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17A-014 14 HASTINGS HGTS BP- 2010 -0058 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 17A - 014 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categor BUILDING PERMIT Permit # BP- 2010 -0058 Proiect # JS- 2010 - 000066 Est. Cost: $38265.00 Fee: $229.20 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ED LENNIHAN 042506 Lot Size(sq. ft.): 13503.60 Owner: KULP JASON & MONA Zoning: URA (100) //RI /WSP Applicant: ED LENNIHAN A 11Y Applicant Address: ` Phone: Insurance: 76 Bancroft Road 587 -0437 WC NorthamptonMA01060 ISSUED ON:711812009 0 :00 :00 TO PERFORM THE FOLLOWING WORK.-Convert Breezeway to mudroom POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: 3 "10A� l X Footings: Rough : Rough: House # Foundation: Driveway Final: Final: it' M IT al:/7� / Rough Frame: (�� �'� of G(_ Og Gas: Fire Department Fireplace /Chimney: Rough: Oil: ____ __ Insulation: Final: Smoke: Final: Q K l© ` 0 760 —14 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 aid: Amount: Building 7/18/2009 0:00:00 $229.20 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Connnissioner - Anthony Patillo i E i P ✓ Qe�} 1en Oisertly City of Northampton s 3errrt , 5. Building Department �� a . E q, 212 Main Street '0''_4 a Room 100rae�lA�tiat� Northampton, MA 01060 Tets pfi Structural Platas phone 413- 587 -1240 Fax 413- 587 -1272 P��Pf s 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 / y /--1,4 S 1 `'`i Gr # Map Lot Unit Zone Overlay District Elm St. District _ CB District SECTION 2 - PROPERTY OWNERSHIPJAUTHORIZED AGENT 2.1 Owner of Record Name (Pri Current Mail' g Ad re s o� _!lj -!+i- 3oZ9'3 Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: a/o U ��— 1 -/l 3 �- Gi S -3�o6 L Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated - Cost- {Dolla.rs) -to -be Official Use Only completed by ermit a licant 1. Building (a) !Building' Permit Fee 2. Electrical � (0) Estimated .Cost of 3 ` Construction from 6 3. Plumbing Z 3 �- Building Permit Fee _ _ -q , 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number _ _ _ TFfis Section Foy Of#r`cia[ Use On7' Date Building Permit Number: Issued: Signature: - 0-7 11-7 / C Building Commissioner /Inspector of Buildings pate • � e Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing,,, Proposed Required by Zoning a f� This column to be filled in by � `� r Building Department ft . w 1 d Lot Size Frontage Setbacks Front �,j < ;` qa Side L: ,- R. __ _ L. ,. /-.k__ R Rear S(rs .'•: _ . __ Building Height P, ; µ5 ! J Bldg. Square Footage ~ % 2 2 i 2� Open Space Footage _•_;. % (Lot area minus bldg & paved X71 (8 7 p arkin g) # of Parking Spaces ?" _.�_ Fill: volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES 4 j IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO I DONT KNOW m YES _._.. "} IF YES: enter Book _ Page, i and /or Document # B. Does the site contain a brook, body of water or wetlands? NO j 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 0 NO IF YES, describe size, type and location: 3 D. Are there any proposed changes to or additions of signs intended the property ? YES 0 NO E) IF YES, describe size, type and location: _. E. Will the construction activity disturb (Gearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YFS, then a Northampton Storm Water Management Permit from the DPW is required. s SECTIONS- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 17 Accessory Bldg. ❑ Demolition ❑ New Signs 101 Decks [Q Siding [0) Other [E j Brief Description of Proposed Work: •2 teze 4,.<ry -/o '/Z 4.4 �r �.e �,, r , - 2 e C i s e4,, Alteration of existing bedroom Yes _� No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 1 qL ' - Ne�nr. house anc ;ar add tl n o..exis Ana. vus�ncr'',eorrrplete tF o� 6w, i aa` 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 COMPLETEti WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I 14 - as Owner of the subject property hereby aufthorFze J clrr�/u. /� L „r V- . V to act on rrw behalf, in all matters reI ve to authorized by this building permit application. - t c- 0 Signature of Owner Date I, S_ d<vlv✓ci 'r7 F,.lu�N v as4Dwner /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. c Print Name Signature of ®per /Agent Date n SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder �?��Iunr - D - D. L Ear - -4-v CS - elzs x; License Number 7�0 �XI rJ C2o �T / 1Vo L , , 94 , Yr' a J r -44 . o i o 6o Jlzr to )o Address 6cpiration Date Signature Telephone 9.: Reiisfered; lorne .:Irnroveiaent= Garitz�cfor: , Not Applicable ❑ �Fco Ar�f ea "3,4 v i� a, Lc 1 6/1 Company Name Registration Number -;�, 12? q,�iC2a � lZ� 6l/s/2 Address Expiration Date Telephone 1 -//1 (o SS = ✓�66Z SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, §- 25C(S 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....... [E' 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 buildina 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- perrnit- is-i-ssued------ - - - - -- - - - - -- _ 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 thus peniiit. 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 The Commonwealth of Massachusetts Deparbnent of Industrial Accidents " � = Office of In vestigations 600 Washinb on Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organization/IndMdual): D1 y r4 Cy�vs�e�G - io J Address: '7( Z;4 Jceb0r le ' City /State /Zip: ,A1oR-rWAerr P4"W , / °i o Phone #: t/ /3 -Std 7- o X137 Are you an employer? Check the appropriate box: Ty' New e of project (required): 1. X I am a employer with 4. ( am a general contractor and I construction employees (full and/or part- time).* have hired the sub - contractors 2. El am a sole proprietor or partner- listed on the attached sheet. ® Remodeling ship and have no employees These sub - contractors have . ❑ Demolition working for me in any capacity. employees and have workers' 9 E] Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ 1 am a homeowner r- doing -aH- work -- -- - - -- officers have exercised thei _ _ 11 ❑_Plumbing repairs or additions myself. No workers' comp. right of exemption per MGL 12. [1 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 #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who subinit 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 ha employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: T)A V&Z - -RS _7;Zd .?4-tC2 �� • _ Policy # or Self-ins. Lic. #: 7 !?-Tcf8 - Ixf9T — /3 ' / w S Expiration Date: .S /Zd o Job Site Address: /y / '�"'« /� ��'`� City /State /Zip: 4 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 as welfas civil penalties -in fheTorm -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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature ei-L— Date: � �(�A Phone #• eJl�� - yS7 O ficial use only. Do not write in this area, to be completed by city or town offcciaL City or Town: - Permit/License # Issuing Authority (circle one): ��•'�u�lQi ^�� e¢artrnetal 3. Citvi --Tuwu Clerk -_ .- Elect rical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: VDAC �1 T RAM' ERS J WORKERS COMPENSATION ' AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) r� t POLICY NUMBER: (7PJUB-0545N13 -1 09) RENEWAL OF (7PJUB- 7757837 -1 -08) INSUR140: RAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 1 NCCI CO CODE: 13579 INSURlid1:I PRODUCER: DELONG�i. �1 I TRUCTION LLC WHALEN INSURANCE AGENCY 11 n 76 BANCIft� T ROAD 71 KING STREET* NORTHAkI T ONN MA 01060 PO BOX 478 NORTHAMPTON MA 01061 -0000 t: L, Insim, A LIMITED LIABILITY COMPANY Othbl brk places and Identification numbers are shown in the schedule(s) attached. I, 2. They p 4py period is from 05 -26 -09 to 05 -26 -10 12:01 A.M. at the insured's mailing address. 1 A. �KERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers )d ensation Law of the state(s) listed here: LOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in i{errl3.A. The ilmits of our Habllity under Part Two are: o Bodily Injury by Accident: $ 1000000 Each Accident OEM ''� Bodily Injury by Disease: $ 1000000 Policy Limit o� Bodily Injury by Disease: $ 1 000000 Each Employee AM C. 0 1ER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: b ( '.' d ipI RAGE REPLACED BY ENDORSEMENT WC 20 03 0GA � r D. f j'H�ipolicy includes these endorsements and schedules: a 5dIF�'LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE - 4. Thb 0 Mium for this policy will be determined b our Manuals of Rules, Classifications, Rates and Rating a Plods.''', it required Information is subject to verification and change by audit to be made ANNUALLY. . kk I I'I i X4 1 � i DATE P %SUE: 05-12-09 DR ST ASSIGN: MA C 1 0�(FICE: DIRECT ASSIGNMENT 701 P d(NOCER: WHALEN INSURANCE AGENCY 28LKF 1301024 G G' �j