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42-025 �m BP- 2010 -1204 GIs #: COMMONWEALTH OF MASSACHUSETTS h a g" . i 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- 2010 -1204 Protect # JS- 2010- 001738 Est. Cost: $24300.00 Fee: $72.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID FORTIER 008026 Lot Size(sq. ft.): 111949.20 Owner: SKUBISZEWSKI MICHAEL J & HEATHER SKUBISZEWSKI Zoning: SR(100)//WSP II Applicant. DAVID FORTIER AT. 809 WESTHAMPTON RD Applicant Address: Phone: Insurance: 32 Laurel St (413) 586 -8965 WC NORTHAMPTONMA01060 ISSUED ON :71112010 0:00:00 TO PERFORM THE FOLLOWING WORK .-CONSTRUCT 12 X 12 LIVING RM ADDITION 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 7/1/2010 0:00:00 $72.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -1204 APPLICANT /CONTACT PERSON DAVID FORTIER ADDRESS/PHONE 32 Laurel St NORTHAMPTON (413) 586 -8965 PROPERTY LOCATION 809 WESTHAMPTON RD MAP 42 PARCEL 025 001 ZONE SR(100) //WSP II 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: CONSTRUCT 12 X 12 LIVING RM ADDITION New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 008026 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO J ATION PRESENTED: (/ M 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 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 5�atus of,Perrnit. :. eparttnett# Building Department Gurb CutCl3tiueway Permit 212 Main Street Seyuerv yailatlitity Room 100 Water/V1ieAailabill Northampton, MA 01060 ulrp bets of Struturl Plans - phon 3- 587 -12{0 Fax 413- 587 -1272 es Ir Pfas �; x APPLICATION TO CONSTRUCT, R, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address pp // � This section to be completed by office �D� Uj 1-z St Uf �l Q div ,8- Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record a e (Print) ^ Current Mailing Address: V. A L' -) VJiv Telephone Signature 2.2 Authorized Agen I�1 / f AUl l&z :Z LAue I�t C - • 'y�0ZtUAftl /Y4.01 Name (Print) Current Mailing Address: Signature V Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building 9L331 (a)' Building Permit fee � ©� 2. Electrical (b) Estimated Total Cost of C ? �5 . Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 0 0 lCheck Number This Section For Official Use Onl Building Permit Number: IIsssued: Signature: Building Commissioner /Inspector of Buildings Date Section 4 ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information �y Existing Proposed Required by Zoning r This column to be filled in by Building Department Lot Size Frontage _........ _.. _.._ _._... ,.. Setbacks Front " Side L : ._.! R. ._. L ((+A ; R 7_. Rear Building Height r Bldg. Square Footage Open Space Footage _ • % _,.• (Lot area minus bldg & paved p arkin g) ..................... _.. # of Parking Spaces — — - -= Fill: i s volume & Location _.. . _, _. ----- ...._,,. _....... _ ,_._...__ .. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW YES IF YES, date issued: IF YES: Was the p f- Deed NO Q DONT KNOW Q YES 0 IF YES: enter Book Page' and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q 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 0 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 Q 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 M Replacement Windows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other [O] Brief Description of Proposed t Work: Va )t. I'a F�(_Touil fJ ap r7wS't (A)b LION &Iewd"I 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 .Mousing,'' complete the following: 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. ( �C S r Dimensions ! I 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 5 c Private well City water Supply S_ SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, A t , as Owner of the subject prope y hereby authorize A 0 k � �2 7 L li a to act on my behalf, i all ma r relative to work authorized by this building permit application. Signature of Owner Date I, A f J 1 : u (4 as Owner Authoriz Agent hereby dec are that the statements and information on the foregoing application are true and accurate, to the best o nowledge and belief. Signe under the pains and penalties of perjury. / ! J,� c- t l Eo- &-r ( gz Print N /Oil 'Gc)(o Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Sup /� 1s Not Applicab ❑ /, Name of License Holder U (' �� ! �� �y � r (7 y �' "7/ License Number Addr �- //�� _ Expirati n Date U Ll V Signature Telephone 9. Registered Home Improvement Contractor: , Not Applicable ❑ Company Name Registration Number "A A &1"A Q- 010t'o I Ito t 3010 Address Expiration ate Telephon 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 ©weer ��emx>ltion 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 UT. Department of Industrial Accidents - Office of Investigations 600 Washington Street Boston, MA 02111 www.mass govIt is Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print LegibIv Name (Business/Organization/Individual): QtL _UW A C.ke - i f- AWO �l� c��l '1 t,�l�. ,. - Address: 4 vU_ &t t , City /State/Zip: o &L - 14AR A RV, at o Phone. #: Are you an employer? Check the appropriate box: Type of project (required):. 