44-094 AcoRD CERTIFICATE OF LIABILITY INSURANCE OP ID CA • DATE (MM /DD!YYYY)
_..:. _. KLOTE -2 10/27/11
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Dowding, Moriarty & Dimock Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
139 Union Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Rockville CT 06066
Phone: 860-875-2523 Fax:860- 875 -0921 INSURERS AFFORDING COVERAGE , NAIC#
INSURED INSURER A: PEERLESS INS CO
INSURER B:
Kloter Farms , Inc . INSURER C:
216 West Road i INSURER D:
Ellington CT 06029
I 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.
I4I N wO1YUu POLICY EFFECTIVE POLICY EXPIRATION
LTR INSR[! TYPE OF INSURANCE POLICY NUMBER •DATE (MM /DD/YY) DATEJMM /DD/YY) LIMITS
GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000
A X X COMMERCIAL GENERAL LIABILITY PR IU KEN ttU
PREE SES (Ea occurence) $ 100,000 .
CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5,000
CBP8083948 10/24/11 10/24/12 PERSONAL BAOVINJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: . PRODUCTS - COMP /OP AGG $ 2,000,000
POLICY 7 E 0 I I LOC
AUTOMOBILE LIABILITY I
COMBINED SINGLE LIMIT
A X ANY AUTO (Ea accident) $S1,000,000.
ALL OWNED AUTOS 3A9906944 10/24/11 10/24/12 BODILY INJURY
$
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS
BODILY INJURY $
X NON -OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
I ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG I $
I EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE I $ $ 5 , 0 00 , 0 0 0 .
A X OCCUR CLAIMS MADE CU9907247 10/24/11 10/24/12 AGGREGATE 1$$5,000,000.
i $
I DEDUCTIBLE ' $
1 RETENTION $ $
WORKERS COMPENSATION AND X 01H-
A EMPLOYERS' LIABILITY (TOR
Y L LIMMITS ITS , ER ,
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT 5100,000
OFFICER/MEMBEREXCLUDED? I WC9773633 10/24/11 10/24/12 E.L. DISEASE - EAEMPLOYEE! $ 100, 000
If yes. describe under
_ SPECIAL PROVISIONS below 'i I
E.L. DISEASE - POLICY LIMIT I$ 500,000 I
OTHER
I
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
I
CERTIFICATE HOLDER CANCELLATION
SPECIME H SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFDRE THE EXPIRATION
' 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
"SPECIMEN COPY ONLY" IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
10 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
,'ED GIZA
ACDRD25 (2001/08)
(FN. rnnr,r •nnn
•
Cape Storage Building 2012
with overhead door '
I< VARIES >I I< VARIES >1
./ 30 YEAR r--- --
ARCHITECTURAL
�� ASPHALT SHINGLES I
END VENT
i \� EACH SIDE
( 1 SINGLE HUNG --- - - - -._ __...----- ...._._._T_ —_
-- ALUMINUM
,._. _.__ � - - -_� - i WINDOW � -:�
i _ f---7- VARIES: 1 11 1
i I 5/8' DURATEMP —= __
j TEXTURE 1 -11 �'��
OR HORIZONTAL \\
OVER ' /z "CDX
_ _-_--.-_..__ .__.____.... .-- ....__. . -
--__ -- -- OVERHEAD DOOR
1 I u- i r 1 9 ' 0 „ x 6'5" r r
FRONT SIDE
*shown with standard single door and standard windows
30 YEAR ARCHITECTURAL
--' , ASPHALT SHINGLES
r ,�
r r ' /z" PLYWOOD - \,, "° ' /z" CDX PLYWOOD ROOF SHEATHING
-,,} GUSSETS BOTH -, �`h
SIDES �; AS
'
s 2 "x 4" RAFTERS "`.‹ -.
16 0.C. . /ALUM. DRIP EDGE
i 1i I ^�
I 1 (2) 2" x 4" TOP PLATE FINISHED SOFFIT
I I and FASCIA
I'
SIDING VARIES:
j j �- fie"
DURATEMP
I ! TEXTURE 1 -11
OR HORIZONTAL
I I 5 /e" BC PRESSURE TREATED OVER 1/2" CDX
I 5 -PLY PLYWOOD 2" x 4" STUDS
I 2" x 4 "PPRESSURE TREATED �— 16"0.C.
FLOOR JOISTS 8" O.C.
— 1 •. ! ,,, 1 ! I' , PRESSURE TREATED
I: 4 "x4 "BEAMS
dam_ ►X1 ► �' 10' WIDE: 5 BEAMS
II -1lIF: tE (l '0l q..0 - 7- QI I(.(a4( =.I,I LI. 1uL( Lt, (7--E ll(�v. = 14�= 1�u1�w,c - - , l' R12'WIDE:5SEAMS
SECTION 14' WIDE: 7 SEAMS
iii KLO TER FARMS
NOTES:
Design meets requirements Designed to resist wind gust of
•® www.KIoterFarms.com of 2005 CT Building Code 120 MPH for 3 seconds
Residential Section 301.5 Design wind force - 34psf
860 -871 -1048 800 - 289 -3463 Fax 860 - 871 -1117 Floor will support 2000# load Design snow load - 40 psf
216 West Road (Rte 83), Ellington, CT 06029 applied over 20 sq. in. Design floor load - 100 psf
/7 11,741
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H
. City of Northampton _
Massac .
i,,, - ' il ,,,,,,/ " DEPARTMENT OF BUILDI INSPECTIONS r„�
u * . ,
� 4 ,nr '' �.� ?°"`' r 212 Main Street • Municipal Building ma y°».
