Loading...
29-594 - R�>6f&d PfaAj T 44J bOT)s RD ) BP- 2011 -0561 GIs #: COMMONWEALTH OF MASSACHUSETTS :W&i 10 - 594 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categor BUILDING PERMIT Permit # BP- 2011 -0561 Project# JS- 2011 - 000927 Est. Cost: $31000.00 Fee: $186.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: INTEGRITY DEVELOPMENT & CONSTRUCTION INC 059672 Lot Size(sq. ft.): 20865.24 Owner: KONCKI DAVID E & SHARRON GIFFORD Zoning: URA (100 //� Applicant: INTEGRITY DEVELOPMENT & CONSTRUCTION INC AT. 142 WOODS RD Applicant Address: Phone: Insurance: 110 PULPIT HILL RD (413) 549 -7919 Workers Compensation AMHERSTMA01002 ISSUED ON.1 /11/2011 0:00:00 TO PERFORM THE FOLLOWING WORK.- REMODEL KITCHEN 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 Si FeeType: Date Paid: Amount: Building 1/11/20110:00:00 $186.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0561 ' APPLICANT /CONTACT PERSON INTEGRITY DEVELOPMENT & CONSTRUCTION INC ADDRESS /PHONE 110 PULPIT HILL RD AMHERST (413) 549 -7919 PROPERTY LOCATION 142 WOODS RD MAP 29 PARCEL 594 001 ZONE URA(100)HWSP A,�i}• N THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: REMODEL KITCHEN ,L New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/ Statement or License 059672 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQIt AATION 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 Demolition Delay y — / /i 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. Version 1.7 Commercial Buildin Permit May 15, 2000 pacflnenuse only E s r r + a City of Northampton F Building Department 212 Main Street r ^� v L., Room 100 r Northampton, MA 01060 phone 413 -587 -1240 Fax 413- 587 -1272 PIp1IS'Ife Paris ° y x ; APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address This section to be completed by office i .._. ......_ -- r J'j' UQr'1 Map Lot Unit T 7 L c ? � C' i� L.E 1 r � "� Zone Overlay District _._.....-__. .......--- ,..�.._.__...__._..._ �_._...._. _,...,._._..... - _._ _ Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED 2.1 Owner of Record: Name (Print) Current Mailing Address: Signature ✓ -4� r Tele hone _ P 2.2 Authorize Aaent: Name (Print) Current Mailing Address: _.... _. _.___. _ .... _ ..._ ..... -_ ..... .. J`tl` - � Signature Telephone SECTION 3 - iESTiMATED CONST RUCTION 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) __... _.._ ,,.M ..........._._.__._..... ..... 5. Fire Protection _. ,....., . 6, Total = (1 + 2 + 3 + 4 + 5) (do Check Number This Section For Official Use Onl Building Permit Number Date Issued Signature: I Building Commissioner /Inspector of Buildings Date f � Version 1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR.110.11). Independent Structural Engineering Structural Peer Review Required Yes © No SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Owner of the subject property hereby authorize to L act on zbehalf .in all matters elative to work authorized by this building permit application. Signature of Owner Date as Owne uthorized �gent reb y declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge a f. Signed under the pain and penalties_of perjury Print Name "F Signature' of 0 /Agent Date SECTIiAN 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not App licable ❑ Name of License Holder License Number CAS' Address Expiration Date Signature Telephone SECTION 1 - WORKERS' COMPENS TION INSURANCE AFFIDAVIT (M.G.L, c. 152, § 25C(6)) Workers C mpensation 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 a r Versionl.7 Commercial Building Permit Ma 15, 2000 ��Oepartinentuse ont City of Northampton Status o,W �° � � 0 �, Building Department Curb Cut/Q{tveway Perm F 212 Main Street Sewer15ep17c Auatibri,ty ' Room 100 WaterlWell Rua,lalility � � ` � _� �` C (? Northampton, MA 01060 Two Se s o Str,icturaC Plans phone 413 - 587 -1240 Fax 413 - 587 -1272 Plat/S,te Plans Other Spec,fy APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address This section to be completed by office Map Lot Unit Zone Overlay District Elm St. District rict CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record ' /' ..", . ;Av�" , - 7 / Name (Print) Current Mailing Address: Signature Telephone (Na rized Agent: t) Current Mailing Address Tel ,____- ephone 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 �s .. .. ........ _ .... ..m._ _.. 4. Mechanical (HVAC) _,..., _,..__._... .._..._ . ... ......... 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) QJIU• (� Ci Check Number G This Section For Official Use Onl Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date Version 1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 0 CUBIC FEET OF ENCLOS S P A CE Interior Alterations ❑ Existing Wall Signs Demolition❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other Q' Brief Description ;Enter a brief description here. Of Proposed Work ; co f I�-� ICr.C,o SECTION 5 - USE GROUP AND CONSTRUCTION TYPE` USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ ! -1 ❑ 1 -2 ❑ 1 -3 ❑ 313 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑ U Utility Specify: _...,_. ..._ ....__....._._ . , ,......_.. M Mixed Use ❑ Specify: S Special Use ❑ Specify:.. - COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: ,.. _.. �_- .... ,__ _ __ Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): !.-„ .,. ,. _ _ ,.._. ._ ... SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) a 15 _ 1 St 2nd _.._. _. ....... 2nd ., 3 _.._ 3�,_. 4tn _.._..,......_ 4 cn _._., Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) Total Height ft 7. Water Pupply (M.G.L. c. 40, § 54) 7.1 Flood Zone information: 7.3 Sewage Disposal System: Public Private ❑ Zone Outside Flood Zone[] [ Municipal On site disposal system❑ Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Q!l_- ..__ -,. __ ._._ . 1��.'. _,.., .,__. .... _ ,.., .. _ _ .,___._._•: Frontage 0 Setbacks Front Side L " R _. L R Rear Building Height Bldg. Square Footage % _,_._... _.._..,. Open Space Footage _.._._. (Lot area minus bldg & paved � "- •,,..,,_., # of Parking Spaces - -- Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 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 , Date Issued. C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address _ _._ _..__ -------- Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address w Registration Number Signature Telephone Expiration Date _ ...._ . Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Na Responsible In Charge of Construction Address Telephone, e Versionl.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No SECTION 11 - OWNER AUTHORIZATION -'TO BE. COMPLETED. WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _ 1. -Lr: �. .. -� .. -.., _ \a�kF� ......... ................ ....! as Owner of the subject property hereby authorize Fes X �C�. t ,S_.5Q . to �. _d,__... _._. L act on m behalf in all matters elative to work authorized by this building permit application_ Signature of Owner Date as Owne uthorized gent h reby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge a ief. Signed under the pains and penalties of perjury._ . ... -. _.� .. ....._ ..._ ....:._ Print Name Signature of Ow /Agent Date S 4J,9N.12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone SECTION It WORKERS' COMPENS TIONINSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers C mpensation 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 0 N The Commonwealth of Massachusetts Department of Industrial Accidents a'°�"�'f Office of Investigations t . 600 Washington Street Boston, MA 02111 x` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): a Address: 4J SA C:1C;v1__)_ City /State /Zip: Phone #: 1 4 1 q Are you an employer? Check the appropriate box: Type of project (required): ZS4 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. E] New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. cEg: Zemodeling ship and have no employees These sub - contractors have g, ❑ DemoIition 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.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions o myself work' right of exemption per MGL y � workers' comp. 12.❑ 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. r 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 isproviding workers' compensation insurance for my employees. Below is thepolicy andjob site information. z Insurance Company Name: Policy # or Self -ins. Lic. #: A-IM 1;9 g190/ U Expiration Date: Job Site Address: L ZO( / A &I, � _� yY1J 0 Gi~' »J City/State/Zip: T Z6' c. 1 e ,� 4, oG 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 o the DIA for insurance coverage verification. 1 do hereby c ify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: " 16 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 #: DATE (MMIDDIYWY) AC®RE CERTIFICATE OF LIABILITY INSURANCE 04/12/2010 PRODUCER 413. 586.0111 FAX 413. 586. 6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Webber & Grinnell Ins. Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 8 North King Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. thampton, MA 01060 INSURERS AFFORDING COVERAGE NAIC # INSURED Integrity Development and Construction, Inc. INSURER&. A.I.M. Mutual 110 Pulpit Hill Road INSURER B: Amherst, MA 01002 INSURER C: INSURER D : 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. INSR AOD'L TYPE OF INSURANCE POLICY NUI:g3ER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MNVDD DATE MMIDD /YW GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMn.GE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ H ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WMZ80062242010 04/10/2010 04/10/2011 X ORYLIrnlrs X ER AND EMPLOYERS' LIABILITY YIN -- ANY PROPRIETOR/PARTNER/EXECLITIVE ❑ El EACH ACCIDENT $ 500,000 A OFFICER /MEMBER EXCLUDED? - -- (Mandatory In NH) E L DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT ISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. - - - -- For Information Purposes Only - - - -- AUTHORIZED REPRESENTATIVE C nthia Henderson CINDY ACORD 25 (2009/01) ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �la,.achuat�. - Dcltartinrnt of Puhiic �'afct� Board of Builtlin "� Rc ",ulaticin anti Stantlartl� Construction Supervisor License License: CS 59672 Restricted to: 00 a % PETER W JESSOP " 110 PULPIT HILL RD AMHERST, MA 01002 Expiration: 6/7/2012 ( ,nuni Try: 26864 \ Boa �t of + ,n g' egula oiis`a �d 5 ar�us i HOME IMPROVEMENT CONTRACTOR - = Registration: 118041 Expiration: 1/20/2011 Tr# 278284 Type: Private Corporation INTEGRITY DEVELOP & CONST INC PETER JESSOP 110 PULPIT HILL RD AMHERST, MA 01002 Administrator