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17A-022 a J 5 , 15 HASTINGSHGT'S BP- 2010 -0926 GIs #: COMMONWEALTH OF MASSACHUSETTS -021 1 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 -0926 Project # JS- 2010- 001375 Est. Cost: $8550.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TAYLOR & BRYAN ASSOCIATES 101410 Lot Size(sq. ft.): 12501 .72 Owner: LENKOWSKI LINDA C Zo ning : URA(100) //RI Applicant: TAYLOR & BRYAN ASSOCIATES AT. 15 HASTINGS HGTS Applicant Address: Phone: Insurance: 60 SCHOOL ST (413) 387 -4252 WC HATFIELDMA01038 ISSUED ON.51312010 0:00:00 TO PERFORM THE FOLLOWING WORK .-CONSTRUCT 6 X 4 COVERED ENTRY 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 5/3/2010 0:00:00 $55.00 c (� fl 6 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 1 File # BP- 2010 -0926 APPLICANT /CONTACT PERSON TAYLOR & BRYAN ASSOCIATES ADDRESS/PHONE 60 SCHOOL ST HATFIELD (413) 387 -4252 PROPERTY LOCATION 15 HASTINGS HGTS MAP 17A PARCEL 022 001 ZONE URA(100)//Rl THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out r Fee Paid Typeof Construction: CONSTRUCT 6 X 4 COVERED ENTRY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 101410 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFq4fMATION PRESENTED: 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 ('� 10L - 1 o l b 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. i Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 -587 -1240 Fax 413 - 587 -1272 Plot/Site 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 section to be completed by office { �1NEs`� 1fi�tbz}c Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record A'Ap y Name (Print) Current Mailing Add ess: 41 1. Jed �w�� Telephone Signature 2.2 Authorized Agent: TkAO VANe, - 9 ",kv13 �� Si nt , . R ni (c.L,�?, 1A A 0/ Name (Print ) Current Mailing Address: 44L f 0 a 4 1 - -, 1 7 — 3 � '7 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building T4 t 9 y 5 (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 = 0 +2+3+4+5) Check Number o 5� This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning 4� This column to be filled in by V Building Department Lot Size Frontage 1 6c' ( t Setbacks Front 1 00 f _V 4 Side L: �-y� R: L: N R: OG Rear Building Height ' Bldg. Square Footage % tJ Open Space Footage % (Lot area minus bldg & paved N F3�Fi p arking) # of Parking Spaces D CM *p CX4 Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO l DON'T KNOW /—,\/ YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO (�K DON'T KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , 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: E. Will the construction activity disturb (clearing, grading, exca ation, 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. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition Replacement Windows Alteration(s) ff — Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [El Other [O] Brief Description of Proposed Work: ( -e "' x 4' -0" t7PPC Ci;V- ift�lY'^( �c�tc t�N (��ywt�:' S- c iJ 5 f n�� �✓ i - Lf ° G✓ Alteration of existing bedroom Yes No Adding new bedroom Yes x 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 J unit: ( o Number of Bathrooms c. Is there a garage attached? l t �K l�<< d. Proposed Square footage of new construction. SF Dimensions CU ` q e. Number of stories? I � - f. Method of heating? J Fireplaces or Woodstoves N c Number of each g. Energy Conservation Co11m��pliance.. " Masscheck Energy Compliance form attached? h. Type of construction W uc �> FrL&& 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 P/A k. Will building conform to the Building and Zoning regulations? ✓ Yes No. I. Septic Tank City Sewer f Private well City water Supply ✓ SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, L t o9A C. as Owner of the subject property t hereby authorize �] " �• � '� e, F �iff- � iu W7T- &r 7ivi C& to act on my behalf, in all matters relative to work authorized by this building pe Mt application. �4r /v Signature of Owner D to 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 - u}n�d�e�r the pains and penalties of perjury. 1 Rt ^k f- - bfhi� ►�1v� Print Nam b- Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor q Not Applicable ❑ Name of License Holder � .� t �1 �.1�'LI� C `J j G 14 ( b License Number Address Expiration Date �/ 4 Signatife 12 Telephone 9. Renistered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Lo &C�-UL Address Expiration Date L0 Telephone `l1 "3YJ7 � Z�z 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 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 and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Construction Supervisor License Update Address and return card. Mark reason for change DPS -CA1 0 5OM- 05106- PC6490 Address Renewal Lost Carc Massachusetts - Department of Putrlic Board of Building Regulations and �tandarrls Construction Supervisor License License: CS 101410 Restricted to: 00 KELLY NEALE 768 SOUTH ST SUFFIELD, CT 06078 Expiration: 5 /3/2012 (.an +ni..ioner Tr»: 101410 00 - Unrestricted 1G -1 2 Family homes Failure to Possess a current edition of the Massachusetts State Building Code is arse for revocation of this license. Refer to. WWW.Mass.Gov/DPS `PX 4fi ce e =e, I MAff . �i,, an iB 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Reqistration: 164072 Type: Private Corporation Expiration: 8/14/2011 Tr# 287999 TAYLOR & BRYAN ASSOCIATES LLC. KELLY NEALE 60 SCHOOL STREET HATFIELD, MA 01038 Update Address and return card. Mark reason for change. Address I Renewal Lost Card Employment DPS-CA1 0 SOM•04104-0101216 J7. W- Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 164072 Office of Consumer Affairs and Business Regulation Expiration: 8/1412011 Tr# 287999 10 Park Plaza - Suite 5170 Boston, MA 02116 Type* Private Corporation TAYLOR & BRYAN ASSOCIATES LLC. KELLY NEALE 768 SOUTH STREET SUFFIELD, CT 06078 y N Undersecretar val without signature At® CERTIFICATE OF LIABILITY INSURANCE OP ID AC DATE(MMIDDfYYYY) TAYLO -3 03/05/10 Cha ER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Charles G. Marcus Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 842 Silas Deane Highway HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.0- Box 290756 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wethersfield CT 06129 - 0756 Phone:860 563 -9353 Fax:860- 257 -8404 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A: National Gwanc je Mutual 14788 INSURER B: CYBERCOMP TAYLOR BRYAN ASSOCIATES LI,C DBA TAYLOR BRYAN COMPATdSr INSURER C: 768 SOUTH STREET SUE'E'IELD CT 06078 INSURERD I INSURER E' COVERAGES 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER �Y L RAT O DATE MM/DD/YYYY DATE MM/D LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1 000,000 A X COMMERCIAL GENERAL LIABILITY MP,T0449M 03/05/10 03105/11 PREMISES ( cccwenee) s500,000 CLAIMS MADE EK OCCUR MED EXP (Any one person) S 5 0 PERSONAL t: ADV INJURY S1,000,000 1 GENERAL AGGREGATE s2,000 GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG s 2 r 000 0 00 PO jECT L OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Par parson) HIRED AUTOS BODILY INJURY NON-DWNED AUTOS y (Per acddeM) $ �PROPERZTY DAMAGEer acci) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S ANY AUTO EA ACC S OTHER THAN _ AUTO ONLY AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE S _ S DEDUCTIBLE S RETENTION g S WORKERS COMPENSATION - AND EMPLOYERS' LIABILITY YIN X TDRY LIMITS I ER _ B ANY PROPRIETOR/PARTNER/EXECUTIV4---j TWC3234857 03/05/10 03/05/11 EL EACH ACCIDENT I $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYE S 100 , 000 Hyes, describe under SPECIAL PROVISIONS below E.L DISEASE - POLICY LIMIT I S 500 000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHO REP" E I ACORD 25 (2009101) ©1988 -200 CORPORATOR All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): . :81 Lo i - ?7M &r� 60 iii AP%j Address: - 7L'b 5- L ' City /State /Zip: S J � 0-t-Q Gr 6I , 0 Phone #: 54�0 (v 3`77 Are you an employer? Check the appropriate box: I am a general contractor and I Type of project (required): 4. 1. [9 I am a employer with [ ❑ g employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have g. ❑ Demolition working or me in capacity. employees and have workers' g any p �'• � 9. ®Building addition [No workers' comp. insurance comp. insurance.+ 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ 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 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: CIV2eg -c-lw� Policy # or Self -ins. Lic. #: TwC. 5z�J ��`� � Expiration Date: 3 Job Site Address: City /State /Zip: PAA 010 6J- 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificat I do hereby certify under the pains a d penalties of perjury that the information provided above is true and correct. s C Si nature: { vw. Date: / it Phone #: 41$ $61 42-6i Official use only. Do not write in this area, to be 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 #: