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24A-008 (2)
5/NV1 itC5RE) CERTIFICATE OF LIABILITY INSURANCE OP ID SF DATE(MM /DD/YYYY) ROSSS50 07/07/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION IRM Insurance Agency, Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Barry M. Stephens , CPCU HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR , 75 North Main St . -P 0 Box 564 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Longmeadow MA 01028 Phone: 413- 759 -0010 Fax:413- 759 -0017 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Central Insurance companies 20230 INSURER B: Stephen Ross INSURER C: 36 Service Center Road INSURER D: Northampton MA 01060 INSURER E: COVERAGES 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 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 AWL POLICY EFFECTIVE POLICY EXPIRATION LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE (MM /DD/YYYY) DATE (MM /DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY CLP8123544 07/01/10 07/01/11 ' PREMISES (Ea $ 300000 CLAIMS MADE [X I OCCUR MED EXP (Any one person) $ 5000 PERSONAL & ADV INJURY $ 100 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2000000 X POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WCSlAILI- OTH- AND EMPLOYERS' LIABILITY X TORY LIMITS , ER A PROPRI MEMBER OR /PAR NER /E ECUTIVF II if WC812355916 07/01/10 07/01/11 E.L. EACH ACCIDENT $ 100000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 100000 If yes, describe under SPECIAL PROVISIONS below E. L. DISEASE - POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CONS 001 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Construct Associates 36 Service Center Road REPRESENTATIVES. Northampton MA 01060 AUTHORIZED REPRESENTATIVE P IRM Insurance Agency Inc. ACORD 25 (2009/01) ©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 El Name of License Holder : �c� `�'� � � s'- egq 7 7/ License N tuber r I) ; ems (',.€_ /W R�� V Z9// / Address Expi tion Date %f/ c/4_ -r,-_p n �l 4 6/ V a G Signature Telephone YFF/ 9. Reglstered'Home Improvement Contractor : Not Applicable ❑ S e- �- p !2o ys C'.e 6« e /..v--- .24'3 3/y Com - nv Name Registration Numb r Address Expirati n D p ate � /�°"-�v 7`�-� 4 Gr!d GrU Telephone c`Y/ • %'z Y 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 6 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing ❑ Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [17J - Siding [O] Other [0] Brief Description of Proposed ' ' �/ 1 J J _ Work: Turn part of existing garage into office /workshop Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll - Sheet 6a.jf 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 famil nit: Number of Bathrooms c. Is there a garage attached? d. • •posed Square foot- .e of new construction. Dimensions e. Nu •er of stories f. Metho• •f he • ing? Fireplaces or Woodstoves Number of each g. Energy • .ervation Compliance. Masscheck Energy Compliance form attached? h. Typ= of constr . tion - construction withi 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 1, 14' / 1 C G f /'L ` i/ i t 1 , as Owner of the subject property hereby authorize 59./- '`A- 405 to act on my behalf, in all matt6rs relative to work authorized by this building permit application. Signature of Owner Date 1, -•� i �„, 5 , as Owner /Authorized Agent ereOf 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. P 0,1 Print Nam .C) ( jam_, ///f t 7 ignatur- of Owner /Agent Date , 4 / ic - e (5' II ' 4 ' 1 ) rrol- P ---- 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 00 Open Space Footage (Lot area minus bldg & paves 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 0 IF YES, date issued: IF 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 Obtained , Date Issued: C. Do any signs exist on the property? YES 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: 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 0 1 Department use only City of Northampton Status of Permit: 9 `i0�� Building Department Curb Cut/Driveway Permit .V1 212 Main Street Sewer /Septic Availability 3r9 Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans; p hone 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 _S-� -772_ r in c - Lt +-I Map L ot Unit t r1w � �: Zone Overlay District ` EIm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Michael Marvin 55 Terrace Lane Name Current Mailing Address: No rthampton ma 01060 0.....Av^ Telephone , 3 Signature 5 80 6 2.2 Authorized Accent: � 1 1 -t /7), o5; ! T .5-le y---4/ t '(' ( „„ 7 / - v - f�' C / Name ( mt) Current Mailing Address: , e ) !/` /4„',s-4_ /� mid C 7,60 Signal a Telephone S/li 3 � (2 Z SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. 1. Building < L)t.,' , GA> (a) Building Permit Fee 2. Electrical / , ' -c% (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) 7 t7 O . Check Number J/02 �� This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0642 APPLICANT /CONTACT PERSON STEPHEN D ROSS ADDRESS /PHONE 36 SERVICE CENTER RD NORTHAMPTON (413) 584 -1224 Q PROPERTY LOCATION 55 TERRACE LN MAP 24A PARCEL 008 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out itcC Fee Paid Typeof Construction: CONVERT PART OF GARAGE TO OFFICE/WORKSHOP New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 079160 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Demolition Delay �./ 1 /0 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. x L. BP-2011-0642 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON N '4�yZ"kryE*Q' Lot: -001 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 -0642 Project # JS- 2011- 001042 Est. Cost: $7700.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN D ROSS 079160 Lot Size(sq. ft.): 16639.92 Owner: MARVIN MICHAEL F & HEATHER L HOLMQUIST Zoning: URB(100)/ Applicant: STEPHEN D ROSS AT: 55 TERRACE LN Applicant Address: Phone: Insurance: 36 SERVICE CENTER RD (413) 584 -1224 () WC NORTHAMPTONMA01060 ISSUED ON:1/20/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: CONVERT PART OF GARAGE TO OFFICE/WORKSHOP 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 1/20/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner