38B-312 BP- 2011 -0312
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit # BP- 2011 -0312
Project # JS- 2011- 000510
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN STRIEBEL 037133
Lot Size(sq. ft.): 4835.16 Owner: HOLLAND EVELYN J
Zoning. URB(100)/ Applicant. STEPHEN STRIEBEL
AT. 130 SOUTH ST
Applicant Address: Phone: Insurance:
497 MAIN RD (413) 774 -0260 WC
GILLMA01396 ISSUED ON :101812010 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL MAIN HOUSE SILL REPLACEMENTS
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 10/8/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0312
APPLICANT /CONTACT PERSON STEPHEN STRIEBEL
ADDRESS /PHONE 497 MAIN RD GILL (413) 774 -0260
PROPERTY LOCATION 130 SOUTH ST
MAP 38B PARCEL 312 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL MAIN HOUSE SILL REPLACEMENTS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 037133
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF�MATION PRESENTED:
a/ 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
to L - 7 I0
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.
City of Northampton N
Building Department -k
212 Main Street W, k
�0 R Om 100
Norlhampkon, MA 01060
C` phone 413 -880 Fax 413 -587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 'I SITE INFORMATION
1.1 Property Address
This section to be completed by office
Map , Lot Unit
Zone,' Overlay Drstrict
l D16trict . ' CB,District
SECTION - -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
BUG
NKe (P ' t) Curren a i ddr s: /
K
Telephone (?( ignature Z /,3 I JQ (p
2.2 Authorized Aaent: x1
Name (Print > Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number r
This Section For Official 'Use Onl
Date
Building; Permit Number: Issued:
Signature:
Building Commissioner/Inspector-of Buildings Date
J
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 t R ._.m...._..�..�....... �. �.w,_.,W..w�. �_�..
Frontage
Setbacks Front j
Side L: R: L---j L: _ R:
Rear
Building Height° — °t
Bldg. Square Footage '1'0 r�
Open Space Footage %
(Lot area minus bldg & paved a
par
# of Parking Spaces ° °—
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q D ONT KNOW 0 YES 0
IF YES, date issued: 9
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT K NOW 0 YES Q
IF YES: enter Book Page; and /or Document #�
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued
C. Do any signs exist on the property? YES 0 NO
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 E
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 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
d�
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition K❑ New Signs [0] Decks Siding [Q] Other [a
Brief es
: 2 o r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes u No
Plans Attached Roll - Sheet
s� :, 1f l teyr #�l $ attcl ��$ +ri ill t 9e I "614i &i Y I e F fo[I tt I a:
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 B15 COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
>L I �� "' / /` �� as Owner of the subject
property ' n
hereby authorize
to o my b half, in all matte relative to work authorized by this building permit ppli tion.
ignature of Owner Date
I, S T V 1G' % , agAw lr /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.
S ! - ��• - 7Z «tic -�Z
Print Name
Signature of Owner/Agent '_' LL ' Date
SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder f= ,G" --s 7 / 3 S
License Number
1114 0/ 3SW
Address Expiration Date
Signature Telephone
9 , Reclisterec l mi )2 t►r^w -/� n � A � �' Not Applicable ❑ r- �
CA 6w/a
Company Name I Registration Number
S MO P 342142� //- / - X010
Addresss &t, Expiration Date
C- l C — &4 of? Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. 6.152, § 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...... ❑
x N
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.
Homeowner Signature
T
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
Applicant Information Please Print Legibly
Name ( Business /orgmizaton/Individual): Wi`71 GK
Address: 2 7 4 pT />74
City /StatelLp: G /CIA. O/ 5 Z /` Phone. # 1 413 v r 04 6
Are you in employer?. Check the appropriate'box: T e of 4 rect o (required):
.. I am a general contractor and I p I
1. [ I am a employer with Z g 6. ❑ New constriction
employees (fall and/or part time). * have hired the sub- contractors
2.. [] I aai a sole proprietor or partner- listed on the sheet 7. [] Remodeling
These sub - contractors have.
