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11C-025 (2) 6 STOWELL ST BP- 2012 -0161 GIs #: COMMONWEALTH OF MASSACHUSETTS Map .-Bloc 11C - 025 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Above ground pool BUILDING PERMIT Permit # BP- 2012 -0161 Project # JS- 2012 - 000239 Est. Cost: $2291.00 Fee: $30.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin Homeowner as Contractor Lot Size(sq. ft.): 8494.20 Owner: HOGAN AMY Zoning: URA(100)/ Ap plicant: HOGAN AMY AT. 6 STOWELL ST Applicant Address: Phone: Insurance: 6 STOWELL ST (413) 727 -3079 () LEEDSMA01053 ISSUED ON. 8112120110:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 18' ABOVE GROUND POOL 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 8/12/20110:00:00 $30.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2012 -0161 APPLICANT /CONTACT PERSON HOGAN AMY ADDRESS /PHONE 6 STOWELL ST LEEDS (413) 727 -3079 Q PROPERTY LOCATION 6 STOWELL ST MAP 11 C PARCEL 025 001 ZONE URA(100) 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: INSTALL 18' ABOVE GROUND POOL New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 2MATION PRESENTED: (V 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 ��-- -� 5-/4 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 Northa 5 Building Depart 212 Main Stre Room 100 0 Northampton, MA 1 phone 413 - 587 -1240 Fax 1- - 3 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 lY ��Gtii I p LQtJnit _ �� � dS 41'1{ 0 � J 3 v ane O �Elrii 5t`Distrlct :CB Distr'icY SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZEQ AGENT 2.1 Owner of Record NamA(P* Current Mailing Addle: 2a 7 Q Telephone LL( n 2.2 Au thc4ed A t: 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 (O building Permit Fee 2. Electrical (b) Estimated Total Cost of Constructions from 6 3. Plumbing BulldingPermit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) d Check Number 30< Od - - -- This Section For Official Use Onl Date Building; Permit Number: Issued: Signature: Building Commissionerllnspector-of Buildings Date Section 4. ZONING All Informa on Musto nied Due To Incomplete Information UL E _istin top ed Required by Zoning This column to be filled in by r 1 Building Department ' Lot Size Frontage Setbacks Front Side L: R: = L:=b R: !_:��.:.NE J --- Rear F --- Building Height�� Bldg. Square Footage % � (� —Open Space Footage i v W _- - % - (Lot area minus bldg & paved p arkin g) # of Parking Spaces ....��._ a a.._ ...�.... . r._ Fill: ? $ volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW Q YES 0 IF YES, date issued: -� IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON K NOW Y ES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO 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 IF YES, describe size, type and location: ' i E. Will the construction activity disturb (clearing, grading ex avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check ill applicable New House ❑ Addition ❑ ReplaceAidnt Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [p] Other [ Brief Description of Proposed Q Work: jJ Alteration of existing bedroom Yes 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: — Nurr er of Bathrooms c. Is there a garage attached? u �) d. Proposed Square footage of new struction. 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. s construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Witl'.building conform to the Building and Zoning regulations? Yes NO. I. Septic Tank City Sewer ✓ Private well City water Supply V SECTION 7a - OWNER AUTHORIZATION - TO: BE GOM!?LETED' WHIN OWNERS AGENT OR CONTRACTOR APPLIES FOR BILDINGPERMIT 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 I gent he eby decl re Owner thorized A that t tatements and information on the foregoing application are true and accurate, to t %� of my knowledge and belief. Signed under the pains and penalties of pedury. L Print �e n CW J Signature of ;1 /Age Date i � t F RUCTION TION 8 - CONST SERVICES icensed Construction Supervisor Y Not Applicablg ❑ Name of License Holder License Number Address Expiration Dat Signature Telephone r` i Not Applicable ❑ J Company Name Registration Number Address Expiration Zeleptone i SECTION 10 Wa1�KERS'' COMPENSATION IN RANCE;AFFIVAVIT.(M G.L. c. 152, § 25C(fi }) 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...... ❑ .. NA ell 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 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. Akerson 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 I Z i g La n State of Massachusetts General Laws Annotated. Homeowner Signa re LL s�6 OiQ The Commonwealth of Massachusetts Department of Industrial Accidents. . Office of Investigations _ 600 Washington Street Boston, MA 02111 MM.,mass gov /din -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Pi ht Legibly Name ( Business /Orgmizatiowindividual): . Address: City /State/Zip: Phone. #: Are you .an employer ?. eck the appropriate box:.. - Type of project (required): 1. ❑ I am a employer with 4.. E] I am a general contractor and I - employees - (fiill and%r p =fime� * - - -. - -- -have hired tbe- sub - contractors —6- N co nstruction___ 2. ❑ I am a sole proprietor or p er- listed on the attached sheet. 7. 0 Remodeling -- ship and have no e loyees - - These sub- contractors -, - .8. Q Demolition working for me in any capacity. employees and have wo 9. Q Building addition [No workers' comp. insurance in� comp. ,1, an te $ ' re uirecL 5. El We are a coipoiatio and its 10.0 Electrical repairs or additions q ] officeYed their 3 I am a homeowner doing all work 11.❑ Plumbing repairs or additions myself [No workers' comp. right oer MGL 12.�.ROof repairs insurance required.] t c. 152, have no emploers'. 1311 other mp. ized }. "Any applicant chat checks box #1 must also fill out the section bel their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all dd=: hire outside contractors must submit a new affidavit indicating such ( Contractors that check this box must.attached an additional sheet showin name of the sub - contractors and state whether or not those entities have employees. If the sub-contractors have employ=, they must .provide th cis' comp. policy number. lam an employer that is providing workers' compensip6on ins ante for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self ins. Lic. #: Expiration Date: Job Site Address:. City /Stafe/Zip: Attach a copy of the workers" compens on policy declaration page (sho the policy number and expiration date). Failure to secure coverage as required der Section 25A of MGL c. 152 can lead the imposition of criminal penalties of a fine up to $1,500.00 and/or one. -year risonment, as well as civil penalties in the of g STOP WORK ORDER and a fine of up to $250.00 a day against the ' lator. Be advised that a copy of this statement be forwarded to the Office of Investieations of the DIA for " ce coves Lye verification I do hereby certify under the p and penalties of perjury that the information provide above is true and correct t�hone : Date: use only. Do not write in this area, to be completed by city or town officiaL Town• Permit/License# Authority (circle one): d of Health 2. Building Department 3. City/Town Clerk 4. Electrical, Inspector 5. Plumbing Inspector Pei son: Phone #: - I a E 1 HOME OWNER EXEMPTION ACKNOWLEDGEMENT 1 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 budding department for the City .of Northampton wants person(s) who. seek to use the home .ownnz . . exemptron, act as their owa corrstructroa supervisor; 'tor - be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection. process requires that the.building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before , your), 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'fo make sure that the trades hired secure their proper �ermits 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 DIELAY the project until such time as the proper permits and inspections are made I, L ✓' understand the above. .(Home ow er /resident)g signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to-hie. _ Date S Address of wor location j The Commonwealth of Massachusetts Department o Industrial Accidents P f Office of Investigations " 600 Washinoon Street Boston, MA 02111 www massgov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electriaiaus/Plumbers Apylicant Information Please" Print LeQ►i"bly Name (Busi 'ess/Organizad 'victual): / e. -S-r• . -VA"£. Address: �� . 3wW e (�( Sr City/StatdZip: t e d fj MA b 1• 3 Ph #: � Id � - '� d 7 � Are you an employer ?.Cbeck the'appropriate•box: Type of project (requires!): No�,E punt i . Q I am a employer ms ith 4. ®I am a-gtme berand I 6. Q New construction employees (fall md/or part- time).* have hired the sub. !wntraetars. N 2. 0 am a sole pmpncwror Farmer= _ iistui on "the �attache`3'Set: ; 7. .. g ship and have no employees These sub - contractors have 8. Q Demolition working forme m any capacity. worketx' comp. insurance. 9, Q Building addition [No workers' comp. insurance 5. Q We area corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself. [No workers' comp. C. 152, §'1(4), and we have no 12.0 goof repairs insurance required.] t employees: [No workers' 13 JR Other D comp, il�i Qe.required.] 'Any applicant Sint checks box #1 moat alto fill out the section below showy g fh* watim q' tuonveasation policy ia*..ftion: r Homeowners wbo submit This affidavit indicating they are doing all work and then hire outside coubsommMsubmftmwiffi&vitin&cathi o such CContrwwrs that check this box must attachad an additional abed showing The name of the sub -eont maem andThair workers' comp, policy infortnation. T am an employer that is providing workers' compensation insurance for my employees Below is the policy andJob site information. . Insurance Company Name: 91A2 A9�Az /h1.4 i zYe�J . Policy # or Self -ins. Lie. #: 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 segue covera90 as required under Section 25A of MGL.c. 1s2:s east to thr, I MPOSWon oforfmfnalp ltaies a fine up, to $1,500.00 and/or one -year impnsonmc'A as weA as civfl penalties in the form'of a STOP WORK 101M R aad a fine :)f 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. f do hereby certify under the p a d skies Jwy that the information provided above 6 correct. LZ cstcaC7bhj � . Sip ature: Date: Phone #: O,TICial use only. Do not write in this area,.to'be completed by city or town o,*kl City or Town: Permit/I,icense # ' 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 #: ACORa CERTIFICATE OF LIABILITY INSURANCE 98%91%2011 PRODUCER 413.536.0804 FAX 413.534.7874 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ' Martin 1. Clayton Insurance Agency, Inc. ONLY AND CONFERS NO FIGHTS UPON'THE CEA FICATE. 1649 Northampton Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES EELOW. P. D. Box 989 Holyoke, MA 01041 -0989 IN SURERS AFFORDING COVERAGE NAIC'# INSURED Rich Dupuis INSURER A: AIM MUTUAL INSURANCE COMPANY AIM DBA: Pool Tech INSURER 0: P.O. Box 705 INSURER C: Holyoke, MA 01041 INSURER D: INSURER E: i COVERAGE 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR Dp' TAME EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER UMITS` GENERAL LIABILITY EACH OCCURRENCE �.. COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED i CLAIMS MADE r_j OCCUR MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GEN AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $` POLICY JECT PRO - 0 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO t , (Ea accident) S ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE S. (Per accident) GARAGE LIABILITY AUTO 91}11VY - EA AGC(OBNT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURittN E $ OCCUR FI CLAIMS MADE AGGREGATE $ s DEDUCTIBLE S RETENTION $ $ WORKERS COMPENSATION AND VWC600254701 08/04/2011 08/04/2012 X I WCBTA - 0TH- EMPLOYERS' LIABILTY E.L. EACH ACCIDENT $ 100, A ANY PROPRIETORIPARTNER/EXECUTIVE �-- — OFFICERANEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE S, —` 400, SPIF Yea.- dascr'. ECIAL PRSt heltiv/ _ - — .:-- ...- ._._ ^_ _ - -� ., .— — _ EL- �IS K ASF : cYLIM $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT i SPECIAL PROVISIONS CERTIFICA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE' CANCELLEDBEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, POOL. TECH BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION'OR LIABILITY P 0 BOX 705 OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.. HOLYOKE MA 01041 AUTHORIZED Daniel Sullivan. IANE ACORD 26 (2001108) ©ACORD CORPORATION 1988 . �� �s � \I j �� J ;, ,� y, �'�) V .,` 1 � i { r �� -�� �.~ �.�, �: ,�, .,�.,