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ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYII
03/07/2011
PRODUCER 413. 586. 0111 FAX 413.586.6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Webber & Grinnell 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 Loudville Road INSUUERB: WCAR- Savers Property Casualty
Easthampton, MA 01027 INSURER C
INSURER ID:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 ADD'L POLICY EFFECTIVE POLICYEXPRATWN
LTR NSRC TYPE OF INSURANCE POLICY !EMBER DATE (MMIDDIYYYY) DATE (MMIDDIYYYY) LIMITS
GENERAL UABarrY MPI51046 06/29/2010 06/29/2011 EACH OCCURRENCE $ 1,000,000
X cOMNRAL GENERAL LIABILITY PREMI (E ooc
CI rrence) $ 500, 000
CLAIMS MADE I X OCCUR MED EXP (Any one person) _ $ 10,000
A PERSONAL 8 ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEM. AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
POLICY pi F LOC —
AUTOMOBLEUABLnY
COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY
SChEDRED AUTOS (Per person) $
-
HIRED AUTOS
BODILY INJURY $
NON -OWNED AUTOS (Per accident)
PROPERTY DAMAGE
(Per accident)
GARAGE UABLIY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS I UMBRELLA UABLITY EACH OCCURRENCE $
OCCUR I I CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AR0426606 07/07/2010 07/07/2011 X I ORYLIM s I I ER
AND EMPLOYERS' LIABILITY Y / N
B � O RPARI I CUTIVE I I E.L. EACH ACCIDENT $ 100,000
(Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 100,000
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL. PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUNG POURER WLL ENDEAVOR TO MM. 10 DAYS WRITTEN
NOTICE TO THE CE TIRCATE HOLDER NAMED TO THE LEFT, BUT FALURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY MD UPON THE INSURER. ITS AGENTS OR
REPRESENTATIVES.
Evidence of Insurance AUTHORI2EDREPRESENTATIVE c :* •--
Jenna Rodrigue, CISR /3ER
ACORD 25 (2009101) O 1988 - 2009 ACORD CORPORATION. All rights reserved.
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 : -H C_r>C✓ (! 1 6 / Z G
License Number
r
� � / � , 1 (l f k A � /� / )
`� �� r' �� lc �. � r r�1 �l rIYLJ r V 1 1 g - ze, - ) r /
Address zi Expiration Date
j(,3 Z -‘ ) - 7 -- 2;'51L)
Si ature ephone
9. Registered Home Improvement Contractor: Not Applicable ❑
4 - 3 . (5 Z 7,4-) l
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. - 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 1083.5.1.
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 ❑ Replacement Windows Alteration(s) Roofing
Or Doors CI
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [4 Siding [0] Other [0]
Brief Description of Proposed V 1
Work: 'v �� �c�� �.y (l 5 i� < U� i f t)c , l v
Alteration of existing be &oom 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
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
��
I, I" C , as Owner of the subject
x property
hereby authorize U 1
to act my behalf, in all m rs relative to work authorized by this building permit application.
Signature of Owner Date
I, 41 J - , - r.�h_- , as Owner /Authorized
Agent h eb declare that the statements and informatio o e foregoing application are true and accurate, to the best of my knowledge
Y 9 9 PP Y e 9
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of or er /Agent P Date
N` / L
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 z . 3 3 PIC f
Frontage
Setbacks Front 501
Side L: 5 d1. R: 5 01 L: R: 9p,/14-C,
Rear Z.e) 3 04
Building Height z ��t/ Pb 014.
91 s�
M ! v ) Bldg. Square Footage i o t % (Z zZ , 1 Z
V Open Space Footage
0 (Lot area minus bldg & paved Mat )
parking) b I l 9 f�1.
# 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 ;i1`I YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
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 ,,4
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q ,Date Issued:
C. Do any signs exist on the property? YES Q NO
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 `li%
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 Q NO / 0
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
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 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
Map Lot Unit
t l co -Th ift 3 , J\ (>l> 2_ Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
IDe r'ctJ -\ L uL' 42 c L —j ; . , j3P\,0, P� �.
Nam Print) Current Mailing Address:
H fS ?
Telephone
Signature
2.2 Authorized Agent:
H tz_N :A.> .it r�. C ��:c 5 r-<-1F5 - ` A
Name (Print) / Current Mailing Address:
(- 113
Signa � Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building i �� — (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) ( - 3 2e47 _ Check Number �11. O j , (eU
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP-2011-10600
14a6G
APPLICANT /CONTACT PERSON THEODORE TOWNE JR ` C� �/
ADDRESS/PHONE P 0 BOX 503 EASTHAMPTON (413) 297 -2916 () S
PROPERTY LOCATION 50 LOUDVILLE RD �1 r p ��� fi,P � �� J5
MAP 41 PARCEL 010 001 ZONE RR(100)//WP
f
ILO � • \1P4 \kl
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out p/! o / G. D
Fee Paid (� (� '
Typeof Construction: CONSTRUCT 300 SQ FT SIDE DECK & 2ND FLR 4 X 12 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 722
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED: CL? ),Z.e GJ i4A 6 r Al- PA Sae
1.-'Approved Additional permits required (see below)
/7-7 / i '
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
6/41, 7 (
Signature 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- 2011 -1060
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 41 - 010 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP- 2011 -1060
Project # JS- 2011- 001707
Est. Cost: $13200.00
Fee: $69.60 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: RR(100) //WP Applicant: THEODORE TOWNE JR
AT: 50 LOUDVILLE RD
Applicant Address: Phone: Insurance:
P 0 BOX 503 (413) 297 -2916 () WC
EASTHAMPTONMA01027 ISSUED ON:6/27/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 300 SQ FT SIDE DECK & 2ND FLR
4 X 12 DECK
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 6/27/20110:00:00 $69.60
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner