23A-203 4 SUN HILL DR BP-2017-0155
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A-203 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category' vinvlsiding BUILDING PERMIT
Permit# BP-2017-0155
Project# JS-2017-000250
Est.Cost:$32400.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Grouo WELLS CUSTOM FRAMERS LLC 66275
Lot Size(so.ft.): 15289.56 Owner: PROBOLUS GEORGE F&JUDITH A
Zoning: uRBno0J/ Applicant: WELLS CUSTOM FRAMERS LLC
AT: 4 SUN HILL DR
Applicant Address: Phone: Insurance:
1407 NORTH ST (413) 684-5274 O WC
W I NDSORMA01270 ISSUED ON:8/3/2016 0:00:00
TO PERFORM THE FOLLOWING WORK::INSTALL SIDING, REPLACEMENT
WINDOWS/DOORS
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 it 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 8/3/20160:00:00 $100.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Departaienteseonly
City of Northampton steps asPem
�rBuilding Department CteD CuUD ive.ty Perm$
fan+ 3 2016 212 Main Street Sewer/Soptic AvailehiBy
„mn Room 100 Wale me AvMebr ty
put or e. .n - rn Northampton, MA 01060 *t d
phone 413-587-1240 Fax 413-587-1272
Other Sped/y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
S,AA,71 Jam, `- Map Lot unit
00/TA C r, /11 Zone Overlay District
Elm$t District Ca DIsbict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
6re.7e (�,.oba/415' at 344 JP" Ten— ?/ us.,3 Ucg9 A r
Name(Print) /J Current Maili'g Address: E.S I L 7
$(y�' � Lc6xr- vas_
J Telephone
Signature
2.2 Authodzed Anent:
j,To'4G) 2 Lk-Pi I Yo7 t)-r 4 ' Jt �,n d✓'y't /��'
Name(Pmt Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building -?z 90 U_ os (a)Buildingnny PeFee
J
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mec anicai(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 32 joo ,00 Check Number faQcj ��'lll�J#/r6This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Bulkting Commissioner/Inspector of Buildings Date
Section 4. ZONING An 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
Side L: R: L: R:
Rear
Building Height
Bldg, Square Footage
Open Space Footage
(Lot area minus bldg&paved _.
parking)
#of Parking Spaces
Fill:
(volume&Inom on) - -
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES O
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 O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
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 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
_TON 5-CfEESCRIIPGONOF_Pgr)PO P0W0�K jd'rent hapnimehett
New Hoene — Afldi@no ° Replacement Windows ' Alteration(s) E' Roofing r-1
Or boars ,., _
Acne 5 yBlu Ll Dement/en, ., Nr 9ns G Deeks r n9 Other[C
os(]F^>i...
Era if New house and or addition to existing hotlsin0_complete the following-
ra,
Number LA morns el eeceeamiy ung Nerermn nenen .a_
. n ..ntts�
r f )t 'Ig' JOK Te . YT'�dP
SECTION Ya .OWNER AUTHOR)ZATION TO BE COMP!ETEO WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERM'
ac Owner of the nee,an,
Milaiiiiiiiiiiiiia
('tIeArr.. tot ;.i.,....,.f .T,Jal'y.
a 1.di, 6
rr
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Homer: Tino /2 Uri/5 L - oedz
/� License Number
) 907 N^:+I. J4 Ctl i.T cbon / ` c D/2 )0 //1//)
Address Expiration Date
T74I - otl- Jz)y
Signature-' Telephone
P.Renistered Home lmnrovement.Contractor Not Applicable ❑
-TR 4!e/U Cu.1io.a &v.-r LCC YdZ3ey
Company Name Registration Number
Ivo? Ne-44 J} /J, iJDn A4 01273 c//6
Address Expiration Date
Telephone 4rS 6k Y. f-2))
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,$26C(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 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 borne 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
City of Northampton
Massachusetts �:S. 'c(
d
Ia 11 ..f i DEPARTMENT OF BUILDING INSPECTIONS i A
212 Main Street • Municipal Building `` �•�
Northampton, Ia 01060 V' gegCI6
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER FXEMPTION 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 backfilll, sonotube holes (before pour).a rough build) y inspection
• • 1. - • - 1 •I 1 : : 11.• , I • C1 , I1 1 1 • NW- • 1
The building department requires these inspections before the work is concealed, failure to secure
1 '
• . ; .. 1 C 1 :1 F • •1:. i " I • • . 1. _ 1 1 : L♦ : 1 •e
in&pelted.
