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42-112
698 WESTHAMPTON RD BP- 2010 -0083 GIs #: COMMONWEALTH OF MASSACHUSETTS Map :Bloc 42 - 112 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeory: BUILDING PERMIT Permit # BP- 2010 -0083 Project # JS- 2010 - 000090 Est. Cost: Fee: $350.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License. Use Group: JDR BUILDERS 074105 Lot Size(sq. ft.): 59415.84 Owner. LABARGE RICHARD J & MARIANNE L Jt1R R tjq.nERS AT. 698 WESTHAMPTON RD Applicant Address: Phone: Insurance: P O BOX 66 (413) 665 -7587 WHATELYMA01093 -0066 ISSUED ON. 712312009 0:00.00 TO PERFORM THE FOLLOWING WORK.-strip and reshingle 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: Roijah: Oil: Insulation: Final: Smoke: Final: (f k �.�o f. p c7 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL ION OF ANY OF ITS RULES AND REGULATIONS. - oe Certificate of Occup Sienature: FeeType: Date Paid: Amount: Building $359 -HtT'� 3�3 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo __ _. 'Departmentuse only City of Northampton Status Permit:, Building Department Curb'.Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water Availability Northampton, MA 01060 Two Sets of 5trUctural Plans phone 413 - 587 -1240 Fax 413 - 587 -1272 Plottsite`Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address This se lo kilo c m by r -- Map Lot Unit JU L vas' Zone } Overlay District Elm St. District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record AW Aj— tAaA e cif W�,'�c,� Name (Print) Current Mailing Address: Telephone Signatu S' � ! 93� re '1 2.2 Authorized A-q t: Name ( rint) Current Mailing Address: u6s �5u Sig 6a r IV Telephone SE ION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only com feted 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) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number Z.._ This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 4 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 _ oho Open Space Footage % (Lot area minus bldg & paved p arkin g) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DON'T KNOW © YES IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , 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 O NO 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 O 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 ❑ Replacement Windows Alteration(s) Roofing Or Doors F-1 Accessory Bldg. ❑ Demolition ❑ New Signs [[J] Decks [Q Siding [O] Other [C]] Brief Description of Proposed Work: fL'(] W F RCmCJ�< T(),1 wI AA 30 1 6:�,6L A-S fI Lt(� rr ; sh,►, Ie . Alteration of existing bedroom Yes }S� 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 housing 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. 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 �V-1k` TICK LA- 6,NkZ property as Owner of the subject hereby authorize to act on ;ha lf, in rs relativ to work authorized by this building permit application. Signat o 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 bf Agen Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder 7 ZT�YYzs 2-,. 5 License Number Address Expiration Date Signature Telephone q / &1 9. Registered Home Improvement Contractor: Not Applicable ❑ ` 0 (L 11 Cry 00C R Company Name Registration Number 13 03 Address Expiration Date Telephone 3� 2-12 Cl 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 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 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 v lriussactiusetts Department of Industrial Accidents ' Office of Investigations 600. Washington Street ` Boston, MA 02111 i� www.rnass.govldia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �p (Z. 0' U0 Address: P() ` 0t k(u (o City /State /Zip: AA4- (} 6 Phone #: (� S " 1 )5 c 9 Are you an employer? Check the appropriate box: ox: Type of project (required): [9 1. I am a employer with 1 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. ?. ❑ Remodeling ship and have no employees These sub - contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp, insurance comp. insurance. 9. F Building addition 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.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12M 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 #I 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: L_% r_ - a;r4 hV'TuM- Policy # or Self -ins. Lic. #: (1) CA ° 3 1 S — 3 2 j ,540 - G l g i Expiration Date: � ' a �' " 2 C i c Job Site Address: mu2p""T-C,1x- City / State /Zip JVCr,71+.+3Mpi -c4j AU- C IO (, 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 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 cer y under th pains and penalties of perjury that the information provided above is true and correct. Si ng ature: Date: Zo q_ (� Phone #: " 7 Official use only. Do not write in this area, to he 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 #: AR WCIP Liberty ISSUING OFFICE 181 Mutual.. workers Compensation and INFORMATION PAGE Employers Liability Policy ACCOUNT NO. SUB ACCT NO. Liberty Mutual Insurance Group/ Boston 1- 371520 0000 LIBERTY MUTUAL FIRE INSURANCE CO 16586 POLICY NO. TD /CD SALES OFFICE CODE SALES CODE N/R 1ST WC2 -31S- 371520 -019 XX X WESTON 102 REPRESENTATIVE 3000 1 YEAR ASSIGNED 2009 Item 1. Name of JAMES D ROSS DBA JDR BUILDERS Insured FEIN 06- 1559981 Address PO BOX 66 RISK ID 147592 WHATELY, MA 01093 Status 01 - INDIVIDUAL Other workplaces not shown above: SEE ITEM 4 Mo. Day Year Mo. Day Year Item 2. Policy Period: From 01 -29 -2009 to 01 -29 -2010 12:01 AM standard time at the address of the insured as stated herein. Item 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA 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 100,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily Injury by Disease 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rates LINE 110 Per $100 Estimated Code Estimated of RE- Annual Classifications No. Total Annual Premiums muneration Premiums SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 500 ( MA) Total Estimated Annual Premium $ 3,462 Interim adjustment of premium shall be made: ANNUAL This policy, including all endorsements issued therewith, is hereby countersigned by Authorized Representative Date 02 -26 -09 Loc. Code Term. Oper. Audit Basis Periodic Payment Rating Basis P.I. H.G. I Home State I Dividend 02 -26 -09 1 1 NR I MA NEW to R1 Copyright 1987 National Council on Compensation Insurance WC 00 00 01 A Insured Copy