32A-196 (2) 22 PHILLIPS PL BP-2017-0143
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 196 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:vinyl siding BUILDING PERMIT
Permit# BP-2017-0143
Project# JS-2017-000233
Est.Cost:$27000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group DAVID FORTIER 008026
Lot Size(sq. ft.): 7666.56 Owner: STODDARD MIKE
Zoning: URC(I00)/ Applicant: DAVID FORTIER
AT: 22 PHILLIPS PL
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965 WC
N O RTHAM PTO N MA01060 ISSUED ON:8/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL CEDAR CLAPBOARDS
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 8/1/2016 0:00:00 $60.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only.
y of Northampton Status of Permit:
B ilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
FAUG - 2 2018 Room 100 WalerMtett Availability
No hampton, MA 01060 Two Sets of Structural Plans
06'r.or BUILDING = 13-.87-1240 Fax 413-587-1272 Plot/Site Plans
NORTHAMPTON • . ...
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pn�spe^M Address:
VVI This section to be completed by office
pH" ` L (pS �� , Map Lot Unit_-
Zone Overlay District
Elm St.District, CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
fii,6�HAet,.SIFo-bAanA �1 ftitlris PAae.. Nof as �i r2A.
Lamee((EP-riyn`tt))�`[ a �// { y Current M fn A dress-
�.Mjdaf 41).e—.-`._ - -- .�.�- 71 7
jdf Telnphorfe
lure
Z.2 Authorized Agent: /'
0A oil EL TITCH,. r\a 141/4 (Lb C-7-,
Nfteg(Printlyiev Current Mailing Address'.
2/ 1: - act)—3;{`t
Sign ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Official Use Onty
com.leted b ermit applicant
7. Building girl l2 (a)Building Permit Fee
r
t]/ 600, 06
2. Electrical (b)Estimated Total Cast of
Construction from{6)
3 Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) V) is_if pj Check Number 719'
This Section For Official Use Only_
Building Permit Number'. Date
Dated'
Signature.
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information
Existing Proposed Requucd by Zoning
This ceiumn to be rued in by
Building Depamnem
Lot Size
Frontage _
Setbacks Front
Side G .. R:... L; R:.., .
Rear
Building Height
Bldg. Square Footage io
Open Space Footage /
tot arca minus bldg.&paved
packing)
#of Parking Spaces '-
Fill .._ ..�
(vaiumc&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO a DONT KNOW Q YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW Q YES Q
IF YES: enter Book Page' and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES a
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO (3
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0
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'I acre? YES O NO O
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 n Replacement Windows Alteration(s) n Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs (D] Decks jp Siding(XI Other[CA
Brief Description of Propose
Work. 514 f .(t f{N9 HdJCR,..... rI S r ' del !
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.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. Massoheck 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
//t
I, zifitL, pQppao as Owner of the subject
property
hereby authorize 1lujfl �i-Y!ITit_
to act n my behalf,in all matters relative to work authorized by this building permit appliccaatition.
nature of OwnerDate ��?/1y
I, �P t4.0 '11"Ptasi Watt— asaamer/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.
OF1 00
Pont Na
YAK
Signature Owner/Agent Date
•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holtler: OrUFel -ron't KA 09 -4-
License Number
5a i-flvai Si /vortfit00I(w 114 n(Oipo ]c,( moG�
Address / Expiratio Date
Telephone
Signature Te ephone
9. Renistered Home Improvement Contractor: Not Applicable £
Utku1,0011Pi-- OUP-AW h 1x3910
Company Name ti
Registraon Number
i'9
' N Lnv k24, .— �/SC 0V UEI Pik\a(CO / /. gol.td 1 j ; 6 /S?Address I ]9\--6_ Expiratio Date
Date
Telephone4!3 r-
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,I building permit.
Signed Affidavit Attached Yes.._J( £ 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 ofthe 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
The Commonwealth of Massachusetts
ik,,
8
1 Department of Industrial Accidents
Office of Investigations
600 Washington Street
� kp Boston, MA 02111
uis."
.,;,.. wwne.mnss.gorldia ..
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
,---
Name (Business/Organization/Individual):
Name(&uiness/Organization/Individual): t 2 fj B$. ibtiana,es _
Address: 3 a Lac,R-tii 611 -
Ci 7StateIZi o - 'h' P �ti�Yf � II �l Phoned: Oct).9i+� - ,5�1�
Are you an employer?Check the appropriate box: Type of project(required):
1.71 I am a employer with a 4. 0 1 am a general contractor and I _
employees (full and/or part-time).* have hired the sub-contractors 6. El New construction
2.J 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees arid have workers'
[No workers' comp. insurancecomp. insurance.I '4. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10. Electrical repairs or additions
3._ I ama homeowner doing all work officers have exercised their 11.9 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MOL 12.17 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No worker? 12.& Other 5( Q l ib C„g_
comp.insurance required.)
*Any applicant that checks box tFI must also fill out the section below showing their workers'compensation policy information.
tHo=owners who submit this affidavit indicating they are doing all work and then hire outside contractors must avhmit a new affidavit indicating such.
I(bntraciors that check this box must attached an additional sheet showing the name of the sub-contractors and stat,whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information.
Insurance Company Name: Olio S€c ON (1y -'NS' Co .
Policy#or Self-ins. Lie. if: X W 5 mg"'}al S _ Expiration Date: t"1411 a Oka
lob Site Address: . ,y . City/State/Zip: Iv %Cy it"AFION/ IIA -OICYai
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 MCL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 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 ertiif yader the pains and penalties o f perjury that the information provided 4ove is true and correct
*nature: kC( 't Date: ')r917-C)l0
Phone#: 1113 - 40.. 33+ .... _.
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 9. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other_
Contact Person: Phone it:
City of Northampton
/-?-1j Massachusetts <zss
P L` 1,
DEPARTMENT OF HVZLDZNG INSPECTIONS
i213 Naiv 6thamp . HP. 1pal Buil 0
Northampton, MA 01060 'f r.6 P�.
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
City of Northampton 212 Main Street, Northampton, IMA 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: aQ 6Hlu ,AnS eL I /)nom/*AN) FM,
The debris will be transported by: 1)4,to tc.0 tet
IIII
The debris will be received by: I/tyrl&y Cc"/CLOuV
Building permit number:
Name of Permit Applicant 11vR L, to f- 4 44kt
rlatelLi
Date Signature of Permit Applicant
07/26/2016 THU 11:13 FAX 21001/001
ACORD
D CERTIFICATE OF LIABILITY INSURANCE eT Beime
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 BET/NEC4 THE SSUING 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
Ring b Cushman Inc. .E. 1 {413)584-5616 wsFa -eyed
P.O. Box 447
1T6 King Street INSVRERISI AFFORDING COVERAGE _ I{ RAID
Northampton MA 01061 Realms A:ohio Security insurance Co. 24082
INSURED INSURER s:Safety Indemnity Insurance Company •33R1$
David Fortier Builders MAURER C:
32 Laurel St INSURER o:
INSURER ... -.. .._ _
Northampton __ ryY_MA 01060 INSURER F: _ _ _ ___ .L.
COVERAGES CERTIFICATENUMBER:CL16T2801596 REVISER NUMBER!
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE PASUREO NAMED ABOVE FOR THE POLICY PP.RIOO
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, ;tate OR CONDITION Of ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,TIE INSURANCE AFFORDED BY THE POTIONS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Ims EXP
LTR TYPE OF INSURANCE 1N-SD'W3 POLICYNUMBER 'IMWIDOPOYYY1'IMLICY EFF ' MICCMYn LIMITS
X COMMERCIAL GENERAL LIABILW EACH OCCURRENCE 5 1,000,000
A COADA MME LX I aavR C�mMUF&wrsaJ s 300,060
eT555i22$35 22/2/2015 12/2/2016 MEDEXP DeenePerw 4 15,000
I PERSONAL 1.AOv INJURY S 1,000:000
L OEN'L AGGREGATE LIMN APPLIES PER GENERAL AGGREGATE 5 2,000,000
X POLICY jeer i.LOC PRODUCTS-COMP/OP AGG s 2,000,000
OTHER Eaossse Mixese t I S
Mt OMOTDER UA&Ye IVN6 NDSINGLE WE5 11000,000
B ML At SCRAWLED I - 1
AUTOS (X..AUTOS 6225305 30/S/20L9 1D/B/20 POIRO 1 'M+1)r5
X IlIPIDAUTOS % AUTOS Are Seder)
Vn'nwuemness Is TOYS S 1001000
—
MORELLA i149 OCCUR I EACIOCCURRENCE $
I IXCESS MAO ICIAMSMAOE MkGREGATE E
I DE RETENTQN$ $
WORKERS COMPEVSAIION STPTIn_E 0Th-
MD OPavus UAMLm TI 14
MY PROP EEORPARI*IttFEGmWF — EI.FAD'NACLGENT .5 10Tt 060
OF#EERAEN0R E CLIOLO! NIA
A —
(eeS•toi nNH) YA¢55172835 aft/EWA 9/6/2016 EL DISEASE-EAEMPLOYEE$ 100,000
Mq d&Rb lMar
OE3CRIPTON OF OPRAI1ONe Ido 61.DISEASE-POLICY LIMIT $ 8OD.000
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oESCmViMMOP OVAv mil;I LOCYTOJStvnctf iA0DRO151,}dWbMI Ataxic*soefuf.Inry be WeMOnmdp BM*IA,eQ.tntl)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THEABOW DESCRIBED POLICIES BE CANCELLED BEFORE
City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE BELNEREO IN
210 Main Street ACCORDANCE WITH THEPOLICYPROVISONN
Northampton, MA 01060
AUTHORIZED REP`RESEMAINE)27t1 {^f-'\!
1 14814 A�ORD C RPO ION. +1gf hts reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD �,
INS026I201am1
4907.21 I 0.00 ( 0.00 I 0.00 I 0.00 I
119.87 DISCOUNT ALLOWED PER
TERMS:2%10TH NET EOM
500655
Transaction Codes
A-Adjustment C-Credit I-Invoice
B-Balance Forward F-Finance Charge P-Payment
This statement covers transactions on your account for the period ending on the date above.Changes,payments,and credits received
after the above date will be shown on your next statement.