23B-070 (2) 2010 -09 -20 12:23 NASH HEARTH LEISURE 14136655501 >> 4135871272 P 2/2
NOTICE NOTICE
TO TO
EMPLOYEES E IPLOYE'ES
The Commonwealth of Massachusetts
E DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617 - 727 -4900 — http: / /www.state.ma.usldia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give
g you notice that I (we) have provided for payment to our injured employees under the above
mentioned chapter by insuring with:
:1. INSURANCE COMPANY rIE THE M. DWES?'
NAME OF INSURANCE COMPANY
g ONE PARK PLACE, 300 S. STATE ST., 7TH FLOOR_
. k
ADDRESS OF INSURANCE COMPANY
me 08 WEC LF0053 08/13/10
— POLICY NUMBER EFFECTIVE DATES
Ira WEBBER & GRINNELL INS AGENCY INC 8 NORTH KING ST SUITE 1
NORTHAMPTON MA 01060
NAME OF INSURANCE AGENT ADDRESS PHONE
NASH HEARTH & LEISURE, INC. PO BOX 273
TELY v' 01093
= EMPLOYER ADDRESS
mme
LOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
- The above named insurer is required in cases of personal injuries arising out of and in the course of employment
= to furnish. adequalli and reasonable hospital and medicai services in accordance with the provisions of the
Workers Compenst►n Act. A copy of the First Report of Injury must be given to the injured employee. The
employee may select his or her own physician. The reasonable cost of the services provided by the treating
- physician will be paid by the insurer, if the treatment is necoos+rry 41 n reasorialahy tennectst,'a.t Ie wen % related
- injury. In cases requiring hospital attention, employees are !'.?'.ail; notified that ttw)nsueer Jiask.mtanged.far such
attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Form WC 88 20 01 C Printed in U.S.A.
r , )
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. 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 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 backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final 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 the work can be inspected.
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
jermits 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, ,,: ) �l.'` ,..,, 4 (c understand the above.
om 1P� ure e owner /resident's si at requesti g aem 0L— tion g 9 xemption)
'11 call to schedule all required building insp necessary for the building permit
issued to me.
Date 7
Address of work
location 1 0 - `.`
R t,'Y'4
. -
. The Commonwealth of .111assachuse
_ -7.-• ,-_-7---- Department of Industrial Accidents •
1 .---- ,
' Office of Investigations
SUE= rr 600 Washington Street
.
Boston, MA 01111
- , www.mass.gov/dia .
' •
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiblv
Name (Business/organization/individual):
• • Address: ,- •
City/State/Zip: . Phone.#: -
Are you an employer? Check the appropriate box: • •l'e of project (required): /
1. D I am a employer with 4• 0 I am a general contractor and I
N
6
employees (full and/or part-time).* have hired the sub-contractors . 0 New construction
listed on the attached sheet. 7. 0 Remodeling
2. 0 I am a sole proprietor or parin.er-
These sub-contractors have.
ship and have no e-waoyees S. 0 Demolition
eniployecs and have workers'
working for me in any capacity. 9. 0 Building adclitiOn
(N® wor comp. i nsurance . _ corop..—..innrmice. 1 : .
10.0 Electdcal repairs or additions - . 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers havexercised their • 11.0 Pluming repairs or additions
,- b •
myself [No workers' COMp. right of exemption per MGL
12 0 Roof repairs . -
insurance required.] t • c. 152, § 1(4), and we have no •
3.0
employees. [No workers' 1 Other
comp. insurance requiredj - 0
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information_ — .
t Homeowners who submit this affida indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such_ .
1 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 woricers camp policy number.
1 am an employer that is providing workers' compensation insurance for my einployees. Below as the policy and job site
information. - .
.
• - .
'mu:ranee Company Name:
Policy # or Self-Ms. Lic. #: Expiration Date: - -
. . . .
Job Site Address: • City/State/Zip: - • ' - _
Attach a copy of the workers' compensation policy declaration page (showing the policy number andexpiration date).
, . .
Failure to secure coverage as required Under Sectioii 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 ancVor one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to tlie Office of
ioni of the DIA for insurance coverage VerifiCatiOli
_ /do hergb_ycertifr under the pains-and penalties ofperjury that the information provided :above_isinte_and_correct._______ _.
