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25A-081 BP- 2011 -0552 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 -0552 Project # JS- 2011- 000911 Est. Cost: $2700.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH SEITZ 97827 Lot Size(sq. ft.): 6621.12 Owner: SHULMAN -RYAN MARA & LUKE F Zoning: URB(100)/ Applicant: JOSEPH SEITZ AT: 27 COOLIDGE AVE Applicant Address: Phone: Insurance: 196 LINE ST (413) 687 - 1227 EASTHAMPTONMAO1027 ISSUED ON:12/16/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL CABINETS & DISHWASHER 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 12/16/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0552 APPLICANT /CONTACT PERSON JOSEPH SEITZ ADDRESS/PHONE 196 LINE ST EASTHAMPTON (413) 687 -1227 PROPERTY LOCATION 27 COOLIDGE AVE MAP 25A PARCEL 081 001 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 7r Typeof Construction:_INSTALL CABINETS & DISHWASHER New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 97827 3 sets of Plans / Plot Plan THE FOLL 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 Commission Permit DPW Storm Water Management lif y /2' 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. r • City of Northampton ;' Building Department V g a y 212 Main Street Room 100 ��� \ MA 01060 4 ;;.. phone 413- 587 -1240 Fax 413- 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section. to be completed by office Zq C,) Map L o t Unit 1:'i'A 0 I �' c " Zone OverlayDistnct Elm St District ' ` CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: f c4i✓t- a 2: Name (Print) Current Mailing Addres / / Telephone Signature 2.2 Authorized Anent: Name (Print) Current Mailing Address: Signa re / 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) 3. Plumbing S Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) a Check Number k ), ( �✓ This Section For Official Use Only Date Building Permit Number: Issued: 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 Lot Size I 7 L__ _„_ ____ Frontage ._ _. _ Setbacks Front e j ; _4 Side L: €_ R:17 L: i R: _M_a __.,.._..t Rear 1 l Building Height , �� I Bldg. Square Footage € i 1-711 1 % F-1 I I I Open Space Footage (Lot area minus bldg &paved 11111 t i , s, parking) # of Parking Spaces 77 Fill: ���... �.. ��. ..�W.,��,,��....�.....,�..��,�. �..� _.�_,e.___e.� , (volume & Location) l A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: , IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES C) IF YES: enter Book i Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO of IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, exca tion, 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 Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E ] Siding [D] Other [0] Brief Description of Proposed / Work: Ale w i,...14 � /1 ,, i, c/i9.3/ Li..4 Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No / Attached Narrative Renovating unfinished basement Yes ,/ No Plans Attached Roll - Sheet sa.. rNiii ..house �nct r cTdliia ' ` fitil asir `tith tita atv` l a a. Use of building : One Family i Two Family Other b. Number of rooms in each family it: 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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT tjeC 4 � / j I, /K A ) .� 1 a 44 t I i I : Y (-- v's , as Owner of the subject property hereby authorize to act pn my behalf, in all matters relative to work authorized by this building permit application. i /7p3 /0 f 9i�ature owner Date I, O () t "t , 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. .1 0e l Print Name 'Ow Ili Signa - e of Own/ • . e SECTION 8 - CONSTRUCTION! SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ ! Name of License Holder : � J c ! q 4 4 ?` ��/� C License Number j 4 451 pL p�'i A ifl (401;o 12 Address Expiate i -6— 7 Sign ure Telephone 9,.Rentsten LHotne::llmproverr> ntCcntractrori' ' n r ` i f Not Applicable ❑ 75 64; Company Name /, Registration Number c t Cc / 4 Address ( r Expil ate Telephone I 2- ‘''74,),.2.;- 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 permit. Signed Affidavit Attached Yes .0' No ❑ 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 1 ..k. The Commonwealth of Massachusetts Department of Industrial ACcidents p =■::=0:8 el Office of Investigations • * =.- 1.= ...... 600 Washington Street Boston, MA 02111 r -..,:-. , , www.mass.govidia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciatts/Plumbers Applicant Information Please Print Legibly .' t , Name pusinesitorganizzionandivicin.D: .,, , Address: in E, t, x S1- City/State/Zip: Cc. 1/4z4. 14 4 oio)---) Phone.#: ( ? • 6/7 ( 2, .27 Are you an employer? Check the appropriate box: Type of project (required): I 4. 0 I am a general tt conracor an,d I 1. 0 Jam .. employer with 6. 0 Ne atic , *. ;on have hired the sub-contractors ....loyees (full and/or part-time).* listed on the attached sheet 7. Tr .. - line; 2. a I am a sole proprietor or pariner- These sub-contractors have ship •and have no euvloyees 8. 0 Demolition engaloyees and have workers • . working for me in any capacity. . 9:1313tilding altdiIiiin [No workers' comp. insurance _ comp. inturance.;_ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. 0 I am a homeowner doing all work officers have4xercisecl their . r 11.0 Plumbing repairs or additions right of exemption per MGL myself [No workers' comp. 12.0 Roof repairs insurance required] t c. 152, §1(4), and we have no 0 employees. [No workers' 13. Other • comp. insurance reqUired.]. • *Any applicant-that checks box #1 must also fill out the section below showing their conipensation policy infontiation. t Homeownere who subrnit 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 whetheror not those amities have employees If the sub-contractors have employees, they must provide their workers comp. policy number . Lam an employer that & 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/Stare/'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 ofMGL - C. 152 can lead to iinPOSitiari of Clinninal penalties of a fore up to S1,500.00 and/or one-year imprisonment as well as civil penalties ha th.e form of a STOP WORK ORDER and a fine of up to $25000 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of EfieitigationSOf the DIA for iniiiiiike " -- _ I do herehy_certifr un the ains. and penalties ofperjmythat the information provided;Savi and e !Tea Signature: q4 , _ iiite: 1 1 3 /r0 - • - - • • 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 #: a► 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 ' O Rd CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/10/2010 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 an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Susan Prostak Blair Cutting & Smith Ins. Agency, L.L.C. PHONE A//C No, Ext): (413) 549-4971 (/C No): (413) 549-4974 an Encharter Ins LLC Agency Itica @encharter.com PRODUCER D0061665 25 University Drive CUSTOMER ID #. , Amherst MA 01002 INSURER(S) AFFORDING COVERAGE NAIC # _ INSURED INsURERA:Preferred Mutual Insurance Co 15024 INSURER B : Joseph Seitz, DBA: Build It INSURER C: 33 Elizabeth St INSURER D: INSURER E : Northampton MA 01060 INSURER F : COVERAGES CERTIFICATE NUMBER:20 -2011 GL 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. 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. INSR TYPE OF INSURANCE A L UBR POLICY EFF POLICY EXP LIMITS LTR , INSR WVD POLICY NUMBER (MM /DD/YYYY) (MM /DD/YYYY) i GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED © COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 100, 000 A CLAIMS -MADE X OCCUR TO BE ISSUED 8/10/2010 8/10/2011 MED EXP (Any one person) $ 5,000 ■ I PERSONAL &ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY EO I ■ III LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS — BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON -OWNED AUTOS $ . $ , UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB ■ CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N I TORY LIMITS ER , ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under 1 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT , $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Easthampton ACCORDANCE WITH THE POLICY PROVISIONS. 50 Payson Ave Easthampton, MA 01027 AUTHORIZED REPRESENTATIVE W Dowd, Acct Exec. /NO (A—).41....W410, a - ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD irta»acuusetts - veltarttnent of ruunc ,atet■ Board of Building Regulations and Standards Construction Supervisor License License: CS 97827 JOSEPH SEITZ 33 ELIZABETH ST NORTHAMPTON, MA 01060 Expiration: 11/6/2012 ontmissioner Tr#: 6427 ,f.tetaaaas.tapan Q l,.t.'ltk NOldWt/H12JQN ' 1S H138b7f3 €€ Z113S Hd3SOf Z113S 8H •f lenPIA!Pul ZL.oM /8 :uol ;endx :ed/tl SLZL9l :uopeJ;st6a-a 21010 v211NO31N3W3A021dW1 3WOH / = =` 0 a 2 , x ssa 7 sate a aturisst° jo aa930 • • "1 114 C ( 4 1 5 1' , • • 1„ 30" 54" 30" • 81" 331" 24" 7 18" Y 27" 24' 18" • • W3030 W3030 : 11 I B24 BUTT BWBT18 -, SB27 BUTT 24.DISHW DB18 UF3 . I I' zy t,.� � r'', .,. , _is , 07„. _________---,--- ,__,,.„-_--. • ------13 ,. \ , . . , 3 o('. ,,,s co41,x--1' , i , • , .,„ ,-, - , , , _ ____„ .,,,,, . . . „ , 53 f, j aOR - REF B '� B UTT (30- RANGEI TD" :' t2 ° UF3 1\6 li )2r W 3 01 5 JV 430 BUTT '\..__! . SEA +30L �►`Dy `� � ' L 10.6 u r F.- boo► • 3 24.x- - ! 30" 9' 15" 54" 24 30" _ :! 24" �/ 30" f / , �z q * 93 All dimensions size designations given are Ihis is a r i g inal design and must not be Designed: 10/26/2010 subject to verification on job site and r 0-1( r copied unless applicable fee has Printed: 10/26/2010 adjustment to fit job conditions. LowE been paid or job order placed. yan.sp.kit All Drawing 0: 1 Note: This drawing is an artistic Designed: 10/28/2010 interpretation of the general appearance of {• f s a Printed: 10/28/2010 the design. It is not meant to be an exact G J rendition. ryan.sp.kit I All I Drawing #: I • 1 alinis I. Ettl Note: This drawing is an artistic Designed: 10/28/2010 interpretation of the general appearance of LIMES Printed: 10/28/2010 the design. It is not meant to be an exact G rendition. — – ---- ryan- sp.kit All ,Drawing #: I