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18C-030 (2) 906 BRIDGE RD BP-2017-0511 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C -030 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2017-0511 Proiect# JS-2017-000839 Est.Cost:$2000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 14200.56 Owner: NLAZZA MARIO L&MARY C AND RONALD A MAZZA Zoning: SR(100)/ Applicant: MAZZA MARIO L & MARY C AND RONALD A MAZZA AT: 906 BRIDGE RD Applicant Address: Phone: Insurance: 906 BRIDGE RD NO RTHAM PTO N MA01060 ISSUED ON:10/17/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF entire building 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: FeeTvpe: Date Paid: Amount: Building 10/17/2016 0:00:00 $40.00 212 Main Street. Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner f.,)'k 7-6 , :y.-4,67- I Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit RECEVED 212 Main Street Sewer/Septic Availability t- Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans _ _a 2016 phone 413-587-1240 Fax 413-587-1272 PIoUSite Plans ,��gg Other Specify °t: '��"' y gg ATI TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING A1dPiCN,M SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office `10(42 t. v � � �� Map Lot Unit . 0' " CI ",P • "C�kZone Overlay District > Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ima\ k tta tel, ?r \� Name(Print) {���/ _ a(--0/ Current Mailing Address: �.e �7/I/�' /:`� Telephone . �7 �( Sign ` i9�� I{), j / ) ll 2.2 Authorized Agent: Name(Print) 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 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of _ Construction from (6) '7-) e, 3. Plumbing Building Permit Fee - 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4 +5) g cvO _ Check Number /V,0. This Section For Official Use Only Building Permit Nu •- . - 171- Issued 1 Signature 70 - /7-/d Building Commissionerrinspector of Buildings Date Section 4. ZONING All 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&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O 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 0 , 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. 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 [Q Siding[0] Other[0] Work�esatption of Proposed �fp et.Zct lex' f k.S� t /YC� / 6 t? Brief I/R� Alteration of existing bedroom Yes No Adding new bedroom Yes No -BUJ 4://1 -› Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and or addition t 'sting 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. 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. Wilt 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 ,11I, /194yrzem 4.3114,6 - P ,as Owner of the subject grope 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 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. Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable 0 Name of License Holder License Number Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavi ust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi 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(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. pc Homeowner Signature //� ( •i` G2 434-air/ The Commonwealth of Massachusetts Department of Industrial Accidents _; !_ l Office of Investigations iii _' � _y 1 Congress Street,Suite 100 Boston,MA 02114-2017 �IMIt www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.D I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub contractors have 8. ❑ Demolition workin: for me in any capacity. employees and have workers' 9. ❑ Building addition [No • orkers' comp. insurance comp. insurance.= P.s uired.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. l! 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 12.0 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. t Homeowners 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. Lic.#: Expiration Date: Job Site Address: 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 certify under the pains and penalties of perj that the inf rmation provided above is true and co rect. Signature: Adr.....Wit..—I_ Q'— A� Date: /6 r 7^! X �� 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 150k Address of the work: l 6 - - AA":" The debris will be transported by: The debris will be received by: a Building permit number: Name of Permit Applicant c-Air262//(_. 4 297 a -a Date/—M >< Signature of Permit Applicant City of Northampton qz NAM \ � ‘S, •• Si .t Massachusetts «� �. iii ` `f . DEPARTMENT OF BUILDING INSPECTIONS = e !� y 212 Main Street • Municipal Building Jti r_ +/ 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 fQu_nddtion/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, A -Q0/ /'( ���z ,�jj l� �� �� understand the above. H me owner/resident's signature ure requesting exemption) I will call to schedule all required b ilding inspections necessary for the building permit issued to me. Date Address of work location 7frOe< From:Berkshire Ins Agency 413 447 1977 10!07;2016 12:35 #905 P.001/001 AC CORD OF LIABILITY INSURANCE DATE(MMIDD"YYY) `--� 10/07/2016 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 policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require art endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Judith Mabee BERKSHIRE INSURANCE GROUP INC. , Ho Exo, (413)553-3090 (;,�Not EMAIL ADDRESS: jmabee@berkshireinsurancegroup.com 60 ALLEN ST. INSURERS)AFFORDING COVERAGE • NAICA PITTSFIELD MA 021204270 INSURER A: LM INS CORP j 33600 INSURED INSURER B VALLEY HOME COMFORT INC INSURER C: INSURER D: 20 WAREHOUSE STREET INSURER E: SPRINGFIELD MA 01118 INSURER F: COVERAGES CERTIFICATE NUMBER: 92032 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUEDTOTHE 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. INSRADDL SUDR. POLICY EFF POLICY EXP TYPE OF INSURANCE LTRINSR WYD POLICY NUMBER (MM/OD/YYYY)I(MMJDDJYYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED I CLAIMS-MADE LJ OCCUR PREMISES:E0 occu-rence) S ._.. . MED EXP(My one person) S NIA PERSONAL&ADV INJURY S GENt AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE_—$PRO- — _----- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER - $ AUTOMOBILE LIABILJTY COMB NEDSINGLE LJMII $ Me accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per ac-/dont) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accidenI) UMBRELLA LtAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE - $ DED RETENTIONS $ WORKERS COMPENSATION X STATUTE I I TRW AND EMPLOYERS'LIABILITY Y r N A OAFFC,EOWMEMBEREXC UDEDEC E n WA WA WC531S342615016 04/11/2016 04/11/20171E.LEACH ACCIDENT $ 100,000 (Mandatory in NH) EL DISEASE-PA EMPLOYEE $ 100,000 If yds,describe under DESCRIPTION OF OPERATIONS below C.L DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Ic required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensatlon/Investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Wiiliam Ewers 20 Beacon Street AUTHORIZED REPRESENTATIVE • Florence MA 01062 I Daniel M.Crov✓ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD -