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41-010 ■ i tt F C 1 `' e 1 1_ _/ x —i — - 4 - i F i l i _ - € i_; i — F - - -- - _ ` O ? t F 1 — L ;___ S, .. 1 . ; ;_ __ : ; — �t_! i I t i — __. — - - - -- ` i ,i_ 1 U } �_ __ - -.—. —� — - F _ ( - I T i -- f�S i_ _ i I —; `F I _ i� i • i -- jam' �� . ' -- � { ' BUILDING DESIGN REMODELING L _F i -- = ; �sf. 3 S � r ;L y R ` 3 :_iii H___ 0 4. ;_________i_____I ': f , . T Th eodore Towne Jr. TowneJr@aol.com . v ^ V �) i # 21 Loudville Road i (413) 527-9645 Home 7 '— -` — _ A 01027 (413) 297 -2916 Cell ; . I 7 , ,- ; � i ( Eastham •• on� M '! -�. I l i A. i - - - - I _ - - ._._ } _ l -- A CCREZ DATE fIDDrewr CERTIFICATE OF LIABILITY INSURANCE 07/12/2011 I THIS CERTIFICATE IS 'Sale) AS A MATTER OF *FORMATION ONLY AND COMERS 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 poily(tes) must be endorsed. If SUBROGATION 18 WANED, subject to the terms and conditions of the policy. certain policies may require an endorsernent. A statement on this certificate does not confer rights to the certificate holder in feu of such endorsement(s). CONTACT PRODUCER Webber & Grinnell Ins. Agency, Inc. m*** 413.586.0111 413.586.0111 [ u F M ° ' ( IC Na: 413.585.6481 8 North King Street EMAIL ADDRESS: Northampton, NA 01060 P E Q e 00005097 CUSTOMER INSURER(S) AFFORDING COVERAGE RAC I INSURED e1SWERA: Main Street Aa)erica /NGN 29939 Theodore Towne, Jr. MINERS: InterGUARD, Ltd. PO Box 1503 INSURER C : Easthampton, MA 01027 NSURERD NSURERE INSURER F COVERAGES CERTIFICATE NUMBER: Master Exp 2012 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 CONDrrION 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 CONDrT1ONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE NSR WVD POUCY NUMBER ¢ POLICY LIMITS GENERAL UABIJ1 Y MPI51046 06/29/2011 06/29/2012 EACH occumsucE $ 1,000,001 DAMAGE X com ERCIAL GENERAL LIABILrrY P SF_S ) $ 500,001 CLAIMS-MADE IX [ OCCUR MED ow (Any one person) $ 10,001 A PERSONA. & ADV eI.WY s 1,000,001 GENERAL AGGREGATE $ 2 ,000 ,001 GEM_ AGGREGATE LIMIT APPLES PER- PRODUCTS - COI$YOP AGG t $ 2,000, I P. POLICY [ 1 n LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY IN.L RY (Per person) S Al ONTFJ) AUTOS BODILY @LANKY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) NON -OWNED AUrOS S S UMBRELLA LIAR _ OCCUR EACH OCOARENCE S EXCESS UAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION THMIC223940/NYR 07/072011 07/07/2012 X [ S L [ 1 AND EMPLOYERS' LIABILITY Y I N ANY PROPRIEIOR/PARINERIEXECUrIVE E.L. EACH ACCIDENT $ 100, U, I B OFFICERMEMBER Excn OEU1 ( / N I A M n yIn NN) EL DISEASE- EA EMPLOYEE $ 100,001 If yes describe /alder DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT $ 500,0I1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Mach ACORD 101, Addidonei Remarks Schedule, Brame space be required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE YVB.L BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR/ REPRESENTATIVE Evi of Insurance ]enna Rodrigue, CISR ]ER O 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD , The Commonwealth of Massachusetts ( Print Form ' i1 : Department of Industrial Accidents 4 _ Office of Investigations % s , 1 Congress Street, Suite 100 T ' _ Boston, MA 02114 -2017 ` 7 .- " www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organizati on/Individual): Theodore Towne Jr Address:P•O. Box 1503 City /State /Zip:Easthampton, MA 01027 Phone #:413 297 -2916 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. 0 I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction 2. 0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' g Y P h $ 9. 0 Building addition [No workers' comp. insurance comp. insurance. required.] 5. 0 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 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 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: 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 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 h eby certi under the pains and pen ies of perjury that the information provided above is true and correct. tgnature: Date3 2 -12 Phone #: 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: f Not Applicable ❑ Name of License Holder : ({ - 9Q Q. C (0(.4-> '.! 