Northampton, MA 01060 �t .. N''
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 - a - home - owner."
The building department for the City of Northampton wants any 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 permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
th permits and inspections as required can DELAY the project until such time'as the proper permits
d inspections are made
!Se ,i�bt
I, t
understand the above.
(Home owner /resident's signature requesting exemption)
Twill call to schedule all required building inspections necessary for the building permit issued to me.
Date_ `/ /o / /Z-
Address of work location 4• iZ ciy 4 r ZO A D
/6/2"r4Ce- / "4 0 / 0 6 Z
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): k4 p 7-6 / 1/!At S .SN C _
Address: a 2I6 6—lest" (2oliD
City /State /Zip: rift tip fie,) r C v i. o Zg Phone #: A n - / - /b V ft
Are you an employer? Check the appropriate box: Type of project (required):
i. n I am a employer with 4. ❑ I am a general contractor and I
employees (full and /or part- time).* have hired the sub - contractors 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2. n I am a sole proprietor or partner-
- - These sub- contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
— _ [No workers' comp. insurance - comp. insurance
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3.17 I am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ 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: Y tc g. /et S Z""j Co .
Policy # or Self -ins. Lic. #: tic I .F .7 677 Expiration Date: //Z ¥ l / Z.
_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 hereby cert under the pains and penalties of perjury that the information provided above is true and correct.
�natur. Date:
Phone #: 5� /a- .5 - 11 -9 SS's
- 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: Not Applicable El
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9 Re ist re ed. Home;lm • roverrient Contractor. ;, .. ;T.r „,.? , r:; MV2 Not Applicable El
Company Name Registration Number
Address . Expiration Date
Telephone
SECTION 10. WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L a 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 ❑
tioir g eCwnee '7 6111 - 1A1:011
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 Zonin. aws and State of Massachusetts General Laws Annotated.
Homeowner Signature _ _ _ _ -
•
SECTION 5 = 'DE OF.PROPOSED4WORK (check a ll applic I. ,
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
t — Or Doors 0
1
- Accessory Bldg. I I Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [D]
rief Description of Propose
Work: /. Z• j9. - f Chloe SJ+ees a _guild 1 j
U
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
M Elfeew ouse andlor=additron to a is't nq�h"ousinq oc pl`ete.the,folfowtnq:
6a��,
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
4 ti .,a .� 5. a % m .v `,i9 . h r^:i1&
;SECTION 7a OWNER AUTHORIZATION `TD BE COMPLETED, WHEN
OWNERS AGENT OR s+:.i, : _ CONTRACTORA'PPLIES'FORBUILDINC PERMIT
-.w.,. . ._ `' #Nw ,,-TM,_. t_, r ......W. , : ,.u.., x �, y. s ., ...a�..,, - -=,,W , �._,.,, a i .e,a
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
-I, 4d 7ri.4e. - - - -- -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 penalt ies of perjury.
j7 ' e " C /2 'i t t.
Prin Name
I �ignature of. r e Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by'Loning
, , This column to be filled in by .
Building Department
1
Lot Size 9 1 i 1 3 t
Frontage
Setbacks Front l j - €
Side L:` R: L:`Lr VR: Ai
? ' Q i v I
Rear I
fixes ` ) `;
Building Height ;_______ i i
Bldg. Square Footage i % s
i
Open Space Footage
(Lot area minus bldg & paved 1 i ( 1
parking)
# of Parking Spaces
Fill: i_ _ ' €
(volume & Location) i
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 Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
r 1
IF YES: enter Book ! 1 Page! 1 and /or Document #1
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES I
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ` Obtained 0 , Date Issued: j
C. — Do any signs exist on the property? -YES NO
i
IF YES, `describe size, type and location: 1 i
D. Are there any proposed changes to or additions of signs intended for the .property- ? - YES _ NO 0
IF YES, describe size, type and location: I 1 -
E. WII 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 ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
File # BP- 2012 -0879
GRUB
APPLICANT /CONTACT PERSON BERUBE TAMMY J & STEPHEN C rt+�
ADDRESS/PHONE 450 ROCKY HILL RD FLORENCE (413) 214 -4463 O
PROPERTY LOCATION 450 ROCKY HILL RD
MAP 44 PARCEL 094 001 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
Typeof Construction: ERECT 12 X 20 STORAGE BUILDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 127530
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION Py'SENTED:
Approved V 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*
Tit
Received & Recorded at Registry of Deeds Proof Enclosed W 1 f1J /(70
Other Permits Required:
8061
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
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.