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42-049 T s ' AMP' ON,RP, . BP- 2010 -1186 GIs #: COMMONWEALTH OF MASSACHUSETTS ':Block: 42 - 049 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 -1186 Protect # JS- 2010 - 001721 Est. Cost: $79500.00 Fee: $477.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ED LENNIHAN 042506 Lot Size(sq. ft.): 30666.24 Owner: ROBINSON STEPHEN Zoning: SR(100) //WSP II Applicant: ED LENNIHAN AT: 613 WESTHAMPTON RD Applicant Address: Phone: Insurance: 76 Bancroft Road 587 -0437 NorthamptonMA01060 ISSUED ON. 6/28/2010 0:00:00 TO PERFORM THE FOLLOWING WORK.- REMODEL KITCHEN & 2 BATHROOMS 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¢ nature: FeeType: Date Paid: Amount: Building 6/28/2010 0:00:00 $477.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -1186 APPLICANT /CONTACT PERSON ED LENNIHAN ADDRESS/PHONE 76 Bancroft Road Northampton 587 -0437 PROPERTY LOCATION 613 WESTHAMPTON RD MAP 42 PARCEL 049 001 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: REMODEL KITCHEN & 2 BATHROOMS New Construction Non Structural interior renovations Addition to Existin Accesso1y Structure Building Plans Included: Owner/ Statement or License 042506 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQRMATION 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 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 5frs oP�tt � Building Department 212 Main Street 5orS,Aa p ; ;J Room 100 iCAW W, 'y 2 :� Northampton, MA 01060 phone 413 - 587 =1240 Fax 413- 587 -1272 � r" 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 13 �JF_ S THAMi�� X Map Lot Unit .Zone Overlay District � of -362- Elm.St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT. 2.1 Owner of Record: ` IOU 4� Name (gring (grin Current Mailing Address: 7 ` Telephone IICF� Signature 2.2 Authorized Agent: ti 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 0 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 , 3. Plumbing 3 S� v� Building Permit;'Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 7 Check Number 6��tp 12 Y77 This Section ForAffclal Use Onl Date Building Permit Number. Issued: Signatures Building Commissionerlinspector 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: L_ ___ R :'__1__' L:'­ R _..._. -___. Rear _.- Building Height "' `"" "" Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved # of Parking S aces - •- -• -> Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES IF YES, date issued:= IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book i Paged and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 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 NO IF YES, describe size, type and location: .r- -` D: e there any proposed cfianges to or a pions o s>gns iritended Tor ? 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. s SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) © Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other [tom] Brief Description of Proposed Work: 2 P, , 4 1 ,4e/ /--', rr'-/ EJ , Z fiX i�t2oo�S Alteration of existing bedroom Yes X No Adding new bedroom Yes x No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a ,If..Neuw house arltd oracdr# �fltoezisfitnci; l© uslncl ...coitpre #+e:the..fo #loYUiR: 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 ?a - OWNER AUTHORIZATION: - TO BE COMPLETED' WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, She e 4 AJ ' `Ub/ ^l - SO Al as Owner of the subject property hereby authorize . 2 to act on my behalf, in all matter lative to work authorized by this building permit application. r fi 6 12 Signature of 6wner Date as ®wnrcr /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. S !� ,✓„l r /-1 sJ 1J Print Name - , p -- y - e,- / y// -41) Signature of 9wReWAgent Date s SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction S u pervisor . ` Not Applicable ❑ Name of License Holder: ( -�� v.�� ��/�if//s9 4 J C — y2 6 G License Number Address Expiration Date Signature Telephone ? Recif§teri+d:Homt linprovetttenl ht 6­ 0 ,,, . ,', x ._ ., ._. .r , .. .. , :.: ', Not Applicable ❑ Company Name Registration Number Address Expiration Date � (Wc✓ `a/.yrrt���, �� a 106 Telephone S ECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25 C(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...... ❑ _The_current_exemption_for. "homeowners" w extend to include_ 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 b 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 p ermit. 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 al.-Laws Annotated. ort - ampton r triances e 4 : Homeowner Signature - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Ad 600 Washington Street Boston, MA 02111 www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers Applicant Information Please Print Legibly Name ( Business /Orga=' lion/Individual): 3) F4 o - COyS frr4,4- fry ,/ C C Address: _ 7 l0 7 3 .4,4 c,eo e - 7 - City /State /Zip: Phone . #: c/ t3 S 7 - o V ,.3 7 Are you an employer? Check the appropriate box: Type of project (required):. 1. ® I am a employer with L 4.. I am a general contractor and I employees (foil and/or part-time).* have hired the sub- contractors 6. New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling ship and have To en-g loyees These sub - contractors have. .g. Demolition working for me employ a nd have workers' 9. 0 Budding - addi tion [No workers' comp. insurance comp: msul:ance. . re uirecL 5. We are a corporation and its 10. [1 Electrical repairs or additions q ] 3.0 I am- a-homeo- Auer - doing-� mark - - - - -- - � Ceps v --e er i. d n - -- l-1 -4aPhimbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.D Roof repairs insurance required] t c. 152, § 1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance requited.] "Any applicant that checks box #1 must also fin out the section belowshowing their workers' compensation policy information. t Homeowners who submit this affidavit.indicating they are doing aR 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 empIoyees, 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 _formation. Insurance Company Name: 7` eW Vc 4Fe S Policy # or Self Lic. #: 7 7 TV /3 - � S �/ SA J 3 Expiration Date: 0 116 11 o J Site Address: City /State/Z p: t Ai 4 o 1 . a� Attach a copy of the workers" compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage_ as required under Sec6ion 25A of MGL c. 132 can Iead 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 , ne of up to $250.00 a day against the violator. - lie advised that a copy of this statement maybe forwarded o the Offi e of Investieations of the DIA for insurance coverage verification I do hereby certify under the parrs and penalties ofperjury.that the infor�nattan rovi sled above �slrue- and-correct_ SizMture: ��- Date _ . 2 `/ /d Phone #: t/ - SSA' 7- 0 t/ 37 D�cial use only Do nvt write in this. - amen, to be camp eted y city or town affcial City or Town: Permit/License # _ Issuing Authority (circle ®ne): I: Board of Health 2. Building Department 3. City/Town 4. EIectrical, 5 Plumbing ector 6. Other - _ Y Contact Person: Phone #: VDAC TRAVELERS I WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (7PJUB- 0545N13 - 1 -10) RENEWAL OF (7POUB- 0545N13 -1 -09) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA NCCI CO CODE 13579 1. INSURED: PRODUCER: DELONG CONSTRUCTION LLC WHALEN INSURANCE AGENCY 76 BANCROFT ROAD 71 KING STREET NORTHAMPTON MA 01060 NORTHAMPTON MA 01060 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 05 -26 -10 to 05 -26 -11 12 :01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA c B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1000000 Each Accident Bodily Injury by Disease: $ 1000000 Policy Limit a Bodily Injury by Disease: $ 1000000 Each Employee �-� C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A o h D. This policy includes these endorsements and schedules: , SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE —" 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. Ail required Information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE 04 -22 -10 WC ST ASSIGN: MA OFFICE: DIRECT ASSIGNMENT 701 PRODUCER WHALEN INSURANCE AGENCY 28LKF 001F99