Loading...
36-343 (3) I \\`� w - a <- 3acrus. , l�� DEP FT1v_` VT GF BUILDING izSP.ECTIONS E • z INSPECT-OP 212 Main Str.et • Municipal Builciinv Northampton, MA 01060 • TTIIME 411W 1G'YEM TIl1N A . CI,'NQW7.EDCFAAENT .fivi U f f 1 ILA.\ /La.( 1-1-r J. t ll -A. iv: a.. A.... • .,. The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sups. iLor. 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 any 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 regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before bacltiilI). sonotube holes (before pour). a rough building inspection (before work is _ concea led) in-sulatio -n. inspection (if required) and_afna1 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 -th-e -work can be inspect -ed._ 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 permits 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 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. Date Address of work location l>° , The Commonwealth of Massachusezrs _ Department of Industrial Accidents F ;' Office oflnvestigazior_s s= 600 Washington Street ^ _ C Boston, !LL 1 0?111 ~ www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: City /State/Zip: Phone. -: Are you an employer? Check the appropriate box: Type of project (required): 1. I am a emplo er with 4 . ❑ I am a general contractor and I y 6. ❑ New construction employees (full and/or part-time).* have lured the sub- contractors am fisted on the attached sheet. I 7. Q Remodeling _ ,_ 1 r am a sore proprietor or partner- i ? These sub - contractors have ❑ D r shin and have no e loy ees 8_ emoli ion I working y employees and have workers' I 9. ❑ Building. addition I for me in any capacity. o 1 [loo. workers' comp. i smance. com41 msu ance.* require? 5_ ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [No worker' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance requited_] -- ---'' cny applicant mat coecta pox fa tnust auo nit out me senaon oe:ow snowing their woricers' compensation poiiey mfornmon_ 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 mustar'iched an additional sheet showing the name of the sub- eanaactors and state whetter or not those entities have empiovees- If the sub-contractors .have employers, they must provide their workers' comp. policy nwnbe:. I am an employer that is providing workers' compensation insurance 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 /State/Zip: ' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to sec-..1.7e coverage as required tinder Section 25A of MGL c. 152 can Lead to the imposition of criminal penalties of a fine up to $1500.00 and/or one -year i as well as civil penalties in the for of a STOP WORK ORDER and a line 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 Investi= ations of the DLk for incurance coverage verification. I do hereby cer,?fy under the pains and penalties of perjury than the information provided above is true and correct __ snaMire _.- ,,,r -- 0. ',/ T# A.._ ' _J Date: _ Phone #: '1 O use nnip_ /'o not - x =rare to this arcs, tD be camplered by city or town o iciaL City or Tow - - - P-- ermit/License n 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 -: 1 - SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : / � C _" 70*w-we 0 0 ct- License Number 3 s A -c-f;riat../4 1 C Address 7/144 Expiration Date Signature lephone 9. Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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. - Horne 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. •erson who constructs more than one home in a two -vear .eriod 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition 21 Replacement Windows Alteration(s) ❑ Roofing n Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [❑] Other [❑] Brief Description of Proposed Work: pjf_s4 4„.A /3 p [�� /G- a-¢,= c Alteration of existing bedroom Yes No Adding new bedroom Yes N 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 X Two Family Other b. Number of rooms in each family unit: Number of Bathrooms O c. Is there a garage attached? ` C-4^ � v ,.p,.� -5 ) �G d. Proposed Square footage of new construction. � - / !ir Dimensions e. Number of stories? f. Method of heating? .,,+t.� Fireplaces or Woodstoves . )2-1" Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction .,/.r i. Is construction within 100 ft. of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes X No d , j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? x- Yes No . I. Septic Tank X City Sewer Private well City water Supply x SECTION 7a -- OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 7L--.4-4 - 70--v--a= , 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. 7,4 ,17F-'"" Signature of Owner Date , 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 under the pains and penalties of perjury. ?H� p Toavii Print Name -6,..-4,,..ve__ Signature of caner /Agent 7 Date Section 4. ZONING A[[ 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 Side L: R: ._ L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved narking) 1 # of Parking Spaces Fill: (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 # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 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 NO el/ 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, excavation, 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 Managerrient Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit nr �(0 212 Main Street Sewer /Septic Availability Of i w Room 100 Water/Well Availability N MA 01060 Two Sets of Structural Plans phone 413 -687 =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 9 C —1.11A/ Map Lot Unit Zone Overlay District `1") 0 Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: w — Name rint) Current Mailing dress: �� '7'rf e cr n o R A 7'W'0/C Telephone ,/ Signature (. 