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38B-026
JUN. 20.2011 1:16PM ASSOCIATED INSURANCE Na 1501 P. 1/2 CERTIFICATE' OF LIABILITY INSURANCE DATE ( 0D201 i Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT$ UPON THE CERTIFICATE HOLDER. I T� ' H L. IS CERTIFICATE Does NOT AFFIRMATI eLe OR NEGATIVELY AMEND, EXTEND OE ALTER THE COVEF.Ava An ex :EE ew.ICIeT OZLOW. THIS y ZRTIFICI`.TE Or' IN$VRANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IN$i,YRER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(iea) most he endorsed. If SUBROGATION IS WAIVED, subject to the terms and onnditiona of the policy, certain policies may require an endorsement. A statement on this certificate does not confer ri -hte to the certificate holder in lieu of such andarsement(s). PRCCDmak COMMWT Enchartor Insurance LLC ems, . 9eCPa I MX 25 University Drive WO. m. Erk): ,�. mic. Ec): Amherst, MA 01002 ....tic IIINDECIE MADMEN Lop. TNBUM (II APTCNmmu mvmaaE NALL I INTUpaD DIPDasa a: A.I.M. Mutual Insurance Co Ross K Hartman . MUM E; dba Hartman Construction MUM ei _ 732 Daniel Shay Highway UMW= b Belchertown, MA 01007 TR'°11:1" OMEN T1 _ COVERAGES CERTIBICATE NUMBER: BEVISIUN NUMBER: THIS IS TO CERTIFY THAT THE POLICTEE OF INSURANCE LISTED BELOW BEEN ISSUED TO THE INSURED NAMED .AVE o FOR THE POLICY PERIOD INDICATED. NQTWITHETANDING ANY REflSRREMENT, TERN[ OR CONDITION OF ANY CONTRACT OR OTHER DOCMAINT NITN RESPECT TC WHICH THIS CERTIFICATE MAY HE IHEDED OR MAY PERTAIN, THE INSURANCE AFFORDED WY THE POLFCIEH DESCRIBED HEREIN I' SUBJECT NE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLLCIEB. LIMITS SHOWN HAY SAYE BEEN REDUCED BY PAID CLAIMS. POLICY NURSER POLICY EFT POLICY EXP LIMITS 1 .s. TYPE Of INSURANCE F ,,oO/rnn momv rnl GENERAL LIABILITY EACH OCWiava P El L0PME0.CEAL G[NERAL LIABILITY asiawE To HINTED 0 Q ❑culRa NADE noccua , IIWaia 0.71111 I ._— MED MC/ (Any a,. P.r...) 0 — PEWCWL c Nov 32I701L1 S 0 • AaaEEiDTE $ CNN' L APPREGATa Ludt APPLIED ER, O P:LTCY 0PRO]ECT OLOC PRODUCT/ - CORM Soo 0 a AOTCHOBILE LIABILITY CONK= HSNPLE 1,1111T lie w=Ld..t) a 0 ANY AUTO NODE= nf,7HAY ()1F pimp) 0 ALL OWNED AUTOS ---H 0 80 EOULED AUTOS IQ ZIT YN.nm& {pm oeid.ae) 0 EiSINAI AUmoa F sco =UM Wow aio. I -- NON -aNNEb AUTOS I El a D OHBRELLA LIAR 0 OCCUR Lf8 CCODWmKi 0 f EETEST LDPA ❑ CLAIM HAKE PimtfORTL T 0 DEDUCTIBLE 0 ❑RRTTNTION 8 0 WOR COMPENSATION 1 INV. 4a- . 1211$ mini AND EMPLOYEES LIABILITY THE PROPRIETOR /PARTNERS/ E.L. EACH ACCIDENT 0 100,000 A EYECDTIVE OFFICERS ARE ❑ incl ® exCl 7024500012011 05/21/2011 05/21/2012 E.L. Dim= - gasser LIMIT a 500,000 E.L. mica - EA EIRIAYEE 6 100,000 comma j ozzournou of CIENATICND CS LOCATIms: ROSS K HARTMAN IS NOT COVERED BY THE WORKERS'COMPBNSATIONN POLICY. CERTIFICATE HOLDER CANCELE+ATION TOWN OR' NORTHAMPTON SHOULD ANY OP THE AN0VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EUSLDING DEPT EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE KITH THE G=TY HAIL POLICY PROVISIONS, 210 MAIN STREET NORTHHAMPTCN, MA 01060 Am.= niv urmziTxn _ //////�� Yµ . Versionl.7 Commercial Building Permit May 15, 2000 • SECTION 10- STRUCTURAL PEER REVIEW (780:CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No Offil SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED.'' WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 'D5wd(Vc) .. dh.R le - L . _.._. as Owner of the subject property hereby author act on m half, in all matters lative to work authorized by this building permit application LR Signature of Owner Date ,J a ... 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 und_e_ r the pains and,penalties of perjury ,.._e._. __. . Print Name Airli ..> , Pe if Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ „ „ „„.,,,,_ „,.. , __ _ Name of License Holder R c "_..If}i'Ir, c ,. (Q� �� ., , License Number Address f Expiratio Date // /t e0 ..K �a Sign Vre Telephone SECTION 13 - 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 . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business/ Organization /Individual): — x,= 1•61r< Address: > 1 i ; � Ay. City /State /Zip: � � Phone #: (y, p) en Are you an employer? Check the appropriate box: Type of project (required): 1.J 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. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [ Remodeling ship and have no employees These sub - contractors have 8. , ll Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /)S /1 Policy # or Self -ins. Lic. #: C 7a ?..966e 6e Q f 90/I 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 hereby certify der the ' aini�d p: allies of perjury that the information provided above is true and correct. Sienature: / Date: L Phone #: (q/3 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 #: Version1.7 Commercial Building Permit May 15, 200U SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9 P P e 9.3 General Contractor _...._ Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING 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 Q IF YES; date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page, and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 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 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 NO 0 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 15, 2000 ' SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE s Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accesso Bu'Iding } Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ O er Brief Description E ter a brief description here. Of Proposed Work:: `�� g 3 SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 CI A-2 ❑ A -3 ❑ 1A I ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B . I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I -1 ❑ 1 -2 ❑ I -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: _..__ Proposed Use Group: Existing Hazard Index 780 CMR 34) _. ,,,,, „ Proposed Hazard Index 780 CMR 34) _,.. SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1 s� _ _.. 1 s 2nd _...... .. ... _.. __...__ 2nd .,... ..._ _. .. _ ., 3rd 3rd 4th _......_ _,, 4 m Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 FloodZone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone ,_ ,, _,,, _ „ Outside Flood ZoneD Municipal ❑ On site disposal system E] g Permit May 15, 2000 Versionl.7 Commercial Buildin a ° : Department use on , City of Northampton S ta of Perm ' ��G� B Department ttnrb Cut/D v P f F 212 Main Street Sewe fSepttcAvatla rtt V 0 \ Room 100 Water/I elt R�arfabth hampton, MA 01060 T wo Sets of Structu?2 Plans • 7 -87 -1240 Fax 413 - 587 -1272 PIoUS,t Pla • • .W-.' Other Specify _ ' ATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office (17 SO tWit We T Map Lot Unit �/t�'�har 0 � M 0/06C) _ Zone Overlay District v, m _ Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) y fry-- c� Y1CiL r�Fsg Current Mailmg Address ( i co 6 Signature e. h a V Telephone 2.2 Authorized Agent - 1 4 .9.3. j<- -1444-tinc.y\ - ------:— Name (Print) Current Mailing Address /U ?/t 7 Signature 4.2 • 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 Lj 2. Electrical ( b) Est Total C ost of mated Construction from (6) ._.... _ ,._.v 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection _ 6. Total = 1 + 2 + 3 +4 +5) Check Numbe This Section, For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date — tea d , I ►` (-- gg --/i , '' i ' M 1 M ' — 1 t F '7:I ''*. — '''' ' .." ' ' W ii ; 1514.3;i'14441.1'r4;4412'47'7': 1 :7 ' .: . : ;;;;;:ij...7" , . ItatiogaInVlotxtv't. 4 .0_ I ,,.. ,,...„,..,.,,,„.„....„...„,..: : ,..,.. ,,,,, „. ......,„, .,,,,, .......„,-..,.....,,,,..... .,7,,,,,-.„,„, ,, fib `` A 6M' - fi �y d -. . LL.��r� �zu`,,, _ r k�ac:, .. ` � ' ..P S ,. ; m a'. �,G a '.z .+..s Fi : 1 ., a J1 P Y � � �z� � : � ta r 3 � a� � „ �., �� ' s i I Ti AFhf gay . w y . gi �- ' a` r '•, =% 1 'a° fi 3 E` .. sue r,} { • 7 I .....--„------/r .1(,, fit t- ' a----- " - , . g r i ' l © ' 4`16 C .(4 e 9- b ( fAC 3 ,t26 0( . I ft ft bes 6 (� •\CeeV 1 i' c� File # BP- 2011 -1080 , APPLICANT /CONTACT PERSON ROSS K HARTMAN ADDRESS/PHONE 732 DANIEL SHAY HIGHWAY BELCHERTOWN (413) 626 -8120 PROPERTY LOCATION 117 SOUTH ST - UNIT D MAP 38B PARCEL 026 000 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out / ,--� Fee Paid M. qt 6-#'‘) Typeof Construction: NEW FOOTINGS FOR PORCH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 72902 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 D • . • 'o• ie ./: Z 1 .41 1111# - 11 .& 11 14 1111..-- (-) 3 - ff. . Signa'Tuilding i f '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. 117 SOUTH ST - UNIT D BP-2011-1080 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 026 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -1080 Project # JS- 2011- 001742 Est. Cost: $7000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROSS K HARTMAN 72902 Lot Size(sq. ft.): Owner: RICHARDSON DEIRDRE M & ANN HENNESSEY Zoning: Applicant: ROSS K HARTMAN AT: 117 SOUTH ST - UNIT D Applicant Address: Phone: Insurance: 732 DANIEL SHAY HIGHWAY (413) 626 -8120 WC BELCHERTOWNMA01007 ISSUED ON:6/23/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW FOOTINGS FOR PORCH 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 6/23/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner