12C-089 s BP- 2011 -0578
s # COMMONWEALTH OF MASSACHUSETTS
j 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 -0578
Project # JS- 2011- 000952
Est. Cost: $1413.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101878
Lot Size(sq. ft.): 10018.80 Owner: HOWARD KENNETH W & CAROL SUSAN LOCKWOOD
Zoning: URA(100) / /RI/WSP Applicant. URBAN & SONS INSULATION CO INC
AT. 19 RICK DR
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732 -3922 WC
SPRINGFIELDMA01104 ISSUED ON :1212712010 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
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 12/27/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
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
Maly Lot Unit
Al
c
Zot►'e, Overlay District
Elrri'St bistrl'ct GB Distrlct
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
IKE L i E 0
Name Print) -� Current Mailing Address:
�K C �„,,�� S 7-
Telephone
Signature
2.2 Authorized Agent:
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. lambing / -zt building Permit Fee
��1lcr rN
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
i
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 E
Setbacks Front
Side L: R:
Rear
Building Height
Bldg. Square Footage t" % €---
3
Open Space Footage %
(Lot area minus bldg & paved
par
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued: 1
t
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DO KNOW 0 YES 0
IF YES: enter Book 1 1 Pagef 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 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
IF YES, describe size, type and location:
4
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 O NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aaalicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [r-3] Decks [0 Siding [o] Other [p]
Brief Description of Propo j
Work: , ,J
Sc ,' V -OK J . 1. CAn� 11
Alteration of existing bedroom Yes No Addin new e�'Mom h I'es No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
Ght }f tl eC�fG °. H IS
Y?
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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize Ak
to act on m ehalf, in all Wit relative to work authorized by this building permit application.
Qv`
ignature of Owner Date
I 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.
Print Name
Signature of Owner /Agent Date
J
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor \ ^ Not A /0/19 7 3' plicable ❑
Name of License Holder � �`� �+ I �
License Number
-s 171
Address Expiration ate
Signature Telephone
Not Applicable ❑
tlafe+ etec: :kTotnem"trit3avelrniirfrlcbr'; �� `' ' °"
SLu ��c� /y
Company Name Registration Number
Address Expiration Dab
Telephone � � �~ � � �-�
SECTION 107 WORKERS' COMPENSATION INSURANCE AFFIDAVIT;(M.G.L. c. 152, § 25C16))
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...... ❑
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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
_ 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le�dbIv
Name ( Business /orgmiiation/Iadividual): V V Vl
Address: 3 L
City /State./Zip: J Phone. #:
Are you an employer?. Check the appropriate box: Type of project (required) :.
1. I am a employer with 4.. E] I am a general contractor and I 6. New construction
employees (fall and/or part-time). " have hired the sub- contractors
2. .0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub - contractors have. .g. Dem oliiion
working for me in any capacity. en and have workers'
9 B ud - addition
PNo worke& COiIIp'. InsllldnCC -. Cp11ip. m manrA_ #._ �..
required] 5. We a* a corporation and its 10 Electrical repairs or additions
ercised their
3.0 officers have
I am a homeowner doing all work x
.,. • 11. Plumbing repairs or additions
myself (No workers, COMP. right of exemption perMGL 12.[].Roofrepairs
c: 152, and we have no
insuran required.] t § () 13. Other '
employees. [No workers' - I
comp. insurance requited.].
'Any applicant tisat checks box #Rl mwt also M out the section below showing theirwotire:s'-eornpestsatian policy mfarmation
t Homeowners who subcmt this affidavit :m( icati ng they are doing aD work and then hire outside contixtots must subrmt anew affidavit indicating such.
tConiractrns that check this box must attached an additimal sheet showing the name of the sub- contracim gad statewhether ocnot-thoseastities have
c2mloyees. rthe sub- conv-tois have employees, they awstPrmde their work=,' coaip-.pohcynumber
r am an employer that isproviding workers compensation insurance for. my employees Below is Mepolicy gndjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. y� 0 S � Z G Expiration Date:. I C)j l
lob Site Address: C� 1 cityi8tate/Zip C ( (9
Attach a copy of the workers' compensationpoIicy declaration page (showing the policy number and eapiraizon date).