. _ .. _ .
. . .
Sienattn-e: ' - Datz:
Phone #: i: .
Offickd use otzly. Do not write in this area, to be ciiiipleted by cityor 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 #: . . .
• -
r
SECTION 8 - CONSTRUCTION SERVICES
A 8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
le .; .,ii,, i i g� x AP. Not Applicable ❑ Lt
' gistered..Iiome;lmprovement Gontrctar: �� � < <��_�_ �,.p_, ����� ;. __ ��,,f��, __. _ . , .
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 3 �ame l u r Exe b
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 Zon g Laws and State of Massachusetts General Laws Annotated.
i i IP
o meowner Signature :ALA
e
SECTION 5- DESCRIPTION! OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [M] Decks [E] Siding [0] Other [0]
Brief Description of Proposed �-
Work: f c t r.. S 1"m L 0 1 X L C r ✓Qit1 % 94 `r /t e pL 'fr e
Alteration of existing bedroom Yes ✓ _ No Adding new bedroom Yes '---- No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll - Sheet
sa fifiiiii c icifii c i i tiii*M iti a diets' h fOii"i 616:
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
(e
�
I, 361 P et— -LJ j f — , as Owner of the subject
property 1 � . ,
hauthorize J ' t / ( `-i' ��-'' /�C ` eilN
to a on my behalf, i t ,� 0 matters relative to work authorized by this building permit application.
hereb
Signature of Owner Date
� �� ir� �C
l , LrtrL'.[._,
7 j€o. , as Owner /Authorized
Age t hereby declare h 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.
A e & id,4C--
Print
, Lice / �._ > c t &-- ?/avho
S of Owner / t 7 Date
N
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 _� �y_ _
Frontage 1 1 ' 1 -- - -.. --
Setbacks Front i 1 1
R
Side I.,:' 4 R:__ L:1 ] R:`
Rear = FT - i
Building Height f 1 i I i
Bldg. Square Footage i i i 1% 1 f i , r
Open Space Footage % gg
(Lot area minus bldg &paved 1 1 .! ! , [ 1
parking)
# of Parking Spaces 1 1
Fill:
(volume & Location) i A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
I
IF YES, date issued:; i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 Pa ' and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 ,Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 0
IF YES, describe size, type and location: b i
E. WiII 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1 - .
City of Northampton - a 4114,-.;,,4-f.: q
(-,& Building Department 7
k .
N ; 212 Main Street - ; » `' . _ ems, k5
�'" Room 100
.E� ma y •
G''' Northampton, MA 01060 - �
phone 413- 587 -1240 Fax 413 - 587 -1272
d ; 'ice(,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
This section to be completed by office
1.1 Property Address: //�
/ 6 5 Scr nli A /1� 1u P Map dot Un
rid re i( C e ,tt/4 0 r 4 (o p :'y zone,:- Overlay District
EI n St District CB District
SECTION 2;- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.11 / Owner of Record: — �; / °c1 / / < _
J i et. ( Witty(' I ✓ i0 ` / ,0 k J (Lc 17/ *Xi xi ,C L
Na (P L�� ,¢ rint) T
/ y Cunele t ephone Address:
dress:
/3 5 fY 7 767
yam `�
S ignature
2.2 Authorize 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 6756 -- (a) Building Permit Fee
2. Electrical _ (b) Estimated Total Cost of
a/ CV Construction from (6)
3. Plumbing i1; Building Permit Fee
c7 • 4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) 2 / WO . " Check Number 95
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
ti
108 SOUTH MAIN ST BP- 2011 -0259
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 23B - 070 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP-2011-0259
Project # JS- 2011- 000430
Est. Cost: $2400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NASH HEARTH & LEISURE 99682
Lot Size(sq. ft.): 23696.64 Owner: RYAN SHEILA K & JOHN E DAHL
Zoning: URB(100)/ Applicant: RYAN SHEILA K & JOHN E DAHL
AT: 108 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
108 SOUTH MAIN ST (413) 584 -7769 () WC
FLORENCEMA01062 ISSUED ON:9/21/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL GAS VENT FIREPLACE
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 9/21/2010 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner