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24A-151 26 NORFOLK AVE BP- 2012 -0067 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 24A - 151 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2012 -0067 Project # JS- 2012 - 000098 Est. Cost: $2900.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS STOROZUK Lot Size(sq. ft.): 7927.92 Owner: NOSEWORTHY GORDON L & MARY ANN Zoning: URA(100) Applicant: THOMAS STOROZUK AT. 26 NORFOLK AVE Applicant Address: Phone: Insurance: 50 Plumtrees Rd SUNDERLANDMA01375 ISSUED ON. 7119120110. 00. 00 TO PERFORM THE FOLLOWING WORK: Porch Roof 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 7/19/20110:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner I �Id ON Department use only �pptQN rity of Northamnton C}otyic of Ponr,if: Building Department Curb Cut/Driveway Permit IN 6 1 212 RRain Street S&werlSepfic Availability Room 100 Water/Well Availability, ����, orthampton, MA 01060 Two Sets of Structural Plans 3- 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 i 1.1 Property Address This section to be completed by office �6140VOU 45 Map Lot Unit �® nT AA it n t o, Li Zone Overlay District f Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record R r 0 - U& e Rat V r Name (Print) Current Mai ing Address Telephone Signature 2.2 Authorized Ascent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by rmit applicant 1. Building 2 vo C o (a) Building Permit Fee 2. Electrical l (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 This Section For Official Use Onl Building Permit Number: Date 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved par # of Parking Spaces Fill: volume &Location A. Has a Special Permit/ Variance/ Findin ever been issued for /on the site? NO O DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW d YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , bate issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES © 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 © NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all ayolicab, le New House Addition [] Replacement Windows Alteration(s) ❑ Roofing Dd Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O) Other [a Brief Description of Proposed QQ // } p / �. Work: 112 11r � of�"4 OA _ c� 5 ra u s< 1i�1 k � Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housinla, complete the followina: 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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ell ( 1, `-�' 0�� l u as Owner of the subject property hereby authorize to a my behalf, in a matters relative to work authorized by this building permit application. Signature of Owner Date as Owner /Authorized Agent hereby de%re th9dhe statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and pe of perjury. Print Name 7-t -lf Signature of Ownermgent Z Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not l Applicable 0 Name of License Holde cl s l� 1_({_ 0 A License Number Address Expiration Date Y I j Signature Telephone 9. Renistered Home Improvement Contractor: Not Applicable ❑ �1 t S+ IK23 q Company Name Registration Number �y P1;u�i� '� ���,� u� ✓'!� Gi 3 � ��3 -2 013 Address �J Expiration Date Telephone 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....... ❑ No...... ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied DweUines 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 buildine 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 Office of Investigations g 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business / Organization /Individual): `i, rar-2" - Ik 7r, Address: SU �lilw, l �� R City /State /Zip: 6 7 Phone #: V'3 ZyV 2-066 Are you an employer? Check the appropriate box: Type of project (required): 1.5 I am a employer with k 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. E] New construction — ❑ I 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' 9. ❑ 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. EJ 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 13.❑ Other employees. [No workers' 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. #: 3 – 3 Expiration Date: Job Site Address: W i`fiyf LG /7Ve City/State /Zip: K c �/ x1375 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 perjury that the information provided above is true and correct Si nature: o�. Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitlLicense # 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self- insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid. affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617 - 727 -4900 ext 406 or 1- 877- MASSAFE Fax # 617- 727 -7749 Revised 4 -24 -07 www.mass.gov /dia l ® DATE (MMIDDIYYYY), 4C<> RV CERTIFICATE OF LIABILITY INSURANCE 11/ 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 CONST1TWE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: It 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 eadomement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). CONTACT PRODUCER NAME: J ___ Rt aid Blair Cutting & Smith Ins. Agency, L.L.C. PHONE)y(413)549 -4971 FAX NGj (413)549 -4974 an Encharter Ins LLC Agency ADDRE 25 University Drive PRODUCER J010 042381 Amherst MA 01002 INSUR S) A FFORDIN GCOVE RAGE ; _ - NAIC0 INSURED INSURER A - Preferred Mutual Insurance Co 15024 INSURER B Thomas Storozuk, Jr. INBURERC 50 Plumtree Road INSURER D INSURER E Sunderland MA 01375 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1011201367 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 CO NDITIONS O F SUCH POLICIES. LIMITS SHOWN MAY HAVE BE R BY PAID CLAIMS_ . tLJSR TYPE OF INSURANCE - -- ADOL SUBRI` -- - POLICY NUMBER _ -- III�MIDDY EFf MJDD Y_Y LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1, 000 , O00 AGE TO Fg�N HBO ' X COMMERCIAL GENERAL LIABILITY LPREMISES (Ea 4ccurre $_ 100, _ 000 10/23/2010 110/23/2011 - _- . MED EXP (Any one person) A CLAIMS -MADE X OCCUR CPP0100599124 _$ 5, 000 PERSONAL & ADV INJURY $ 1,000, GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG I $ 2,000,000 X Pot ICY 1 - PR _ - - - - $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ --_ (Ea ac ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) j $ - - - - - SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON -OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAO CLAIMS -MADE! AGGREGATE $ - -- - - - -- -__- - - -. DEDUCTIBLE $ RETENTION $ 1$ WORKERS COMPENSATION WC STATU OTH i AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N / A E L EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? - - �- - -- (Mandstory In NH) E L DISEASE EA EMPLOYEE $ E.L. -- -- - -- - if yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I 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 ACCORDANCE WITH THE POLICY PROVISIONS. Thomas Storozuk, Jr. 50 Plumtree Rd AUTHORIZED REPRESENTATIVE Sunderland, MA 01375 / Dowd, Acot ExeC . /NO ACORD 26 (2009109) ®1988 -2009 ACORD CORPORATION. All rights reserved. INS025 r2oD9091 The ACORD name and logo an registered marks of ACORD Board of Bu►ldin, Retutilation% and '- Office of Consumer Affairs & Bidsiness Regulation D VEME HOME IMPRO 'NT CONTRACTOR License: CS 101768 Registration: 162369 Type: Expiration: 2/23/2013 Individual !estricted to: 00 THOMAS M. STOROZUK JR - HOMAS STOROZUK JR 10 PLUM TREE RD THOMAS STOROZUK ;UNDERLAND, MA 01375 50 PLUMTREE RD. SUNDERLAND, MA 01375 Undersecretary Expiration: 9/21/2012 Tr=: 101768