1✓ V I -, Cs 2 2 I 63 License Number p. C.? , ,x l %— '1/4sT u. P1 -' et k, P g • Lo - /it Address Expiration Date 4 0 3 X7- 2"1[ b Signat e Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ 4-Lt- l 3275 Company Name Registration Number e0. av (5 /az .� A (- Z - ( 3 Address Expiration Date Telephone 4'3 2 /77-V. ' 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 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacementj indows Alteration(s) J Roofing U Or Doors Accessory Bldg. El Demolition ❑ New Signs [D] Decks [0 Siding [D] Other [j Brief Work: Descrip M u L p o _ , 'r N C E 7 � a L k 7 � e)17: G/ - c G Alteration of existing bedroom Yes No Adding new bedroom Yes X No Attached Narrative ` Renovating unfinished basement Yes A, 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 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 0.4 e U C - >�� , as Owner of the subject pro' rty hereby authorize r h eOI (' To CL T e Jr. to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date C e To v.( /V E ` 'Yj c_ _ _ - , 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 o •r er /Agent Date Section 4. ZONING AU 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 DONT KNOW . 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Re istry of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained , Date Issued: C. Do any signs exist on the property? YES O NO �4) IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO IF YES, describe size, type and location: 911.) E. Will the construction activity disturb (clearing, grading, avation, 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. Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability — o e. Room 100 Water/Weil Availability Northampton, MA 01060 Two Sets of Structural Plans OF BUILDING INSPE r r NO M of ,_' ne:13 -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 5 p L-• o v 17 v l t_ t.m PZ L7 Map Lot Unit NI o F-Tht A ell. e r 'v r M 4 01 0 (nZ Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Se re,e Ni `n 17.) offCal4 l N � j 0 La ti17 v I r. -L.,G 1Z9 , �l ol - r rte •v MP Nam (Pnnnt) Current Mailing Address: Z�� Telephone // � Signature E -7 2 i Zl 3 v 3 a, 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 5 . (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 1 3 6 Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection C.J _ 6. Total = (1 +2+3+4+5) �'�° 1 - � '' Check Number 68 7`' 5.3 This Section For Official Use Only Building Permit Number: Date g Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0780 APPLICANT /CONTACT PERSON THEODORE TOWNE JR ADDRESS /PHONE P 0 BOX 503 EASTHAMPTON (413) 297 -2916 Q PROPERTY LOCATION 50 LOUDVILLE RD MAP 41 PARCEL 010 001 ZONE RR(100) / /WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ,59 3 1 ($116,5- Fee Paid / / Typeof Construction: INSULATE & SHEETROCK 1/2 OF GARAGE New Construction 4 r Non Structural interior renovations Addition to Existing �� Accessory Structure Plans Included: Owner/ Statement or License 722 3 sets of Plans / Plot Plan THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 Demoliti• D y ature 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. 50 LOUDVILLE RD BP- 2012 -0780 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 41 - 010 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Pei „it: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -0780 Project # JS- 2012- 001365 Est. Cost: $8900.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THEODORE TOWNE JR 722 Lot Size(sq. ft.): 102366.00 Owner: LUEKENS DEBORAH Zoning: Applicant: THEODORE TOWNE JR AT: 50 LOUDVILLE RD Applicant Address: Phone: Insurance: P 0 BOX 503 (413) 297 -2916 () WC EASTHAMPTONMAO1027 ISSUED ON:3/12/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE & SHEETROCK 1/2 OF GARAGE - RESTRICTIVE COVENANT REQUIRED 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