3 2 � 7- Gfafe 2 zi 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - 'ESTIMATED - CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building _3-- (a) Building Permit Fee 2. Electrical ,2 (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection °? D f3 6. Total = (1 + 2 + 3 + 4 + 5) t -s- C) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspec ofB uildings - Date File # BP- 2008 -0558 APPLICANT /CONTACT PERSON THEODORE D TOWNE ADDRESS /PHONE 21 LOUDVILLE RD EASTHAMPTON (413) 527 -9060 ,.. THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid I �eof Construction:CONSSJ LCT SFH WiATT GARAGE Sm. , s. CO detector locations must be approved at rough/framing ins section r New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 000724 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO . IATION 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 Signat 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. . 4 ACORD CERTIFICATE OF LIABILITY INSURANCE CSR SF DATE(MM /DD/YYYY) • BERGD50 04/12/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION IRM Insurance Agency, Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Barry M. Stephens , CPCU HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 75 North Main St. -P 0 Box' 564 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Longmeadow MA 01028- I Phone: 413- 759 -0010 Fax: 413- 759 -0017 INSURERS AFFORDING COVERAGE NAIL # INSURED INSURER A: Travelers Insurance Company INSURER B: AIG N. R. Bergeron Drywall / INSURER C: 1106A East Mountain Road INSURER D: Westfield MA 01085 . 1 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. INSK AMYL POLTCYEFFECTIVE7POCICY EXPIRAflON LTR'INSRO TYPE OF INSURANCE POLICY NUMBER DATE (MM /DD/YY) I DATE (MMIDDIYY) 1 LIMITS GENERAL LIABILITY ' ! • 1 EACH OCCURRENCE $ 1000000 ',DAMAGE I U REN I EU A ! !, X COMMERCIAL GENERAL LIABILITY 16802259L131TIA07 04/01/07 04/01/08 PREMISES (Ea occurence) $ 100000 j ! CLAIMS MADE X OCCUR ' MED EXP (Any one person) $ 500 Q i 1 li PERSONAL BADVINJURY ! $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: ', PRODUCTS - COMP /OP AGG $ 2000000 IX I POLICY I 78: LOC 1 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 $ 1000000 A I ANY AUTO BA2261L519TIA07 04/01/07 1 1 04/01/08 (Ea accident) ! ALL OWNED AUTOS BODILY INJURY $ 1 X SCHEDULED AUTOS • (Per person) , ! X I HIRED AUTOS BODILY INJURY $ 1 X I NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ 1 ANY AUTO EA ACC , OTHER THAN AUTO ONLY AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A X I OCCUR I , CLAIMS MADE ISFCUP5531Y105TIA07 04/01/07 04/01/08 AGGREGATE ! $ 1000000 I DEDUCTIBLE $ jX RETENTION $ 10000 I I $ 1 1 � X 1 WC S CATU- ,01H-, WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TORY LIMITS ER , 71 ;dC1 767591 04/0 07 04/0 ,J.08 E.L. EACYACCIDENT 5100000 ' AN'Y PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE! $ 100000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Wallboard Installation CERTIFICATE HOLDER CANCELLATION THEODOT 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 Theodore D . Towne Inc. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 26 Church Street Easthampton MA 01027 -1558 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE IRM Insurance Agency Inc. ACORD 25 (2001/08) © ACORD CORPORATION 1988 COR CERTIFICATE OF LIABILITY INSURANCE 05/09/2 PRODUCER (413) 527 -5520 FAX (413) 527 -5970 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Finck & Perras Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6 Campus Lane HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Easthampton, MA 01027 Rebecca Kubosiak INSURERS AFFORDING COVERAGE NAIC # INSURED Wa I unas Plumbing & Heating, Inc. ---'- INSURER A: National Grange Mutual Ins. Co 14788 P.O. Box 148 INSURER B: Southampton, MA 01073 INSURER C: INSURER 0: 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 TI - IIS 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. INSK ,+IUD L TYPE OF INSURANCE POLICY NUMBER NULILY ErrECI IVE • • ' RATION- LIMITS LTR NSRD DATE (MM /DDIYY) DATE (MM /DD /YY) GENERAL LIABILITY MPK470b7 - 08 /0 / /LUU $ • 0 / /1U07 EACH OCCURRENCE $ 500 000 yy COMMERCIAL GENERAL LIABILITY - IIANTAGL.. 1 u RENTED $ rn( uVv n JiJJ it PREMISES (Ea occurence) � CLAIMS MADE FX1 OCCUR MED LXP (Any one person) $ 1,000 A PERSONAL & AD)/ INJURY $ 500,000 GENERAL AGGREGAi E $ 1,0007000 77511 AGGREGATE LIMIT APPLIES PER: PRUDUC AGr; $ 1,000,000 POLICY PRO- LOC JECT AU OMOBILE COMBINED SINGLE= LIMIT $ ANY AUTO (En accident) - ALL OWNED AUTOS BODILY INJURY ' SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accidon1) PROPERTY DAMAGE $ (Per accident) GARAG& LIABILITY AU i U UNLY - LA ALLIuLN I 4, - i ANY AUTO CA ACS, OTiiGR THAN ONLY: 1,0U tJCI. oSJUMBKELLH LIAUILI II thl,H U�GURIi LIVLE W OCCUR CLAIMS MADE o0L1 TEGATE 'S 5 DEDUCTIBLE d RETENTION $ `Z - wuK httt UV nun AND 0 . 0 ' 2-00 9 7LZ - L} Q - 0 0 • OIT RTATt l- OTH- EMPLOYERS' LIABILITY TORY LIMITS ER A ANY PROPRIETOR /PARTNER /EXECUTIVE Ct' � 3 100 000 OFFICER/MEMBER EXCLUDED? - 111.L. Dt3tA3E - CA EM1'LOt tC $ 1007000 If yes, describe under SPECIAL PROVISIONS below ' DI3fA°10 ROtt' - t1MfF 3 500-T000 OTI {FR nom' RIPTION CIF DPFRATIONS / I CITATIONS / VFHICI FS / FXCI IISIONS AnnFn RY FNIlORRRt 1FNT l SPFCIAI PRfrV1°,IONS CERTI • • • - • • A-T14N se:LZU G- oBSCFUGLCI- RpuCILS -uc ' . - EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Towne Bui 1 ders BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 23 Loudvi 11 a Road OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Easthampton, MA 01027 AUTHORIZED REPRESENTATIVE i2 �, 6 1\ Rebecca Kubosiak /BECKY 1WO'"`�1 -,460R-9-26-(24:101108) ©AGGRD- -GE3RP - R^MIGN ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID CR DATE(MM /DDIYYYY) DANIE50 07/31/07 NZODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Reynolds, Barnes & Hebb, Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 166 East Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 4889 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Pittsfield MA 01202 Phone:413- 447 -7376 Fax:413- 443 -7608 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Central Insurance Company 20230 INSURER B: Safety Indemnity Insurance Co 33618 Dan Whiteley, Inc . Whiteley Electric INSURER C: � - 52 Cotta a Street INSURER D: Easthampton MA 01027 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. 1NSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRE TYPE OF INSURANCE POLICY NUMBER DATE (MM /DD/YY) DATE (MM /DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY CLP7938625 07/01/07 07/01/08 PREMISES (Ea occurence) $ 100000 CLAIMS MADE [X OCCUR MED EXP (Any one person) $ 5000 PERSONAL&ADV $ 1000000 GENERAL AGGREGATE $ 2000000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 2000000 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO 3945474 07/01/07 07/01/08 (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ 250000 X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) $ 500000 PROPERTY DAMAGE $ 10 0 0 0 0 (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A X OCCUR CLAIMS MADE CXS8376975 07/01/07 07/01/08 AGGREGATE $ 1000000 DEDUCTIBLE $ X RETENTION $ 0 $ WC STATU- OTH- WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS' LIABILITY A WC7938626 07/01/0 07/01/08 E.L. EACH ACCIDENT $ 1000000 ANY PROPRIETOR /PARTNER /EXECUTIVE /� 0 I� v« fl. ICEMEMDER EXCLUDED^ C.L. DISE�+ E-EAEIVIFLOYEE $ 130000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 1000000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Electrical Wiring CERTIFICATE HOLDER CANCELLATION TOWNS -1 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 Towne Builders 23 Loudville Road REPRESENTATIVES. Easthampton MA 01027 A RIZEDREPRESEN *VE c_. ��` ACORD 25 (2001 /08) © ACORD CORPORATION 1988 � 4 J Iditional Coverages and Factors 07/10/2007 ne of Business Coverages for General Liability average Limits Ded /Ded Type Rate Premium Factor meral Aggregate 2,000,000 'oducts /Completed Ops 2,000,000 igregate !rsonal & Advertising 1,000,000 ijury tch Occurrence 1,000,000 re Damage 500,000 2dical Expense 10,000 .ine of Business Coverages for Workers Compensation :.overage Limits Ded /Ded Type Rate Premium Factor rA DIA 144.00 0.04190 RIA 12.00 0.03000 xpense constant 284.00 djst. to reconcile -exp - 180.00 0.95000 Dd. premium & Employer's liability 100,000/500,000 / 100,000 a-- Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for . the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self- insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street • Boston, MA 02111 Tel. # 617- 727 -4900 ext 406 or 1-877-MASSAFE Revised 11 -22 -06 Fax # 617 - 727 -7749 www.mass.gov /dia "; The Commonwealth of Massachusetts Department of Industrial Accidents , 1 • _ ill_ 'l Office of Investigations _ ec�� 600 Washington Street •4 =1:: = : iF Boston, MA 02111 m b4 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information � ,� Please Print Legibly • Name (Business / Organization /Individual): r w,� 7,4 i�' �r�` Address: ,, 3 ,,t--,—,z4 ( -,c) , ,, , -- )-Y- --- City /State /Zip: ('? 1 CJ a 7 Phone. #: 5 -7-- 90 C C7 0 y G -- C 9 L Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. rni I am a general contractor and I 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 8. ❑ Demolition working ca employees and have workers' g for me in any capacity. tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance. Electrical repairs or additio /,- 10. required.] 5. ❑ We are a corporation and its 10.0 re P, 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing r irs or additions right of exemption per MGL r myself. [No workers' comp. P P 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no / employees. [No workers' 13.0 Other comp. insurance required.] *My 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 subcontractors 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: C-,-,, JL / C 4/ Policy # or Self -ins. Lic. #: G, 5 S ei U C3 `7 5 4 4 o �a 7 Expiration Date: 7/7)(r r Job Site Address: 7 � t z z�. -„-, 1 ' �� a� � 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 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 verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct 1 Signature: 7J>/ ",„.._,_c_c__ Date: 7V-- 7 i Phone #: < ( 7'7 - ?o& , _ , -1 ,F4+ 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 #: yORp CERTIFICATE OF LIABILITY INSURANCE 09 /20 /2007 r: .JDUCER (413) 586 -0111 FAX (413) 586 -6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Webber & Grinnel 1 Ins. Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8 North King Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR g ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northampton, MA 01060 INSURERS AFFORDING COVERAGE NAIC # INSURED Theodore Towne, Jr. INSURER A: NGM Insurance Company 14788 21 Loudvil l e Road INSURER B: WCAR Conti nental /NIA Easthampton, MA 01027 INSURER C: INSURER D: 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. INSR DD' POLICY EFFECTi`JE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE POLICY NUMBER DATEIMINULYT l DATE (MLLDD /YY1 GENERAL LIABILITY MPI51046 06/29/2007 06/29/2008 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 500,000 _P_LiL"ML.`: (F�oo curonco)_ 3, CLAIMS MADE n OCCUR MED EXP (Any one person) $ 10,000 1 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 4 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 333 i POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON -OWNED AUTOS ((Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 1 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND 6S59UB7582A60207 07/07/200 07/07/2008 WC Y l h " ITS OTI EMPLOYERS LIABILITY B ANY PROPRIETOR /PARTNER /EXECUTIVE El y EACH ACCIDENT $ 100 , 000 OFFICER /MEMBER EXCLUDED? DISEASE - EA EMPLOYEE $ 100 , 000 If yes, describe under SPECIAL PROVISIONS below DICEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS i VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCEL!. AT1ON SHOULD ;JP( 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, Theodore & Evel yn Towne BUT FAILJRE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 23 Loudvil le Road OF ANY 'CND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Easthampton, MA 01027 AUTHORIZEDREFRESENTATIVE :.,«cc��t - -- , Jenna ?odrigue CISR /CINDY ACORD 25 (2001/08) ©ACORD CORPORATION 1988 A1ORD CERTIFICATE OF LIABILITY INSURANCE DATE /10 /2 0 PSOCUCER (413) 527 -5520 FAX (413) 527 -5970 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Finck & Perras Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6 Campus Lane HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR p ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Easthampton, MA 01027 Rebecca Kubosiak INSURERS AFFORDING COVERAGE NAIC # INSURED Shea Tree Service, Inc. ✓ / INSURER A: Western World P.O. Box 367 INSURER B: Easthampton, MA 01027 INSURER C: INSURER D: 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. INSR AUU' TYPE OF INSURANCE POLICY NUMBER PULILrtrrEl.IIVt FOLK.T 1,XHI A IION LIMITS LTR NSRL DATE (MM /DD /YY) DATE (MM /DD /YY) GENERAL LIABILITY NPP979850 09 /2b /1UUb 09 /lb /ZODT EACHOCCURRENCE $ S00,000 X COMMERCIAL GENERAL LIABILITY uAIWAGE i U rctN i to $ 50,000 I PREMISES (Ea occurence) CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 5") r 000 GENERAL AGGREGA(E $ 1,000,000 GEN'L AGGREGATE LIMI f APPLIES PER: – 'ffoDU 5 - MP/ A , 1 1 1 , 1 1 1 POLICY PRO- LOC JECT AU 7 OMOBILE LIA ILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) liARAUE LIABILII Y AU I U UNLY - EA ALUDEN I 5 1 ANY AUTO OTHER THAN EA ALL. 5 AUTO ONLY: Abl, $ tAL SS/UMISKtLLA LIAbILI I Y EALYr ULLUKKLIVUt VS OCCUR CLAIMS MADE AuurctoAl --$ – $ DEDUCTIBLE RETENTION $ — 3 –$ ' EMPLOYERS' LIABILITY VVU IS wNI tN kuvN MNU WC STAT E _ TORY LIMITS ER ANY PROPRIETOR /PARTNER /EXECUTIVE - E■kCt I ACCIDC JT $ OFFICER /MEMBER EXCLUDED? r -.L. D13EASE - En LMPLu r EE $ If yes, describe under SPECIAL PROVISIONS below - D13C'A8C - POLICY LIMIT $ CTHFP ❑FSCRIPTION OF OPFRATIONS 1 I ("CATIONS 1 VFHICI PS / FXCI I ISIONS Af)DFB RY FNnr1RSFNFNT / CPFCIAI PRCIVInJ1]NS Workers Compensation Certificate of Insurance to follow directly from the carrier. CERTIFICATE HOLDER e*N- ELLATi6N Y'19 • EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Theodore Towne BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 23 Loudvi 11 a Road OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Easthampton, MA 01027 AUTHORIZED REPRESENTATIVE NALAAAA-- Rebecca Kubosiak /BECKY • _ • LIABILITY ._ - <.__ ..'. ry E .'. :l =^ x /<'11[ t3AT2 (rJNNlif YYYi A CERTIFICATE ` !v" �A 6'9 i„s S] \RY'L 1 05/14 e .1 '7 A It ;ii'713tTx'E nce LOP-c 0.-i. 9 . F40LUtft. 3 Htv G FtTlF6 ;flit, DOES IMOT'AhA"cND, EXTEND OR 73 Market Place Springfield ALTER THE COVERAGE A1-"FORDED BY 1 �PF POLICIES E ELOW M.4 ti110: :4 Phone.: 413-205-2,S42 1%6;c:413-606-0:L90 INSl9E�LRS AFFORDING COVERAGE N NC # INfiUNL` -p I INSURER ft HA710VY:r Y11131.11 :ICE: CO ?.3I 1_' - I INGUi1 FS: A.Y.H. hAitur.l its sswaa Co. _ _ �t' _ , Mark ::al .s.:, Ley & yore 70f-ticking r lNSth?ER C: of lxxl 2snvoL�sa ln+nuceson C.a 01899 t Mark L VA:..I..FlY - - - -- - -- 207 3�/_ZVE3At oad SUREN0: ! X lorrnG@ (!A 01.0!,2 1 .-. .......- .....- ...- .- .._.._ -_--- INSURER E.�„�... ,..�- ..�.. --... COVERAGES _ __ _ T HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED Niaar.; ABOVE FOR THE tPOL C't` PL',RIOD l'IOICATED. NOTWITHSTANDING �( ANY REQUIREMENT, TERM C)R CONC1TION OF ANY CON T PACT OR OTHER DOCUIvE:N"C WITH RESPECT TO WHICH .I HIS CERTIFICATE M.AY LiE 13SUED OR I IVdXY PERTAIN, THE INSURANCE tir f=OR0 00 BY THE FQLICIE.£, UESCRlI3ED HEREIN IS SUBJECT TO ALL THE: i ERtr"F:3, U;LUSIC AND LGNDITIONS OF SUCH I POLICIES. AGGREGATE LIMIT SHOWN MAY HAVE El N REDUCED BY PAID CLAt 1S, J'L.— ___ -_._ r - "ikyl ?'Ti�7�" t: i' 7' Xp( .Tt�Tlbh�_____----- ---- —. ..-- LTR NSRG PPE OF INSURANCE ' PULIal NUMLIER isA - ; (e (N .L G. SAot1P':1Gff'iI� LIY[T. - - -- ■ GENERAL UABILUTY j 1 ZACHCCCUA'NENi i 1 1000000 - -. . C I$ I COMMERCIAL CENEFAI_'_IAE.:ILf1Y' I ; -GLIU- (1'126:11,9- 2- 1MT 12 /10 /0E 1.2/10/07 _ PF1F•h!;.IE::i(EnP::u!.,, , tt :.300000 . CLAIMS MAD_ ' f GOOD S ,AEG EJ(V (A,!y un. ,.+aon) S 500 L___ __......_- _ .. _.,,......._ _.... PERONAL E ADY ItlitIRY ; $ 1000000 GENERALAfFGREEGAT s 2000000 — - - - ---' I a6;GFtieG4r1 LIMiI'APPI —1 P2-?: ARODU�: TC:. COMP/OP ai t? x:�OOOOOLl 7 — - _._ _._ _ - . ! POLICY � -. !IV; L ..._ != � - _ .. r - «._.� . I AUTOMoalc LIAEILITY �.. - -._ - r _ COMCINEG�Ihk;LE ; 1000000 C I I AMY AUTO AA,- 701.6CQ5Fi.- 06-SI~L 09 /26 /OG 09/26/07 l I r i ALL O'�NNELD AUTGS BCUILY INJLq Y .- .— � X I CCRI.�GULFD ALTOS iPcr moon) HIRED AJTUS — , IYI L u nuaIft R } ROt:.17NNcD A L Fvf; L__..__ .. .- -_- - -' -----_- ', UPERT,' DAMAGE I ' 5 (Per ffcndorY.) GARAGE IJAFI!ll7Y T i l i AUP: ONLY - CA ACGGCN7 'e A;,Y nf!TO l 1 , LA AC'_ _ $ _ '..-. OTHER THAN _ 1 AUTO oNLY; AGG S I EJIGES- VUtAti ELLA LIAIlli_rrf EACH CCCURRENCi: m I OCCUR 1 !'.Li IMA9 MAD, ' AGGft!!JATE r." .. 1 -- j' - -- - ! I R.EIV.1 ON 'WURXE-RS CCROPL-NNAII(!y Ni) A ,TORY LIttl TEf - �,,,I., - __ ElArLDYERS' LIMALITY - -- n , r.v P l r_�pizETCRrnAa rE xr c:,TT� ' MMC7000033012006 05 /0U /O7 U w�'03, , EL. EActlncc.oLNr !s100000 OFFICER/MEMBER EX;LUUED7 , I E. L. DISEASE • E1! EMPLOY•:Q, 5100000 f yet dnxcnbe nndnt :� ',---------- .- . -_.-T I SPECIAL. PRO`JiS1ONS Wow 1, E.L CISLASt. _ P U'LIC1Y Limn' ! s 500000 � JT11ES2 - . ___:..�... -- - 1'!Ct,CRil''7iPN Ore /?PkTLtTiUNS LOCA710:i3 7 \'E:!ItsL4iU 7 t;X4LJ51UHei ACDLU [•Y EN UUH:�NMN E T ! 5Fi5C:lAC PK!1`Fl31`JN9, - -��• . i L,...... .....I . CERTWFICAT HC)LDER ' M CANCEL , _ __ — —�!` ��— •` — — } ^OW '2�7FF3k., S HOULG ANY OF THE' At UV[ DESCRtpED P ULIGIG(3 tic GANL'ELLL'D (StSFORE THE EXPIRATION DATE T11(;RL TI -0L WV)M j INSURER WILL f'NDEAVu11 TO MIAIL 30 OATS WRITTEN NOTICE TO TtfE t'tTIF C7 TC HOLDER NAMED TO Ti LEFT, UUt FAILURE To DO SO SNALL MRCS:: NO abLIGATIUN OA LIARIUTY OR IVA ICIND UoUN THC• INSURER. ITS AGENTS OR Ted TLyame� clb7 Tow - nte Bui.i.eincrr: 23 Lou - .11c Road Nspferst7NTATric.s. r LasthAATipt :!n MA 01027 ' AUT1 ORIZZO EYr:'3.�rrAinit AGORD 25 (2001(00 `' - 6 '1,r,C,0 : 0RPOHATION 1 • I ; ,o o 36 —'393 - • . (Gifu cf E..RchR«tt. DEPARTMENT OF BUILDIRG INSPECT IONS • — 212 Min Street - Rlunieipnl Building 1::SPECTQ2 A'orthn inpLori, Al tics- O1OGO Square Footage Amount Basement @ - $.15 ;;CO 00 ' 3d o, dC) 1st Floor Q $- 2N0O0 I O Do 00 2nd Floor @ $ _30 1/2 Floors. Attic. Garage $_33 c2/- 743• h 0 . Deck, Porches $-15 • TOTA I 3 6, • / 3 6 -3 '13 • 1 0 1 C I ) IC l ify t... �rY A 00' Q' p5 "W 128.95 T4TA�- . 1. p I -. 18 _ ;4.n. 1 , 3 . .. Al', 1 r." At R 1 9. Z �, � TOTAL r.. 010 L=106.01 ;-0.1 d , � � � r L =74 1 Ali ` © 19.20 lc , ! wl L. Q 4•7 / , 2 / ' '� r yy C HD�IV51 . 53'42' T $ r z Pi 40 � h 42.43 � , 2 ; �� rrt { rn 30, 34 S f r • /." S L ° \ �"' O. F r .i. S I° '‘t. q 0 ► 2 z4 !,..0._ O N O c ' n `T-11•1 ris 4, f . 241.21 - �? ;�' o �° CV ! - . \ 0 0 4D, t --1 --3 I HOUSE v r- co BARN 3 -3`I3 r> tor 1 oct "' 125.00 --i 1,258 ACRES.. - S1 0'00'00"E { ',1 O? ___ 0 1 0. G7 n FR 1 Q M "T" c -- VU, . '7' Q N: 2937509.69 1 375.15' -� 49.33' �- E: 33 199.05 1 "- 2 "tP 509'32'32"E 425.49' TOTAL. - 1 1 FLUSH • ASSIGNMENT OF HOUSE NUMBER(S) Street: Cardinal Way Assessors Lot No. Area House No. 1D. 36 -343 -001 2 31,818 S.F. #9 00" 36- 344 -001 3 30,347 S.F. #23 36- 342-001 4 5.029 ACRES #29 36- 345 -001 5 40,448 S.F. #37 36- 341 -001 6 2.613 ACRES #71 36-346 -001 7 34,432 S.F. #93 Date: August 19, 2003 Remarks: Reference is made to Plan of Lots in Northampton, Massachusetts Prepared for the Wzorek Family Investment Trust by Huntley Associates, P.C. dated March 11, 2003. Numbers requested by applicant. Ned Huntley Assistant City Engineer cc: Ann Marie Schauer Registrar of Voters Water Division Tax Collector Sewer Division Massachusetts Electric Streets Division Verizon Telephone Inspectors AT &T Broadband Assessors Bay State Gas Police Department Post Office Fire Department Applicant: Wzorek Family Investment Trust P.O. Box 1039 Easthampton, MA 01027 i�ltR n�t 7R *i Ay/lot e; f � 1 1/fGFP++:�L.' Board of Building Regulations and Standards Construction Supervisor License License: CS 722 Blrthdate: 8/20/1962 Expiration: 8/20/2009 Tr# 2488 - Restriction: 00 THEODORE D TOWNE JR 21 LOUDVILLE RD EASTHAMPTON, MA 01027 Commissioner Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration 132751 Board of Building Regulations and Standards = Expiration: 4/2/2009 Tr# 129433 One Ashburton Place Rm 1301 Type: Individual Boston, Ma.. 02108 THEODORE TOWNE JR. THEODORE TOWNE 21 LOUDVILLE RD. EASTHAMPTON, MA 01027 Administrator Not valid without signature BofoiIIu r ing'ffeguTa o adttada 6 Construction Supervisor License 1 „ + License: CS 724 Birthdate: 9/24/1938 Expiration: 9/24/2009 ' Tr# 3192 Restriction: 00 THEODORE D TOWNE 23 LOUDVILLE RD EASTHAMPTON, MA 01027 Commissioner Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes Insulation Thickness in Inches by Pipe Sizes Non - Circulating Runouts Circulating Mains and Runouts Heated Water Up to 1" Up to 1.25" 1.5" to 2.0" Over 2" Temperature ( °F) 170 -180 0.5 1.0 1.5 2.0 140 -169 0.5 0.5 1.0 1.5 100 -139 0.5 0.5 0.5 1.0 Table 2: Minimum Insulation Thickness for HVAC Pipes Insulation Thickness in Inches by Pipe Sizes Fluid Temp. Piping System Types Range( °F) 2" Runouts 1" and Less 1.25" to 2.0" 2.5" to 4" Heating Systems Low Pressure/Temperature 201 -250 1.0 1.5 1.5 2.0 Low Temperature 120 -200 0.5 1.0 1.0 1.5 Steam Condensate (for feed water) Any 1.0 1.0 1.5 2.0 Cooling Systems Chilled Water, Refrigerant and 40 -55 0.5 0.5 0.75 1.0 Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD: (Building Department Use Only) Project Title: 2000 sq ft ranch Page 4 of 4 Data filename: C: \Program Files \Check \REScheck \Cardinal Way.rck Report date: 12/03/07 Duct Insulation: • Ducts in unconditioned spaces are insulated to R - 5. Ducts outside the building are insulated to R Duct Construction: • All joints, seams, and connections are securely fastened with welds, gaskets, mastics (adhesives), mastic-plus-embedded- fabric, or tapes. Tapes and mastics are rated UL 181A or UL 181B. Exceptions: Continuously welded and locking -type longitudinal joints and seams on ducts operating at less than 2 