Failure . to secure coverage:as requuea under Section 25A ofMC Lr d 15Z caii lead the imposition of c imn�}1 penalties of a
fine up to $1,500.00 and/or one- year as well as civil penalties in the form of a STOP WORK - ORDER and a Lie
of up to $250.00 a day against die violator Be advised that a copy of this statement may be forwarded to the O.ffce of
rnvestisatioiis''of the `D for insi rance coverage verifieatiom
_ I do hereby certsfy under thepains-andpenaldes tha - the in ornsation rovrdednbove istzue_au�cvrrert._:_
Date:
Phone #:
Official use only. Do not write in this area, to be completed by city o r town official
City or Town- Permitucense #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
6. Other
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 exemptions -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
�ermits 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 tome.
Date
Address of work
location
Property Address: RI Lh L
Contractor
Name: � r�C�N� � S v � S � � V i c k VI
Address: ? j L� -,�
City, State: �p (� c'Y� !
Phone: — Z
Property Owner �1 "Cl Name: �� � ''t
Address: C ( PCI C IC �) I
City, State: C - e VA(''E._ (41
1, �V�Gri yT)�S%n U !`�R✓� T-% 0 0' 3 (contractor) attest and affirm that the building I intend
to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavit.
Contractor signature
Date Z _ ,
DEC -22 -2010 16:34 From'- MCCLLRE INS. To:5258116 Paee:1/1
ACORN. CERTIFICATE OF LIABILITY INS RA °A ` 01 "
THIS CER TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS uPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIif ELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TH15 CERTIFICATE OF INSURANCE DOES NOT CONWITUTE A CONTRACT SeTWEEN THE MSU1NG INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: the r:erj&m holder is an ADDITIONAL 8URED, the pollcy(les) must be endurt:ed. If SUBROGATION is WANED, Subject to
the terms and conditions of the policy, certain policies may nature an endorsernenL A s tMill it an this cutificate does not confer tights to the
califtate holder in lieu of such endorsemwit(s).
PRODUCER Na11E: Carol Sherman
McClure insurance .Agency, Inc. PH 413781.8711 F µ, ; 413 731-8548
103 Van Deets Avenue ,
P. O. Box 339 ME rork
West Springfield, MA 01090 also i1AFfQPwwaCOVERAW NAIGt
INSUND DrsIIRERA; Acadia insurance
Urban 8. Sons Insulation Co., Inc. a , A I.M. Mutual Insurance Go.
385 LIBERTY STREET INSURER C:
SPRINGFIELD, MA 01104 MUPARO
a19URER 0:
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THIS LS TO CERTIFY TEAT THE POLICIES OF INSURAMPE LISTED BELOW HAVE BEEN ISSUED TO THE i MRED NAMM ABOVE FOR THE PMICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERrr OR COMITiON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
C TIFICATE MAY BE iSSUEU dR MAY PERTA9d, TF� *MR/V� AFFORDED BY THE POIG
I.M DESMIDED HERM IS SUO.IECT TO ALLTHE TERNS.
EXCLUSIONS AND CONOITIONS OF SUCH POLICIES. UWS SHOWN MAY HAVE BEEN RMUCS D BY PAID CLAIMS.
INSKI P't�cP ulrars
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CERTIFICA 1 R CANCELLATION
$Kgµ1.D ANY OF THE ABOVE wftw ED POIIC168 8E CANCELLED BEFORE
Proof Of Coverage TIE EXPOATtON DATE THEREOF, NOTICE WILL afe DELIVERED 04
ACCORDANCE rYITH THE POLICY PR9VIS -
AflVORR1 REPRESEKtAW -V
R191la 4009 ACORD CORPORATION. All rights reserwed-
ACORD 25 (2009109) 1 Oft Tho ACORD name and logo are registered rnaft of ACORD CAS
#548615047847