23A-186 (4) 8 PINE ST BP-2006-0529
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A- 186 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2006-0529
Project# JS-2006-0783
Est. Cost: $13500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: LEON N BERNECHE 015446
Lot Size(scq. ft.): 39291.12 Owner: MAIJRER ROBERT
Zoning: URB Applicant: LEON N BERNECHE
AT:: 8r PINE INE_Z ST Applicant Address: Phone: Insurance:
665 PROSPECT ST (413) 536-2060 O WC
CHICOPEEMA01020 ISSUED ON:11/15/2005 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BY REOPENING WALL & ADDING
CLOSET & INSTALL REPLACEMENT DOORS/WINDOWS & PORCH FLOOR
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: 7 C C p X 0ioK 417105 Louis
J P - Rough Frame:AU-OK. it121 05 STAO
Gas: Fire Department Fireplace/Chimney:
1lUtigs[: vu. .- -- [c...:
Final: Smoke: Final: or.. 0 lit i (le 1., A I S
THIS PERMIT MAY BE REVOKED BY THE 'Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL TIONS.
----- --:_ er„ ,,,,--:,,_ ri -
Certificate of Occupanc _� Si nature: (/
FeeTvpe: Date aid: Amount:
Building 11/15/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2006-0529
APPLICANT/CONTACT PERSON LEON N BERNECHE
ADDRESS/PHONE 665 PROSPECT ST CHICOPEE (413)536-2060()
PROPERTY LOCATION 8 PINE ST
MAP 23A PARCEL 186 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 7��
Fee Paid (JJ/1 6 -
Typeof Construction: REMODEL BY REOPENING WALL&ADDING CLOSET&INSTALL
REPLACEMENT DOORS/WINDOWS&PORCH FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 015446
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Commissio
.....---" 7:0.//,‘"'"Alir---- '1-74' )f---
Signature of Building 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
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
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
ni N- !�P� Map 7 3 A Lot '1� Unit
T (� Zone 1 V1
_ Overlay District
f' t�
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
mitt A cis to . ()vx slF, .N wN,IUA 01007
Name t) Current Mailin ddress:
i3-7-3 -sz73
Telephone
Signa ure
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
G�f/LJ�,�•Z O!o Za 5.7G2_
Si 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
/ ,5 00 — Construction from (6)
3. Plumbing Building Permit Fee
I , 5c,4. Mechanical(HVAC)
5. Fire Protection 500
6. Total = (1 +2+ 3+4 + 5) / 3 soap Check Number .?5/g 6-0
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner/Inspector 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
39. soo _ �f'
Lot Size i V)�3oa - __..
1� 1y . .__
Frontage '
Setbacks Front itv
Side L: R rr L:! 1 0 R: i.........._._.i r
7 � 1
Rear ':s'
Building Height L i
Bldg. Square Footage :7 �=��J C ,/, % J
Open Space Footage �7
(Lot area minus bldg&paved 7� j g •/I L
parking)
#of Parking Spaces ;-!O
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW co YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0�� DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: 6,,,{,t-O'Wf\Jcizs ff- .
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location: C;--i f 1 of,'" N, -71v
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 0 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 indows Alteration(s) �c Roofing i J
Or Doors [,X
Accessory Bldg. ❑ Demolition ❑ New Signs [I]] Decks [0 Siding [O] Other[O)
Brief Descript" n ropo / �/ COO
L�/
Work: �� K eaki �r)KW WOIt/01 D WAtilf•-(Inki
Alteration of existing bedroom _Yes A No Adding new bedroom Yes ' No �� .
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll -Sheet
6a. 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. 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�7� AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1)( ,as Owner of the subject
property
hereby ,uthbrize L-t�0 JV E=e—e--.11f
to act . 'behalf, in all matters relative to work authorized by this building permit application.
Signa re of Owner Date
/ , as Owner/Authorized
Agent -r-.y declar 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 caner/ gent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: .—f /�-1 3iZZ•ki,-t C_tfi z C.,( S 4-4(..
License Number
/s 7 &I. tr✓/A-'r/i-/•.c ra3..4 S% eALC /f' iZ%v.�l•�( —
Address Expiration Date
173 3 z3 55
Signet Telephone
9,Restlstered 4ome Improvement Contractor: Not Applicable 0
^/ � �>�� i v — /0/ 5 53 /o/ 5 55
Company Name Registration Number
GGS p/ins �,=L�- s,— G - zz( -0G
Address Expiration Date
C/74/GcJ7 . / l,4 Telephone 53 6 Z06 o
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 ermit.
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 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
The Commonwealth of Massachusetts
— Department of Industrial Accidents
5 1—
-;Tit= t Office of Investigations
c = Office
600 Washington Street
Boston,MA 02111
•Y ��r .www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): • -7Z/4) ./fK / L
Address: 6C S -PiavS tJ L C-
City/State/Zip: G/h'c.. p,i rt_ A.4A— Phone#: 5 3 G a o 6 0
Are you an employer?Check the appropriate b : Type of project(required):
1:❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors �,,,�
❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• LFJ remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.[ ,lleectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.L ''I lumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.0 Other
*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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ALEA North America Ins. Co.
Policy#or Self-ins.Lic.#: WC1050087 Expiration Date: 3/19/2006
o/oGo
Job Site Address: P, S City/State/Zip: /'1,41ZTifj¢-gyp vnt
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 t ains an tallies of perju at the information provided above is true and correct.
Signature: Date: // _5--
Phone#: 4-13 5-3 6 Zo 6 o
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#:
WORKERS COMPENSATION & EMPLOYER'S LIABILITY
• A I _ . ALEA NORTH AMERICA INSURANCE COMPANY INSURANCE POLICY
55 CAPITAL BOULEVARD Policy Period
_i
rk
ROCKY HILL,CT 06067 Policy Number From To
WC 1050087 03/19/2005 03/19/2006
12:01 A.M.Standard Time at the described location
Transaction
NEW BUSINESS
AGENCY BILL
1. Named Insured and Address Agent
L.N. BERNECHE, INC. IRC, INC.
665 PROSPECT STREET HIDDEN VALLEY FARM
CHICOPEE MA 01020-3050 LYNNFIELD, MA 01940
Telephone: 781-581-7400 9040001
Carrier# FEIN# Risk ID# Entity of Insured
41068 042473349 0000452 CORPORATION
Additional Locations:
2.The Policy Period is from o3/19/2005to 03/19/2006 12:01 a.m. Standard Time at the Insured's mailing address.
3.A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states
listed here:MA
B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A.
The limits of our liability under Part TWO are:
Bodily Injury by Accident $ soo,00o each accident
Bodily Injury by Disease $ Soo,00o policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON,
WEST VIRGINIA, WYOMING, AND STATES DESIGNATED IN ITEM 3.A.
D. This policy includes these endorsements and schedules: See attached schedule.
4.The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans.
All information required below is subject to verification and change by audit.
SEE EXTENSION OF INFORMATION PAGE
Minimum Premium $500 Total Estimated Annual Premium $15,247
Expense Constant $264
Premium Discount $-407
Assessments and Taxes See Attached Extension of Information Page Deposit Premium $15,247
❑ This is a Three Year Fixed Rate Policy
Premium Adjustment Period: ® Annual; 0 Semiannual; 0 Q erly; 0 Monthly
O
Countersigned this 31st day of March, 2005
Issued Date: 03/31/2005 A horize Representative
Issuing Office ROCKY HILL, CT
00
we o0 00 01 0801 INSURED COP Page 1 of 5
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