in. w.g. (500 Pa). • The HVAC system provides a means for balancing air and water systems. Temperature Controls: • Thermostats exist for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and /or cooling input to each zone or f is provided. Service Water Heating: o Water heaters with vertical pipe risers have a heat trap on both the inlet and outlet unless the water heater has an integral heat trap or is part of a circulating system. • Circulating hot water pipes are insulated to the levels in Table 1. Circulating Hot Water Systems: o Circulating hot water pipes are insulated to the levels in Table 1. Swimming Pools: o All heated swimming pools have an on/off heater switch and a cover unless over 20% of the heating energy is from non - depletable sources. Pool pumps have a time clock. Heating and Cooling Piping Insulation: o HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to the levels in Table 2. Project Title: 2000 sq ft ranch Page 3 of 4 Data filename: C: \Program Files \Check \REScheck \Cardinal Way.rck Report date: 12/03/07 0 REScheck Software Version 4.1.1 I nspec tio n Check Date: 12/03/07 Ceilings: ❑ Ceiling 1: Flat Ceiling or Scissor Truss, R-44.0 cavity + R-44.0 continuous insulation Comments: Above - Grade Walls: ❑ WaII 1: Wood Frame, 16" o.c., R -13.0 cavity + R -13.0 continuous insulation Comments: Basement Walls: ❑ Basement Wall 1: Solid Concrete or Masonry, 7.5' ht / 6.0' bg / 6.0' insul, R -7.5 cavity insulation Comments: Windows: ❑ Window 1: Wood Frame:Double Pane with Low -E, U- factor: 0.340 For windows without labeled U- factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Doors: ❑ Door 1: Solid, U- factor: 0.290 Comments: Floors: ❑ Floor 1: All -Wood Joist/Truss:Over Unconditioned Space, R -13.0 cavity insulation Comments: Heating and Cooling Equipment: ❑ Fumace 1: Forced Hot Air. 78 AFUE or higher Make and Model Number: ❑ Air Conditioner 1: Electric Central Air: 13 SEER or higher Make and Model Number: Air Leakage: ❑ Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage are sealed. ❑ Recessed Tights are 1) Type IC rated, or 2) installed inside an appropriate air -tight assembly with a 0.5° clearance from combustible materials. If non -IC rated, fixtures are installed with a 3" clearance from insulation. Vapor Retarder: ❑ Installed on the warm - in - winter side of all non - vented framed ceilings, walls, and floors. Materials Identification: ❑ Materials and equipment are installed in accordance with the manufacturer's installation instructions. ❑ Materials and equipment are identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. ❑ Insulation R- values and glazing U- factors are clearly marked on the building plans or specifications. ❑ Insulation is installed according to manufacturer's instructions, in substantial contact with the surface being insulated, and in a manner that achieves the rated R -value without compressing the insulation. Project Title: 2000 sq ft ranch Page 2 of 4 Data filename: C: \Program Files\Check\REScheck\Cardinal Way.rck Report date: 12/03/07 F . CI REScheck Software Version 4.1.1 Compliance Certificate Project Title: 2000 sq ft ranch Report Date: 12/03/07 Data filename: C: \Program Files \ChecdREScheck \Cardinal Way.rck Energy Code: 20001ECC Location: Amherst, Massachusetts Construction Type: Single Family Glazing Area Percentage: 12% Heating Degree Days: 6404 Construction Site: Owner /Agent: Designer/Contractor: 9 Cardinal Way Theodore Towne Theodore Towne Northampton, MA 01060 23 Loudville Rd 23 Loudville Rd izie Eas thampton, MA 01027 Easthampton, MA 01027 A � 413 - 246 -6841 413 - 246 6841 TETowne@aol.com TETowne@aol.com r Complian,ie: Passes Complia it Than Code Maximum UA: 436 Your UA: 418 Gross Cavity Cont. Glazing UA Assembly Area or R -Value R -Value or Door Perimeter U- Factor Ceiling 1: Flat Ceiling or Scissor Truss 2000 44.0 44.0 24 Wall 1: Wood Frame, 16" o.c. 1600 13.0 13.0 66 Window 1: Wood Frame:Double Pane with Low -E 189 0.340 64 Door 1: Solid 42 0.290 12 Basement Wall 1: Solid Concrete or Masonry 1328 7.5 0.0 124 Wall height: 7.5' Depth below grade: 6.0' Insulation depth: 6.0' Floor 1: All -Wood Joist/Truss:Over Unconditioned Space 2000 13.0 0.0 128 Fumace 1: Forced Hot Air78 AFUE Air Conditioner 1: Electric Central Air13 SEER Compliance Statement: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the 2000 IECC requirements in REScheck Version 4.1.1 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. _ ,j_ _ c /, Na md - Title Signature Date Project Title: 2000 sq ft ranch Page 1 of 4 Data filename: C: \Program Files \Check \REScheck\Cardinal Way.rck Report date: 12/03/07 No g DV/ —i3 FEE +O COMMONWEALTH Of MASSACHUSETTS ' " ' zc13 Board of Health, 4 4i, MA. DISPOSAL SYST EM CONSTRU TFON PERMIT Permission is hereby granted to; Construct( Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at i- 01.411.4.," dz - % c, ,y as described in the application for Disposal System Construction Permit No. , dated f , 1 � /0541, ' • Provided: Construction shall be completed within, three years of the date of this ermit. All local conditions must be met. D Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 67 Board of Health .s.