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43-111 106 WHITTIER ST BP- 2012 -0045 GIS #: COMMONWEALTH OF MASSACHUSETTS Map - Bloc 43 - 111 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: FENCE BUILDING PERMIT Permit # BP- 2012 -0045 Project # JS- 2012- 000018 Est. Cost: $6000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Grouo: Homeowner as Contractor Lot Size(sq. ft.): 87555.60 Owner: GOODMAN AMY SARGIS ESTATE OF HOMESTEAD Zoning: SR(100) //WSP II A GOODMAN AMY SARGIS ESTATE OF HOMESTEAD AT. 106 WHITTIER ST Applicant Address: Phone: Insurance: 106 WHITTIER ST (413) 586 -3020 (� FLORENCEMA01062 ISSUED ON. 7113120110:00:00 TO PERFORM THE FOLLOWING WORK.- Fencing 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 Sienature• FeeType: Date Paid: Amount: Building 7/13/20110:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner 7 EE ci of Northampton Bu Iding Department 12 Main Street ,�1 Room 100 Ortrlampton, MA 01060 N0ATHAMPT0 - 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 Eo be compIgAed by office - ; a gr arltz/Ll1C'! .�' �L x SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record `` L./ UtJC�/f'�,I� � lt/t/! t 11 �i �. ��(JN�1./ ►u /"Y� Name (Print Current Mailing Addre E Telephone Signature 2.2 Authorized Aoent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be C7fficial Use Only completed b permit applicant 1. Building r�, i (al. :luilting Perrrtiit Fee (� go ............... 2. Electrical (b) 6stin ate&T6ta1 Cost.of Construction. from 6 3. Plumbing .Pedr Buildingmil:.Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= 0 +2+ + 5) Check Number This Section Fac OfflciaLUse Onl Date Building Permit Humber: Issued: Signature: Building Commissioner /Inspectofof Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ~^ r Existing Proposed Required by Zoning , E This column to be filled in by Building Department Lot Size m��, $ f—�-- Frontage t !-4 • 777 Setbacks Front Side L:rr R: L: R: ! Rear L J � Building Height Bldg. Square Footage _ --Open-Space Footage __ ._ :_ °!o__ --- [ — ---t _ (Lot area minus bldg & paved par # of Parking Spaces Fill: 1 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 #1 B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , 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 NO IF YES, describe size, type and location: I 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 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTIONS- DESCRIPTION OF PROPOSED WORK (check appal tcahlel h r New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [p] Other [Q Brief Description of Proposed Work: 61ft(nk ba e&VAI It l Alteration of existing bedroom Yes t/ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 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. Wit building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION: OWNER IttiTHOF IZATIQN T© BE CQME!I.E7ffl' WHEN OWNERS AGENT OR CONTRACTOR APPLIES isOR BIEIL,flING;PERMIT I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date as Owner /Authorized Agent hereby1declare 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 Nam ult Signature of er/Agent Date SECTION 8 R CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicab* ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 VfIt RKERS':. COMPENSATIQN INSU..RANC>:!�FFII3AV. T (1111 fi 1+ c 152 § 25 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 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 s The Commonwealth of Massachusetts Department oflndustrial Accidents , Office of Investigations 600 Washington Street Boston, MA 02111 www.mass pyldia - Workers' Compensation Insurance A1l'davit: Builders/ Contractors /Electricians/PIumb.ers Applicant Information Please Print Li2ibly Name ( Business /Organiiation/lndividual): . Address: City /State/Zip: Phone. #: Are you an employer? Check the appropriate'box:... - Type of project (required):. L Q I am a employer with 4., I ani a general contractor and I 6� N co nstruction_ -'- -- - — — 10 ees full and/or - arftime * - - -- havc hired- the - sub - contractors— — - - - - - _ - y P - listed on the attached sheet 7. ❑ Remodeling 2.. I am a sole propnetor or partner= . ---- - These - sub= contractors - ave - - - . sfitp aril - have: no e�ilo3�ees - - -- - h_ .8. ❑ Denolitron working' or for me in an Y capacity. ac rtY employees and have workers' 94 ❑ Building addition [No workers' - comp. insurance comp. insmance " re ed 5. We are a corporation and its 10.0 Electrical repairs or additions � ] - _ 3. I am a homeowner doing all work officers havelxercised their _ 11.0 Plumbing repairs or additions myself- [No workers' comp. right of exemi lion per MGL 12.F ].ROof repairs insurance required.] t , c. 152, § 1(4), and we have no 13.