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 FLAY 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
_W— Department of Industrial Accidents
___
_ Office of Investigations
Ea-i^!�=? I Congress Street, Suite 100
'`SEI—
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information y- Please Print Legibly
Name (Business/Organizationf /.,ndividual): T2 ✓"e//'f `/vi rte'-rC
Address: y`o/I '7 ficrrrk Sf
City/State/Zip: (Aire p''t , /-`cc 61?7o Phone#: yi 3- SIy—J_z ),
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with S 4. ❑ I am a general contractor and I
F p have hired the sub-contractors 6. ❑New construction
employees(full and/or part-time).`
2.❑ 1 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' q ❑Building addition
[No workers' comp.insurance comp.insurance]
required] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 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' 13.0 Other
comp. insurance required]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContracthrs that heck this box must attached an additional shed showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their woken'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: / I°`rte/cin t-p/ay J-'^ P6--t(P
Policy#or Self-ins.Tic. #: L'CL.foo 7 573C R t ot3-A Expiration Date: rfl 9-1/2
lob Site Address: 7 s`r� A' // ( City/State/Zip: flv�r-.c r /419
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 rectify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: l �'�- . Date:
Phone#: V 913- 6 - yl7)'
•
, 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: y 1-4, 1i trk- c Yhtri,c�
The debris will be transported by: j''1`
The debris will be received by:
Building permit number:
Name of Permit Applicant 00r
Date Signature of Permit Applicant
A O a CERTIFICATE OF LIABILITY INSURANCE DATE
OfWzoic
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 policyQea)must be endorsed. N SUBROGATION IS WAIVED,sub(ect to
the tenrm and Conditions of the policy,certain polities may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endoreem ent(s).
PROOIflR ACT Nit Creer
Coakley Pierpan Dolan S Collins Insurance Agency ' E (413)664-9366 FAX (413)664-4723
26 Union Street Arita narear8 epdcinsurance.cos
INe1IRERIS)AFFORDING COVERAGE RAUCS
North Adams NA 01247 INSURER Ohio Security Insurance Co. ,24082
INSURED inmate Ohio Casualty Ins Co. 24074
T.R. Wells Custom Framers, LW INsunmc.
AFgzieav Smplovers Ins Co
1407 North St INSURER 13:
INWPFRE:
Windsor MA 01270 INSURER F:
COVERAGES CERTIFICATE NUMBER:2016 - 2017 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. NOTWTHSTANOING ANY REQUIREMENT,TERM OR CONDMON 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�I��POQQ��LLLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.�
MISRLTR TYFEOFIMeWNOE L Pm1GYPmS R uuel 11M r1 Nga)WVY'/rJ ream
A COMMm6mL GENERAL any i EACH OCCURRR.CE $ 1,000,000
IDAMAGE TO RENTED
A _ CLAIMS-MADE X OCCUR PREMISES(Ea=rem] E 300,000
1 I axs57101250 5/27/2016 5/27/2017 ME D(P(Any oepnmN S 10,000
PERSONAL aADD IWURY $ 1,000,000
GENT AGGREGATE UMIT APPLIES PER. GENERAL AGGREGATE E 2,000,000
R I PoUCY PR0. 1
JECT I IIAC PRODUCTS-COMP/OP AGO S 2,000,000
I°METE 1 BREWae Mod scot $
AUTOMOBILE LIA&U1Y ROC IgN'LE LMT S 1,000,000
A 7 ANY ALTO BOORT INJURY(Per pen,* S
uLONNEO SCHEDULED
AUTOS x AUN6 Im95II01250 2/15/2016 2/15/2017 PROPERTY
f
HIRED AUTOS R AUTOS FD 1 PROP YMWF $
AUr05 (Pm cPlMl
ETE
R UMBRELLA LIB X OCCUR EACH OCCURRENCE S 1,000,000
El I EXCESS LMS CLAIMS-MADE AGGREGATE S 1,000 000
DEO X RET]iiQN$ 0 05057101250 5/27/2016 5/27/2017 6
WORMERS COMPENSATOR R PE ' OTH-
TAER
AND EMPLOYERS*LMSLRY Y/N
ANY PROPRIETORPMTNER/EXECU11VEEL EACH ACCIDENT $ 1,000,000
C4 FICEWNEMBER EXCLUDED? N R/A
C,
(mandatory In NH) RCC5007523012015A 8/19/2015 5/19/2016 EL DISEASE-EA EMPLOYEES 1,000,000
DEiM 3N OO
pESCRIPDON OF OPERATIONS below El DISEASE-KUCYUNIT $ 1,000,000
0ESCNF1ON OF OPERATIONS I LOCATIONS/VEHICLES(ACORD illtAcieltionS Remarks Stlw6^cm 4e NxMda San Mama Maine
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE
TR Wells Custom Framers LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
MITHORIZED REPRESENTATIVE
Kellie Hastedt/DONBIS 5:.C.-L/-u_ a / / t
ID 1968-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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