+ C.H•a MART N OF HEALTH ! — n — 7 • / Dec 13 2007 11:33 Cit of Northampton DPW (413) 587-1576 p.2 MUNICIPAL WATER AVAILABILITY APPLICATION Northampton Water Etpartment 237 Prospect & Nortbrumpton, MA 01060 510-1097 A Department of Public Works Trench Punt shall be required prior to way construction or couneetio• n activity associated with this application, Location: 9 Cardinal Way Inquiry Made By: Theodore Towne 413-297-2916 Date &Inquiry: 11/28/07 Number of Type of Single Family X Type of Private X Units: 1 Ullit(8): A ccessogy 4 Ownership: c Multi-family Rental fAiiralksnat to fill ant the 'bowel Municipal Water Main in Existing service to Front of Location? Yes: X No: site? Yes: No X Size of Water Main: 12" Material: DI Age: 2002 Approximate Static Street Flow Test Conducted: Yes: No: X Pressure: 70 If done attach results Size of Service Connection 1" Suggested Meter Size: 3/4” COMMIllailit The Water Daparintssa comsat goargatee adequate-water pressur e. during peak abinand throes at elevations above 320 feet. • A corresponding water entrance fee stud be paid prior to making any connection to the municipal water system. • °faith installation • . • with the Northampton Water Department with a mionman of 5 days notific • All shall • t• • ,, W &trout specifications. e, David W. Sparks, Superintendent of Water Water Entry 200_ Meter 200 Radio 100 cc: Ned Huntley, Director cc: Tony Patillo, Building Inspector tilricatAkaigiWallykkumseieggingline kliAtikinnillaillINK0111111=Satt wintb1 \ act-nil; \Pet nits`Nla I et App l IC 11 cyrAW a ter Availablitty.ckx-- 1 _ � • 12a.98� -TOT AL - • O �Q _ � N1 _ 69.�►� �rt�� 4 `"' C A CV l CM L �'�1 73.00' TOTAL •, \--408.4::.155": „ La180.10 ,N06'S3 42 . '' L =106A1 0 WF�►P1 • ... L =74.09' 19.2 1--- . 129 30 r g / 5(N/e ) Q R =30.00 " z --I 1. =47.12' or �---- /c14 �- 0 CHD =N51•53 42 " ;' / �� / 2 cn 0 at a r . o LOT 3 C j 42.43' , / ' a Fr..* 3D 3 47 SQ. FT..t Coo O o, co Q � ~ � N � 5." � cn lc( O [�O - O U► s f \ tt- 241 Ni • J D • HOUSE BARN .� 3 rte: M LOT 1 125.00' co CO `t S10' 0' E ej 1.258 ACRES th •- J O to RIGH - O I`' wA 1' 49.33 376.16' TOTAL N: 2937509.69 - --- ��•.__m __ _ Sp9'32'32 E 425.49' E: 334199.05 • ,,.. 21/3 c$ 1 Icu Permit No. D07 -08 Conditions: Driveway Permit In lieu of plan approved by City Engineer I agree to the following added conditions: 1. I will contact the Department of Public Works and have an inspector check and approve the graded gravel base prior to paving to insure compliance with slope and location; 2. I further agree that if in the inspections any of the permit conditions are not met that I will at no expense to the City remove and replace the driveway as directed by the City Engineer. B y: (1 Petitioner Theodore Towne 23 Loudville Road Easthampton, MA 01027 Note: The Public Works Department recommends that you provide a plan showing the proposed driveway with grades and location in the future to avoid possible expense which you will incur by not getting approval of actual plans in advance. For commercial and industrial applicants, a plan showing the proposed driveway with grades and location is required. cc: Building Inspector !' Permit No. D07 -08 CITY OF NORTHAMPTON, MA DRIVEWAY PERMIT Date: 12/3/07 FEE: $25.00 CHECK #: 2568 THE BOARD OF PUBLIC WORKS Driveway must be staked and house & lot number posted The undersigned respectfully petitions your honorable body for: Permission to install a driveway at : 9 Cardinal Way Fifteen (15) foot maximum width at the street line. Gutter drainage not to be disturbed. All drainage shall be directed off the driveway surface to adjacent land and not on the existing roadway. Driveway surface to be paved as soon as possible if the grade of the proposed driveway exceeds 3% or more. Homeowners will be held responsible for any cost to the City of Northampton in the event of a washout of this driveway. By: d7 Theodore D. Tow G� e Telephone #: 413- 246 -6841 Proposed Location Inspected By: .--1 ' ` 7 > / /C —� Gravel Base Grade Inspected By: Final Approval THE BOARD OF PUBLIC WORKS voted that petition be granted. Edward Huntley Director of Public Works (SUBJECT TO ATTACHED CONDITION 1 & 2) cc: Building Inspector • Quick Open Space Calculations Coverages house existing 0 Lot area existing proposed deck existing 318181 0 3244 drive existing 0 shed existing 0 Open Space 31818 28574 shed existing 0 total 0 Open % 100% 90% garage new 524 house new 2000 Open Space Requirement drive new 720 ftP_URA 85% total 3244 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : "7 L , cr 0 C., t a. A, + 2, 1 License Number 2 ( ,,,,„0„„_,.,- Q el - 21- e>1 Address Expiration Date r...÷'5 1N'l fat' f^ r-r c ...1 tJ ti o l O. Signature Telephone 9. Registered Nome Improvement Contractor Not Applicable i Company Name Number Address Telephone I Expiration Date 1— SECTION 10- WORKERS' COMPENSATION INSURANCE'AFFIDAVfT (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. Horne; 8vner Exemption The current exemption for "homeo" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an • - . ividual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780. Sixth Edition Sectii , 108.3.5.1. Definition of Homeowner: Person (s) who own a par : of land on which he/ resides or intends reside, on which there is, or is intended to be, a one or two family dwelling, attach - : or detached ctures accessory to suc use and/ or farm structures. A person who constructs more than one home in a i- ar period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a fo •- acc- , able to the Building Official. that he /she shall be responsible for all such work performed under the buila' 4 permit. As acting Construction Supervisor your presence o e job site will be require m time to time, during and upon completion of the work for which this permi • - • sued. Also be advised that with reference to apter 152 (Workers' Compensation) and Chapter 1 Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you be Iiable 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ,Ki Addition ❑ Replacement Windows Alteration(s) f l Roofing n Or Doors [l Accessory Bldg. ❑ Demolition n New Signs [❑] Decks [[] Siding [O] Other [❑] Brief Description of Proposed • Work: hIL'' ilc%PAc. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. If Ne ho an ad to existin housing, complet the foll a. Use of building : One Family r/ Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? yC d. Proposed Square footage of new construction. vOls� Dimensions 1/4.... r 3 w- I r I e. Number of stories? f. Method of heating? Ix l T v lets. I -C C Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. yT / T Masscheck Energy Compliance form attached? 1 h. Type of construction f&)3') re ft- 4 r i s 1 1 i i. Is construction within 100 ft. of wetlands? Yes ✓ No. Is construction within 100 yr. floodplain Yes 1/' No j. Depth of basement or cellar floor below finished grade ) 0 0 k. Will building conform to the Building and Zoning regulations? ,/ Yes No . I. Septic Tank it City Sewer Private well City water Supply SECTION 7a - 'OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I , as Owner of the subject property hereby authorize . to act y behalf, in all matters relative to work authorized by this building permit application. �' _ 1 . Si ature of Owner Date i Z — , 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 under the pains and penalties of perjury. Print Name Signature of Owner /Agent Date ' Section 4. ZONING All information Must Be Completed. Permit Can Be Denied Due TO Incomplete Information f Existing Proposed Required by Zoning / This column to be filled in by Building Department Lot Size Frontage Setbacks Front i __„jci Side L. ...,. r. R:... ......,_,i I L:,, ,.. R . __.... Rear ,.. _ Building Height Bldg. Square Footage % __- _.._... Open Space Footage I % I I (Lot area minus bldg &paved Dazking) �� # of Parking Spaces Fill: (volume &Location) ;. .., ,_ A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q 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 curnrrron plan that will disturb over 1 acre'? YES Q NU V IF YES, then a Northampton Storm Water - anM agemenf Permit from the DPW is required. • ( Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer�SepficAvailability Room 100 Water/Weit Availability Northampton, MA 01060 Two Sets of Structural Plans' phone 413- 587 -1240 Fax 413- 587 -1272 Plot/SitePlans Other Specify 1 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: / T his section to be completed by office cji C �CrjiG , /�t 6A...1 RY Map ` ,6, � , 5 4 o t � Z Unit OC IV(A viA 07'6,0 eo A U i C> b( _- - Zone OKertay District Elm St District CB- Disfiicf -- SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT rn -,-, 2.1 Owner of Record: 1Ai="0 O s.4, �4.G. j! ( i- e- D: c Name Print CurreptMailing Address: - - X � /' / / d' �� �- -+^•� Telephone Signatwr' ,5 )-1 - ( 40 6 0 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only _ completed by permit applicant 1. Building (a) Building Permit Fee c. '7,i 00 m • 2. Electrical (b) Estimated Total Cost of 1,6 Construction from (6) 3. Plumbing Building Permit Fee td, 5.‘ () 4. Mechanical (HVAC) 5. Fire Protection 9, 5 0 (3 r 6. Total = (1 +2 +3+4 + 5) Check Number d3- 6, # /1 3 76 This Section For Official Use Only / / / /// Date Building Permit Number Issued: Signature: Building :Commissione /Inspector of Date � r File # BP- 2008 -0558 APPLICANT /CONTACT PERSON THEODORE D TOWNE ADDRESS/PHONE 21 LOUDVILLE RD EASTHAMPTON (413) 527 -9060 PROPERTY LOCATION 9 CARDINAL WAY MAP 36 PARCEL 343 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 'l )1378-1 Cv° Fee Paid Typeof Construction: CONSTRUCT SFH W /ATT GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 000724 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: __ pproved 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 R/747 Signature of Building 0 ficial 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. F • 9 �° e 0 a, ‘,.- Y2 ----- I A.A/ /Y 04' `7-/ --- - ; 2.y8 y la.folpidle ry.1-7 /IfftVW 2a1,0(07 9 CARLANAL WAY BP- 2008 -0558 GIs #: - COMMONWEAurti OF MASSACHUSETTS Map :Block: 36 - 343 CITY OF NORTHAMPTON Lot: -001 PERSONS CON7'RACTII\'3 WITH UNREGISTERED CONTRACTORS Permit: __ _ Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL "c.142A) CatefIr�-: BUILDING PERMIT Per!;, .r V BP -2008 -0558 Protect it JS -2008- 000849 Est. Cost: 5260000.00 Fee: 81378.60 PERMISSION IS HEREBY GRANTED TO: Const. Class: 5B Contractor: License: Use Group: R4 THEODORE D TOWNE 000724 Lot Sizef cg_ft)_ Owner: THEOI)ORE D 'COWNE zoni o -BSI: Applicant: THEODORE D TOWNE AT: 9 CA.RDINA! WAY Applicant Address: Phone: Insurance: 21 LOUDVILLE RD _(4131 527 -9060 WC EASTHAMi PTONMA01027 ISSUED ON :12/1 7/210 7 0:00:00 TO PERFORM THE FOLLOWING WORK :CONSTRUCT SFH W /ATT GARAGE: Smoke and CO :':t:. ± or locations must be approved at rough /framing inspection P6 ;'; a' YIDS CARD SO IT IS VISIBLE FROM TFIE STREET inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground :: ,: : /4 -eb? 11'1eter: f , ibtiorz5 Footings: ! 11 ,. , ' Rough: , r ; .- House # Foundation: i2. 7 4 - , . - Driveway Final: Fiii.:1: ia c'lr\ Filial: ., A), ( y/' �� b � Rough Frame: G'\ o l ( L G (d l ( t G:is: Fire Department jt Fireplace /Chimney:t Rough: Oil: � — Insulation:0k I —aa -c8 _ -I Final: il: Smoke: , ,A/ / =' -i Final: O/t" ,3- -- / "O F -- .., i ( 4-11 , 1 TFIIS PERMIT MAY BE REVOK ED BY THE, C OF NORTHAMPTON UPON VIOL4'T ON OF , .NY OF iTS RULES AND I EG[7I.A' S. �/ /de' .,...----' , :-." ,,. CertificaLe of Occupancy _ l _ S_igna }are: _ FeeTye: _ _ Date 'aid: Amount: Building 12/17/2007 0:00:00 51378.602569 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Cc :o missioner - Anthony Patillo