must also fill out the section below showing their workers'compensation policy information.
+Ifomcowners 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.
1 am an emphyer that is providing workers'compensation insurance for n{1 employees Below%the policy and job site
information.
Insurance Company Name:Zurich American Insurance Co.
Policy#or Self-ins.Lic.#:WC937631712 Expiration Date: 10/1116
Job Site Address: 3 7—IfAes4t°.�el L0,4) CityiStatelZip:��.�nG�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under VIGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the forst of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.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 andpenalties of perjury that the information provided above is true and correct
Signature: f 11"'11r�/'/* 'WK
--�� Date: /r,;;
Phone#:309-263c7474 r
P
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 4:
NVOIZKE16 COIMPENStVIFIONAIND EMP1,OYERS 11AIIIIII1,
CONIVERCIAL,LINSUIlLtNCE, LNSURANCE POLICY—IINFOR3VIATION PAGE
Ser vricing Office:
tG5Lfiuic fa;this carer nee p3f! piv,;dzd b� f-:4
AMERICAN ZURICH INSURANCE COMPANY . I CAGO
30" S. RIVERSIDE
ICHTCAGO, T 1 60606
1. Policy N uni txr WC 937631? 12 Renewal of Number WC 93763-11-11
Nwied Ins Lred and Nhilin.(:, Address Producty aid Ntiling Address
MORTON BUILDINGS, INC. A
AON RISK SERVICE'S CENTRAL INC-
252 WEST 200 EAST RANDOLPH STREET
PO BOX 399 13TH FLOOR
MORTON IL 61550 CHICAGO IL 60601
Producer Code 30380-000
Other workplaces not shown above:
FEIN: 37-034'7 310
NCCI Company No. 17965 F] New F1 Renewal F1 Rz%w ke of Prior Policy No.
This information page- with policy provisions and endorsements, ifaiyy completes this policy.
Ins ured is: CORPORATICN
2. Policy Per iod: Fran: 101-01-2015 to 10-01-2016 at 12:01 A. Nt Standard Time at ins ured's mailing address.
Insureds Identification number(s):
9':0484842\2433003\12941113A\080431-\2433003
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the
states listed here: AL,AR,CO,CT,DE,FL,GA,1A,TD,IL,1114,KS,KY,LA,MA,ME,MI,MN,MO,MS,MT,NC,NE,NH,
Ni,NY,CK,PA,SC,SD,TN,TX,VA,VT,?A7
B. Employers Liability Insurance: Part Two ofthe policy applies to work in each stale listed in Item 3.A.
The Limits of Liability undo- Part Two are: Bodily Injury by Accident: 1,000,000 each accident
Bodily lnry by Disease: 1_,000,000 policy limit
Bodily Injury by Disease: 11000,000 each employee
C. OthtT States Insurance: Part I'lirm ofthe policy applies to the states, ifary, listed here:
See Endorsement
D. This Policy—includes these endorsements and schedules:
See Schedule(I Forms and Endorsements.
4. The premium tarts policy will be deter mined by our Nfinuals of Rules, Classt cations, Rates and Rating P tans. All
information requied on the following Classification Schedule is subject to verification and change by audit.
See Classification Schedule
TOTAL ESTIMATED STANDARD PREMIUM $ 476,221-00
PREMIUM DISCOUNT $ -8,063.00 orad icated belay,ad iaslmt au
EXPENSE CONSTANT ofpic Mi2se shall be mi do
PREMIUM FOR ENDORSEMENT Annually 11 Monthly
TAXES AND SURCHARGES $ 63,868.00 Se mi-Annually El This;is a Three
TOTAL ESTIMATED ANNUAL PREMIUM S 532,364.0�0 Year Fixed Rare
Qnanerly Policy
MINIMUM PREMIUM
DEPOSIT PREMIUM $
Agent or Producer Countersigned bY Resident licensed Agent Date
WC 00 00 01 A U WC-D-3 14-A(07-94)
Page I of!
DATE(MM1DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 2/21124,5
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 pOGcy(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 a
Aon Risk services central, Inc. NAM£
chi cago IL Office {aGN o.Ext): <866? 283-7122 FAX
No.: (804) 363-0105 a
200 East Randolph E-MAIL o
Chicago IL 60601 USA ADDRESS: _
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: Zurich American Ins co 16535
Morton Buildings, Inc. INSURER B: American Zurich Ins co 40142
2S2west Adams Street INSURER C: Great American Insurance Company
Morton IL 61550 USA of NY 22136
Mor
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:570060549999 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. Limits shown are as requested
INSR ADD EIR POLICY EFF POLICY Exp
SO
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBERAMID MMIDDIYYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY GLO 1 1 EACH OCCURRENCE
CLAIMS-MADE X�OCCUR PREMISES aoccur� $1,000,000
MED EXP(Any one Person) $50,000
PERSONAL&ADV INJURY $1,000,000
GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,006
X POLICY F]P£CT LOC PRODUCTS-COMP/OP AGG EXC1Uded m
0
OTHER: o
n
A AUTOMOBILE LIABILITY BAP 9376314 12 10/01/2015 10/01/2016 COMBINED SINGLE LIMIT $2,000,000
Ea accident
Ix ANY AUTO BODILY INJURY(Per person) ,- Z
ALL OWNED SCHEDULED BODILY INJURY(Per accident) d1
AUTOS AUTOS
HIRED AUTOS N
QPROPERTY DAMAGE
AUTOS
SWN£D per accident
1:
m
c X uMBR£LusLuda X OCCUR UMS4223219 10/02j2015 20j01/2016 EACH OCCURRENCE $2,000,000 U
ExcEssLIAB cLAIMSMADE umbrella Liability AGGREGATE $2,000,000
SIR applies per policy ter s & condi ions
D£D X RETENTION
B WORKERS COMPENSATION AND I Wc937631112 10/01/2015 10/01/2016X P£R ( IETH-
EMPLOYERS*LIABILITY STATUTE
ANY PROPRIETOR I PARTNER I EXECUTIVE YIN ADS E.L.EACH ACCIDENT $1,OQO,000
A OFFICERIMEMBEREXCLUDED? a NIA wC937631212 10/01j2015 10j01j2015
(Mandatory in NH) Retro-WI, MA, EXCI OH ( E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S1,000,000-
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if mare space is required)
RE:
CERTIFICATE HOLDER CANCELLATION
ti!
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE NTH THE a-
POLICY PROVISIONS.
AUTHORIZED
{^REPRESENTATIVE
.�
<�F43L c�!�C�YG�fLlr4aCta (:.�f2 �!ilQ
01988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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