31B-003 (3) •
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=i =_ = Office • of Consumer Affa and usiness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 160105
Type: DBA
Expiration: 6/25/2012 Tr# 298839
D & D MASONRY & CHIMNEY
NICHOLAS DOUP ----- ___ - --
12 KATI LANE
PALMER, MA 01069
Update Address and return card. Mark reason for char
(l Address Renewal F Employment Li Lost
DPS -CAI 0 SOM 04104- G101216
6ontwron 1 a&4 a 770;:::adrr.uae!!s License or registration valid for individul use only
Office of Consumer Affairs & Buness Regulation g
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
. Registration. 160105 Type: Office of Consumer Affairs and Business Regulation
Expiration: 6/25/2012 DBA 10 Park Plaza - Suite `ii70
Boston, MA 02116
D CD & CHIMNEY
NICHOLAS DOUP
12 KATI LANE
PALMER, MA 01069 _ _ _ _ _ _ _ _ _ _ _
Undersecretary Not valid without signature
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)m:Rosemary DiNatale FaxID: Date:3 /6/2012 03:33 PM Page: 2 of 2
D &DMASO -01 DIRO
..44CG7RL7- I DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 3/6/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER (413) 733 - 3131 REACT Rosemary DiNatale
FieldEddy Insurance PHONE
, Ex t(: 413 - 3131 123 FAX
96 Shaker Road
+ (Arc, No): 413 - ?33 -3191
P.O. Box 709 ADDRESS: RDinataletfieldeddy.com
East Longmeadow, MA 01028 -0709 INSURER(S) AFFORDING COVERAGE NAIC A
INSURER A : Western World
INSURED Nichols Doup DBA D &D Masonry and Chimney INSURER B:
299 Columba Street INSURERC:
Chicopee, MA 01 020 INSURER D :
INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 TH(S
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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILLTTRR TYPE OF INSURANCE INSR WVD POLICY NUMBER IMMIDDAYIM POLICY
LIMBS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X COMMERCIAL GENERAL LIABILITY NPP8085344 1/4/2012 1/4/2013 DAMAGE TO RENT
PREMISES (Ea occurrence) $ 50,000
CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLES PER PRODUCTS - COMP /OP AGG $ 1,000,000
X POLICY O- LOC $ u
AUTOMOBILE COMBINED SINGLE LIMIT
UTOMOBILE LIABILITY
(Ea accident)
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED - SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS --
HIRED AUTOS
NON- OWNED PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED I REILNTION $ $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILITY Y TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE N E.L. EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH) E L DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIME $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more apace is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Northampton ACCORDANCE WITH THE POLICY PROVISIONS.
Building Inspector
AUTHORIZED REPRESENTATIVE
i O 1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : G eU t e . ° / v 2 / 3 L/
License umber
C l 04_ /( >✓ / Yu Pet kV 1 , Ql
Address Expira ion Date
Signature Telephone
9 Re • Istered Home Improvement Contractor Not Applicable ❑
►�1�J N c.( CLwvtet ` ( f 6 C5l 0 S
Company Name l Registration Number
) 2 IC (it it C vfi/ -- Va5 �I Z
Address Expirati n Date
er Telephone ql E'`t Y `f `l
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
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:, R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES C
IF YES, date issued:
YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T 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 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 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, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES () NO 0
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) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of Pr osed
Work: new c`e. ? ,S r. c. C- C `..,,,v i p ,.-..r,_ rtLA_
Alteration of existing bedroom Yes No Adding new bedroom Yes 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 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 COMPLETED WHEN
WNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, /4c/711, 6 CC e, , as Owner of the subject
property
hereby authorize b "/' _--- c" h
to act on my behalf, in all matters relati - . ,,., k authorized by this building permit application.
, 2,, , i -.. / ..2_ 1
, n
a
S i ture of O Date i 44
I, , 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
D epartmentuse'oniy F
RECEIVED
City of Northampton Status of Permit ° . � ,
Building Department Cur•b:Cut/Driveway Permit
VAR — 7 2012 212 Main Street Sewer /SepticAvailablity '
Room 100 Water/Well Availability
.oF BUILDING INSPECTIONS Northampton, MA 01060 Two Sets of Structural Plan! ' - T
NORTM■'"pTON MA 01 413- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify -, r k
Ce
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
(O .ki- Map Lot Unit
N l ' " 1-t" 140-194u-N- Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
i�'L
" - / /' y� � /cr lc� 7 /' (-01 �5 ''' /�' 5crsr T Ste' + k __/47,"
Name (Print) Current Mailing Address:
x/13 �4S ,5 O
r 7 2-- -' 7 Telephone
1.
,, Signat
,,,,, w 1
2.2 A o rizedd Agent:
j
J fil'1u' _ ' r1J ,,(1 - I f9L "t t\ C ') / Z. lc Pt if L.,vTLC i1
e-icr ' v oi�- >(,`j
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 ('ow ( 9L j & c o (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= (1 +2 +3 +4 +5) Check Number 4,053 t5.5
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
A
File # BP- 2012 -0774
APPLICANT /CONTACT PERSON D & D MASONRY & CHIMNEY
ADDRESS/PHONE 12 KATI LANE PALMER (413) 348 -9839
PROPERTY LOCATION 66 BANCROFT RD
MAP 31B PARCEL 003 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 6655 4
Fee Paid '�✓✓��//
Typeof Construction: CONSTRUCT FIREPLACE,CHIMNEY & FLUE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 102134
3 sets of Plans / Plot Plan
THE FOLL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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
Demob' 'o • lay
/ 7- 1/ 21'' ‘
• is ...1 e . e nil. ing O fi 'al 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.
66 BANCROFT RD BP-2012-0774
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 003 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit # BP- 2012 -0774
Project # JS- 2012 - 001155
Est. Cost: $8000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: D & D MASONRY & CHIMNEY 102134
Lot Size(sq. ft.): 8886.24 Owner: GRANDONICO KATHRYN
Zoning: Applicant: D & D MASONRY & CHIMNEY
AT: 66 BANCROFT RD
Applicant Address: Phone: Insurance:
12 KATI LANE (413) 348 -9839
PALM ERMA01069 ISSUED ON:3/12/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT FIREPLACE,CHIMNEY & FLUE
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 3/12/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner