49-007 282 GLENDALE RD BP- 2010 -0858
GIS #: COMMONWEALTH OF MASSACHUSETTS
Ma k: 49 - 007 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 -0858
Protect # JS- 2010- 001276
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED LEARY 47932
Lot Size(sq. ft.): 7797.24 Owner: GAUTHIER LYNDA M
Zoning: SR(100 )//WSP II Applicant: ED LEARY
AT. 282 GLENDALE RD
Applicant Address: Phone: Insurance:
46 SOUTH LIBERTY ST (413) 283 -3561 WC
BELCH ERTOWNMA01007 ISSUED ON :41612010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN & TILE FLOOR
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 4/6/2010 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
t
Y
City of Northampton
Building Department
212 Main Street
0 Room 100
Northampton, MA 01060
phone 413 - 587 -1240 Fax 413 - 587 -1272
NEW
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
Map .. Lot Unit
�� Zone Overlay District
� vv �' - , ElenSt Distrlct CB Distric
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: j
Name (Print Current M ailing 7sk 7�f
Telephone (C
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address: 6 �� �� E ✓,�� �,�
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION C*tTSI
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
OZl Construction from 6
3. Plumbing g Building Permit Fee
11��0
4. Mechanical (HVAC) -
5. Fire Protection OQ
6. Total = (1 + 2 + 3 + 4 + 5) / ODa Check Number �t 4 f 9 1 1
This Section For Official Use Onf
Date
Building Permit Number: Issued:
Signature: a
Building CommissionedInspector of Buildings Date
t
M
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 ` 1
Side L: �_.....� R: L, L R° w
Rear --
Building Height
Bldg. Square Footage % ?
Open Space Footage _ %
Lot area minus bldg & paved z
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 DONT KNOW 0 YES Q
IF YES, date issued:L_
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i _ Page and /or Document #___._.___
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
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 0 NO Q
IF YES, describe size, type and location
wF� - "' �De t ere any pioposed c anges to or a itlons o signs l ® `ntened for - tie property ? YES Q 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.
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [E:3] Other [a
Brief Description of Proposed
Work: Work: � f G� �w eWe - I 1 - 1 1 � e—
Alteration of existing bedroom Yes --�N o Adding n4 bedroom Yes / No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa ', Cif Ketiv'.h ay "sea r i i 'e vll o �'V M a o s i t t Fta r�tr c:
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 - BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, G C�/1 dG 144 C' /t as Owner of the subject
property
hereby authorize
to act on my b n all matters, r roe wo auth 'zed by this building permi application.
Si ure of Owner Date
as Ow :th orized
Agent hereby declare that the statements and information on the regoing application are true and accurate, to the bes of mnowl ge
and belief.
Signed under the pains and penalties of pedury.
Print Name
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES I
8.1 Licensed Construction Supervisor Not Applicab ❑
Name of License Holder : �� D ` 7'Z
License Number
Address Expiration Date
Signature Telephone
` Repitere %1t+aerincaoertteretlaittCaeto . -: Not Applicable ❑
Company Name Registration Number
Anddres_s` Expirati n Date
/?,4-' e e)0 7 Telephone
SE CTION 10- WORKERS COMPENSATION IN 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...... ❑
�56�
_ _The-current-exemption for,"homeowners' was ex 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 n 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 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
t --
trianc ;' a e ral� Laws. Annotated.
T -` ort amptori r
Homeowner Signature
The Commonwealth of Massachusetts
Department oflndustrial Accidents -
Office of Investigations
' 600 Washington Street
Boston, MA 02111
www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
AAP licant Information Please Print Legibly
Name ( Business /Organimnon/Individual):
Address:
City /State/Zip: Phone. #: 91.s
Are yo employer? Check the appropriate box: Type of project (required):.
1. I am a employer with _ 4.. n I am a general contractor and I 6. ❑ New construction
employees (full and/or part time).* have hired the sub- contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
These sub - contractors have ship and have no. employees 8. Demolition
working' for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp. insurance.;
required ] 5. We are a corporation and its 10.❑ Electrical repairs or additions
offi�zs veised
3. [� l am- a�emeowaer- dei$g�werk-- - - - - -- - —�1 �]-- I?Imnliing repairs or additions
myself: [No workers' comp. right of exemption per MGL 12. Fnj Roof repairs
insuran required] t c. 152, § 1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.}.
*Any applicant that checks box #1 anrst also fill out the section below showing their workers' con4=sation policy information.
t Homeowners who sub nit this aT lavit.indicaling they are doing all work and then. hire outside contractors must subarit a new affidavit indicating such.
( Contractors that check this box must.attached an additional shed showing the nz= of the sub- contractors and state whether or not those entities have
employees. If the sub - contractors bave 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
_ in ormation.
Insurance Company Name:
Policy # or Self -ins. Lic. #: 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 imd Secti6n"25A of MGL c. 152 can lead to the iruposition of crimhW 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. 13e advised that a copy of this statement may be forwarded to the Office of
Investieations of the DIA for insurance coverage verification.
hereby certify u derth= and penalties of perjury that the information provided above islrue_aridcorrecn__—
Si tore: .,Date*
/ o
Phone #:
Official use only. Do not write in this area, to be comp ed by city or Town aftcial
- -City or Town: Permit/License #
Issuing Authority (circle one):
- -I_ Board of Health 2. Building Department 3. City/Town Clerk 4 Electrica 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 exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regul The insnection Drocess requires that the building department be calle 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
- - - -. � ite in- -onjunction- the-building pernit dssued,_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 to me.
Die
Address of work
location
04/05/20 11:20 4133238132 BELL AND HUDSON PAGE 01/02
�tCfa I CERTIFICATE OF LIABILITY INSURANCE ° 04 /05 /Z0 0
"Ro-jam (413) 323 -.9611 FAX (41a)323-6117 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Bell & Hudson Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
19 North Mai St . HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.U. !}OX 669
TER GoVERAW! O RDER THE BELOW.
Selchfertown, MA 01007 INSURERS AFFORDING COVERAGE NAIC#t
N Il Leary INSURERA: Notional 'Prang Mu tutal Ins.Ca 20759
08A: Ed Leahy Houle XWrovement INSURER e: Saf ety In ity 33618
46 South Liberty Street INSURERC: Natia; Fire Ins. Co.
BeTchertcan, NA 01007 INSURER D:
INSURER E:
`THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE •POLICY PERIOD INVICATIM. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFOROED BY THE POLICIES DESCRIBED HER91N IS SUBJECT T Al L THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
am TYPE OP I7 StMANCB POLICY WJMHER POLICY EP PI IJMfTB
SMIN OENBRAL UAINLITY MM83639 11/17/2009 11/11/2010 . EACH OC s 1 000 0
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CLAIMS KPOE ! fl OCCUR HA &O Fxn {any onepown) $ 10,
A X 00 PO Deductible - PER80NALiADV S 1 00
Per '1aim 1}ENERALAGCRE{RATE 5 2 000
GENT. AGGR213ATE UNIT APPLIES PER PRODUCTS - COMPIOP •AGG it 2 , 000
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AUTOMONLE LIFOUTY 39SZ 716 COM 04 11/23/2009 11/2 #/2010 Con� SINGLE LIWT 3
ANY AUTO (£a aacieevlt}
ALL OVllld€D AUTOS a 40ILY INNURY
B X SCHEDULED AUTOS (Per penwn) 250,
HIRED AUTOS 8001LY INJURY
NON -OWNED AUroe {Per sccfae�,$) . 500
PROPERTY DAMAGE .
(pgrgfeeWent) . 250,
9ARAGE LIABRAY A13 TO ONLY - fA ACCIDENT S
ANY AUTO OTHER THAN EA ACC t
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EX09MUMSRELLA LIAA9tUTV EACH OCCUR RENCE: 4 .
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RETENTION S 1
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OTHER
0"CRUMON Of OPERA7117NS / LorAT M I Yt"CLES I E=LUX)ONS ADDED BY SKODFAl1WNT I SP&CI.AL PROV13 NO
Interior Carpentry Work / Home IVrovement Work
***Sole Proprietor is excluded from the Workers Compensation payroll.
F TION
SHOULD ANY OF THf: AROW DESCMW POLan BE CANOQJJW 0" no
CIPIRATION DATE THERROF, THE ISSUING INKHMR WILL ENDEAVOR TO MAIL
Ci of Northampton + DAYS NOTIa Tb THE RcATE HoLO F 4,0411 ED TO T" LIT,
Attu : Bui Inspector BUT FAILURE TO fuc/I i'IanuE 9 iEPI73E NO LfaealrY
212 Mai Street Of ANY IIND U. E I XU aye R.
M.
NorthaWton, MA 01060 AUTNORRED
ACORD 26 (20olmM FAX (413) 587 -1272 6olACORD TION 19W