❑ Other repairs Cr employees. [No workers' comp. insurance_regiiired.]. `Any applicant that checksbox #1: must also $11 out the section belowshowing duce workers' convensatiea policy information t Homeowners who subunit this affidavit indicating they are doing aD work and then hire outside contactors must submit a new affidavit indicating such. tContractors that check this box must.attached an additional sleet showing the now of the sub - contactors and state whet=or not those entities have employees..If the sub- rnahaciam have employeeg, they must provide their workers' comp. policy number. lam an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information. . Insurance Company Name: Policy # or Self-ins. Lic. M. Expiration Date: Job Site Address: City/State/Zip. 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 crimingl penalties of a fine up to $1,500.00 and/or one. -year imprisonment; as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of InvestiLlations of the D IA for insurance cov verification. I do hereby c under parns•and penalties of perjury that the information provided above is true and correct -- tore: i �- - -- `►. Official use only. Do not write in this area, to be completed by city or town official -City or Town: Permit/Licen - se s # - --- e Issuing Authority (circle one): .1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• HOME OWNER EXEIWIPTION 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 fancily dwelling, attached 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 wairts persons) who: seek to use the home owner exemptnrron, to° act as their oiwa coastractron supervisor; to` be aware that by doing so you become responsible for compliance with state building codes. and regalations. ' The inspection. process requires, that tle.building department be called to inspect work at various stages, which _include foundation /footings (before backfill), son6tube holes (before-your), a rouzh buildine7insuection (before work is concealed), insulation inspection (if required) and a final building inspection. The building depart re quires the inspections before the work is concealed, failum to secure these ins6kdons can;result_in fafflure to obtain a certificate of occupancy until the work can be 'insoected: If thd- homeowner lures other tra des to perform work (electrical, plumbing & gas)-the homeowner will.be responsible;to make sure'that the trades hired secure their proper �errn is 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 MAY the project until such time as the proper permits and inspections are made I, 6� Q understand the above. .(Home er /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to m►e - -- Date Address of work location /C1p (l�l�'7lty' S7_ 601me , _XA d <�a 7/8/2011 1:19 PM FROM: Charles S. Cariilo 2arillo Insurance TO: 19137851812 PAGE: 002 OF 002 Aco CERTIFICATE OF LIABILITY INSURANCE 7 /8 /2011YYYJ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S►, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Maria Curto, CISR NAME: Charles Carillo Insurance Agency Inc. aIC Ext: (860) 623 -9895 AIC No: (860) 623 -9548 E -MAIL 363 South Center Street ADDRESS: P.O. BOX 403 PRODUCER 0008102 CUSTOMER ID C: Windsor Locks CT 06096 -0403 _ INSURER(S) AFFORDING COVERAGE NAICi INSURED INSURERA 013114 Insurance Comp 4788 INSURER B : Chris Messier INSURERC: 45 Chestnut Hill Road INSURER D: INSURER E : Stafford Springs CT 06076 INSURERF: COVERAGES CERTIFICATE NUMBER:2011 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000 DAMA E }{ COMMERCIAL GENERAL LIABILITY PREMISES "'-N Ea occurrence $ 500, EU A CLAIMS - MADE � OCCUR I35SIQ /15/2010 /15/2011 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 1,000,000 X7 POLICY F7 PRO - ,ECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 750, 000 ANY AUTO BODILY INJURY (Per person) $ A ALL OWNED AUTOS 113581Q /21/2011 /21/2012 X SCHEDULED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ HIRED AUTOS (Per accident) X NON- OVdVED AUTOS Uninsured motorist combined $ 750,000 Undennsured motorist $ 750,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OT H- AND EMPLOYERS' LIABILITY Y/N T RY IMIT ER ANY PROPRIETOR /PARTNERIEXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED'? ❑ NIA (Mandatory in NH) E . DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E . DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Robert L. Goodman ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1163 66 Morgan Road AUTHORIZED REPRESENTATIVE West Springfield, MA 01090 ria CllrtO, CISR /MLC ACORD 25 (2009/09) O 1988 -2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD �� .--. a a H h ;i4 En A � ►-� A En 0 En W4 z v H 4 x ON w J ;;tTS Np cQ U u -1�`! 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