- ship and. have is e,�loyees - -8 . Demolition
working for -me in any capacity. euIoyees and have workers' 9. 0 action
• _. Comp. insur-arrr f
[N® workers' comp. i nsuran ce 10 Electrical r _
required ] 5. [] We are a corporation and its 0 - repairs or additions
3.0 I am a homeowner doing all work officers exempt xercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of ion per MGL i2.
c: 1 and we have no - 0 Roof � airs
insurance required.] t 152 , § 4 ()', tn�g S / e .L S
employees. [No workers' 13.0 Ot3icr
comp. ms=nce required.].
'Any applicant 4hat checks box #I must also fill out the section below showing du it wockws' ion policy information ,
t Homeowners wbo submit this affidavit,indicaxmg they are doing an work and then hire outside contractors must submit a new affidavit indicating such.
IConuacbrns that check this box must.attached an additional sheet sbowing the name of the sub - contractors and state whdfier•or not thoseentities have
employees. If the sub-contr= have employers, they must provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. y
Insurance Company Name: C�_ / - �/I G ' " �: '
Policy # or Self-ins. Lic. #: Expiration Date:
Job S ite Addr C' Stafe/
rty 1 zip
Attach a copy of the workers' - compensation policy declaration page"(showing the pplicy number and eaPiration date).
Failure, tcr secure coverage: as requtrea bif&i7 Sectzon'25A 'of MGL c 15Z can lead'to die imposition "of c� penalties of a
fine up to $1,500.00 and/or one. -year imprisonment, as well as civil penalties is the form of a STOP WORK. ORDER and- a fine
of up to $250.00 a day against the violator. Be advLS , that a copy of this statement may be forwarded to t O ffice of
Investisations of the forinsurance covsrase verification
I do h ,cml under a arms ' m enalizes o : perfrayah pro
- - -- -- �' T' P P. f at the informadan vided abQVe._irsrue_andcarrert
Sit�ture: �� -Date• �' �Ci� �r�
Phone
Official use only. Do not write in this area, to be completed by cry or town"offuiaL
City or Town: Nrmlt/License #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town Clerk .4. EIectrical Inspector 5. Plumbing Inspector
6. Other t^
Contact Person: Phone #:
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 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
Date
Address of work
location
'rom:Syndi Friberg, CISR FaxID: Page 1 of 1 Date:1011/2010 12:26 PM Page:1 of
CERTIFICATE OF LIABILITY INSURANCE OP ID SF DATE(MMIDDIYYYY)
At��C>R i>auum50 10/01 /10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
IRM Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Barry M. Stephens, CPCU HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
75 North Main St . -P O Box 564 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
East Longmeadow MA 01028
Phone:413- 759 -0010 Fax:413- 759 -0017 INSURERS AFFORDING COVERAGE NAIC0
INSURED INSURER A. Nati Union Fire Ins Co
INSURER & Nautilus Insurance Company
Warwick Carpenters Co INSURER C
497 Main RoZt INSURERD
Gill MA 01354
INSURER E
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TNSR_FVDTF
LTR S TYPE OF INSURANCE POLICY NUMBER DA'rc Mn^r} DATE (MMJCl2.A^?'I'T� LLMrTfL
GENERAL LIABILITY EACH OCCURRENCE .$5000000
$ X COMMERCIAL GENERAL LIABILITY NC930557 07/19/10 07/19/11 PREMISI_s(Eaoccurence) $500
CLAIMS MADE lFill OCCUR MED EXP (Any one person) $ 5000
PERSONAL &ADV INJURY $ 1000
GENERAL AGGREGATE $ 2 000000
GEN'L AGGREGATE LIMIT APPLIES PER . PRODUCTS - COMP /OPAGG $ 2000000
rx __ 1 POLICY PRO LOC
JECT
AUTOMOBILE LIABILITY COMBINED SINGLE Limi r
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS [Per person) $
HIRED AUTOS BODILY INJURY $
NON -OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY. AGG $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR ❑ CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY TORY LIMITS ER
YIN X
A A NYPROPRI BOREXC jpEEXECUTIVE WC6783929 07/30/10 07/30/11 E L EACH ACCIDENT $x.00000
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $100000
If yes, describe under
SPECIAL PROVISIONS below EL, DISEASE - POLICY LIMIT $ 500000
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEME
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
CITYN -1 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
City of Northampton IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Chuck Miller
2 REPRESENTATIVES.
12 Main Street
AUTHORIZED REPRESENTATIVE
Northampton MA 01060 IRM Insurance Agency Inc.
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