1. I am a employer with 4.. I am a general contractor and I have hired the sub- contractors 6. ❑New construction employees (full and/or part-time).* 2. El I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and hav e. no loyees These sub - contractors have .8. [] Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition Rqfl workers' comp. insurance cep. nos _ 5. We are a corporation and its 10.0 Electrical repairs or additions required:.] 11. Plumbing repairs or additions officers have xercised their 3. Q T am a homeowner doing aIl work ,• ❑ g ep myself [No workers' comp. right of exemption per MGL 12. Q Raof repairs insurance required.] t c. 152, § 1(4), and we have no . employees. [No workers' 13.0 Other comp. insurance required j. 'Any applicant that checks box #1 must also fin 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 notthose entities have emp loy e es. If the sub - contractors have employees, 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 Insurance Company Name: l �S iri r Policy # or Self Lic. #: " l 1 Expiration Date: - / O lob Site Address: �( W � S 1 4,V P OIL City /stafelZip: 4 001 !�k�ya�pN 1 t • o% U f� 0 Attach a copy of the workers' compensation policy declaration page '(showing the policy number and expiration date). Failure. to secure coverage: as required under Secti6n - 25A of MGL c. 152 can lead to the imposition of crimi *. 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 Iuvestisations of the DIA for insurance coverage verification J416 hereby ceztW under the pains and penalties of perjury that the information provided above rs true aniLrnrrect_ Si� tire: ate f L a 0 j d Phone #: Offrcial 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 5. PIumbing Inspector 6.Other Contact Person: Phone #: �r . IJ + � 1 ��I"- ACORD CERTIFICATE OF LIABILITY INSURANCE CATE(MMIDD T11 1M 06/28/2010 PR DUCER 413.586.0111 FAX 413.586.6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION I' Webber & Grinnell Ins, Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE l 8 North Kin HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. f Northampton, MA 01060 INSURERS AFFO COVERAGE NAIC 0 INSURED Leonard Buck & David Fortier I lrs!.>F:EeA.. Peer I_ns_u NBA: Buck Brothers Concrete Service & slit i Excelsior/Peerless _ 11045 ~I , Dave Fortier Builders PO Box 416 — — - -- - - -- — N R P EP Cf - -- - -- - — — - - - - -- — �� Hadley, MA 01035 IVI &_RE: E COVERAGES THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSJED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N07WITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACTOR OTHER C10CUMEN T 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, EXCLUS:'ONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LI MITS SHO WN MAY H BEEN EDUCED EY PAID CLAIMS. b. 3R EFFEECTIVE POLLI Y E><PIRATION I LIMITS ITS NSR TYPE OF INSURANCE POLIC,)f UMBER GATE (MMIODMM/i 1 OAT (NRUddMNV9 (iENERALLIABILITY T — CBP&5017911 09/05/2009 09/05/2010 1 EACH , J REr� E s 1,0 0_O,OOa I KMVERO A GE RA LIAR LIT" I hErvil �i a r �., 100, �10 I� - - - � - '--- X — -- - - -, 0 - CL P ED E�. - 'nr a �ars.r.) $ — 15,000 A FER D✓ II -R)' t 1 ,000, 000; I ',E NE;AL A'9(,R =_c 4T= 2 , 000 , 0 _00' A3vREGFTE LIMIT APPL!EGPED �F'PODLt:T AGG $ 20 000! ( AUromosr_E LIABILITY B48528085� 10/08/2009 10/08/2010 ;: r ,.,. ,ULe u AUTO - .n � 1 , DD , 00 0 1 I AN'r AL X SCNEuU = - B ti P 7 ACS' , y !pPr 9.'IOen - � l I X i N iJ..0 + /OJE� A,JTC15 � (Per acc'deo 1 i i I I GARAGE UABILITV ! I AU CNL 'r _ _;, A: _ DEN' AUIG E G S j C`Il-I T�iAra EXCESS IUMERELLALIA&L)TJ I j rArr;OC'CUR,RE' +C' 1 MADE DEDJ17 3LE I $ - I RETENTION �$ j $ I WORKERS COMPENSATION -- T WC8503991 09/05/2009 09/05/2010 AND 6MPLGYERB' LIAB( QTY Y 1 N tl'r RppPIE7l7RiPtfTvEF �c_r_U'!uc r -- I i i i ! E.L. EA h A "riCE $ 100, i I , Mandatory In NH) i L I. DI Ase - eA Er.� LOVee $ 100, 001 JesanLe under i r --•- E - 1 ,L PP UiJrvS b;ipw E.L, .. EASE- P )L , L(MIT l a 500, 0001 , THER� — —' I I F�DG >TION OF OPERATIONS I LOCATIONS IVEHICLES I'=XCL`JSIONS ADDED B4 ENDORSEMENT I SPECIAL PROVISIONS ur.; Compensation Policy Excludes owners: Leonard Buck & David Fortier CEPTIFI ,,TE HOLDER CANCELLATION SHOULC ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATON DATE THEREOF, THE ISB'JING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN '1 t y of No rt hanpt on NOTICE TO THE CERTIFICATE I.OLZGR NAMED TO THE LEFT SUT FAILURE TO DO SO SHALL j City Hall IMPOSE NO OBLIGA71ON OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR i Mai r, Street REPRESENTATIVES I NOr*_nampl o I, MA 01060 AUTHORL:EDREPRESINTATIVE / Vicki Vincent , VICKI �xi ACORD 25 (2009j01) 0 1999 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD � r' i { orCK Pie 0 90? oq 13 L& k (00 10 yo 671 ST co OL)& r A M c \Y LA s C�4 2- J � 7< ooul jr • 11 I� c� �i�t G�l3Qt��ar. �a t P 3s r 3 t F p