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__ _ Office of Con sumer Affa & N s in e ss Regulation
` HOME IMPROVEMENT CONTRACTOR
�_ • �
1 ; Registration: 136677
. �
: Expiration: 8/14/2012
Individual Type.
KE TH WILLIAM LYNDS
KENNETH LYNDS
71 RESERVOIR RD.
LEEDS, MA 01053 .--......"--......,,,9„6:5_____
Undersecretary
Nla..achu.etts - Department .,1' r'ti',. .r
e Board of Building Regulations and Standards
Construction Supervisor License
Lic -:nse CS 13668 _
Restricted to 00 -"
rte. =u
KENNETH W LYNDS r ' w
71 RESERVOIR RD _
LEEDS, MA 01053 , , ;.,
' - ---- ----.. Expiration: 7/24/2011
( '..i∎.mer Tr#: 201
OSHA 001953631 0
/f-'✓•t/(' ( s
U. S. Department of Labor
Occupational Safety and Health Administration
has successfully completed a 10 -hour Occupational Safety and Health
Training Course in
Construction Safe & Health
,y_ 609 gal
(Date)
(Trainer)
. ;,✓, - of C
I
fiillY � a Hour ppational 0
Has success Cow in Conin
dow ,,. .Health T� 10
_L. ---- Date
Trainer
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Not valid without signature
Restricted to: 00
00 - Unrestricted
1G - 1 2 Family Homes
Failure to possess a current edition of the '
Massachusetts State Building Code
is cause for revocation of this license.
Refer to: WWW_Mass.Gov/DPS
OSHA recommends Outreach Training roarses as an orientation to ocevpatiaod safety
and health for workers. Participation is voluntary. Workers most receive additional
training en specific hassrds *liken job. This coarse completion card does net expire.
For further infermalimi see or web site at wan, osko.rov /outreoch.html
SAFETY 1 OSHA 10
EQUIPPED Q Fall Protection
Training & Consulting Services
Tel.: 508-332-8959
Bill Kershaw 61 Eisenhower Road
Safety Consultant Swansea, MA 02777
Member of ASSE SafetyEquipped(ccomcast.net
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
•
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her • . nstruction supervisor. The state defines "Homeowner" • . Person(s)
who owns a par.- on which he/she resides or intends to be, a one or family
dwelling, attached . detached structures accessory to'such use and/• farm structures. A
person who constru more than one home in a two -year period all not be considered a
home owner."
The building department fo se City of Northampton w • • person(s) who seek to use
the home owner exemption, t • act as their own constru., on supervisor, to be aware that
by doing so you become respo ible for complianc : • 'th state building codes and
regulations. The inspection proc- s requires that • building department be called to
inspect work at various stages, whi include fo dation /footings (before backfill),
sonotube holes (before pour), a rou build" , g inspection (before work is
concealed), insulation inspection (if r • ' uir I) and a final building inspection. The
building department requires these insp - • .ns before the work is concealed, failure to
secure these inspections can result in f ilu to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades • perform wo (electrical, plumbing & gas) the
homeowner will be responsible to • . e sure that the • des hired secure their proper
jermits in conjunction to the bu • ing permit issued, an i at they get their required
inspections. Failure of the indi 'dual trades to secure the pe ••• 'ts and inspections as
required can DELAY the pro' - ct until such time as the proper , ermits and inspections are
made
1, under and the above.
(Home owner /re dent's signature requesting exemption)
I will call to sched all required building inspections necessary for the b iding permit
issued to
Date
Address of ork
location
,
. .. , .
The Commonwealth of Massachusetts
Department of Indus Accidents
Office of .
600 Washington Street
Boston, PIA 02111
-,....‘,—;....-.:, • , www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
Name (Business/Organization/IndivicinD: e , A.A. g , 2 - 2_ . C._. ,.
Address: P 4.139 4/ Y?
City/State/Zip: Le-e-414 Ahotri. 0/00 Phone #: it/.3-.J 92,p2....
(
Are you an employer? Check the appropriate box: Type of project (required): l
1.0 I am a employer with ).. 4• 0 I am a general contractor and I
6. 0 New construction
employees (full and/or part-tim
have hired the sub-contractors
e
listed on the attached sheet 7. 0 Remodeling
2. w a.131 a sole proprietor or partner--
shin and have no e=q)loyees These sub-contractors have 8. 0 Dernolidon •
eatpees e '
working for me in any capacity. _ . . 1py e ..t: ancl have wanrs 9 Ej Build* addition
[No worke:rs' eomp. insurance
10.0 Electrical repairs or additions
required.] 5. 0 We are a corporation and its
' 3.0 I am a homeowner doing all work officers have4xercised their 11.0 Plumbing repairs or additions
;
myself [No workers' comp. right of exemption per MGL
12.0 Roof repairs . i i 4
insurance required.) t c. 152, §1(4), and we have no
13.02rOther /amide IP12-...btii it
en3ployees. [No workers'
comp. insurance required.]
*Any applicant that checks box ftl must also fill out the section below showing their workers' compensation policy infonnation.
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 =hi have
employees. If the sub-contractors have employees, they must provide their workers comp. policy number.
. I am an employer that is providing workers' compens ' n insurance for my employees. Below is the policy aruljob site
information.
Insurance Company Name: A
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:" • ' - .
Attach a copy of the workers' compensation policy declaration page (showing the policy ntunber and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER. and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
agestleations of the DIA for insurance coverage Verification _ .. _ - ., _
/ do hereby certifi niter the p ,/' and pen . s of perjury that the infornuttion providedabove_is_true_and_corre.ct.____
Si .... -tare: . 4. • . ate- • 7 -/ 0 ,
2. -
Phone #: 9 / 5 61 PI -
Official use only. Do not write in this area, to be completed by city or town'official
City or Tuwn: ' Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical,kspector 5. Plumbing Inspector
6. Other , &
Contact Person: Phone #:
SECTION 8 =- CONSTRUCTION SERVICES
8.1 Licensed Construction Supe isor: Not
eel," Applicable l ❑ /
Name of License Holder : " f 6.4 / J b
License Number
'? / 44 94., 4, 6-0.41 l-u•tid /AUL ;/ d'3 7 - t Z ol/
Address l Expiration Date
e At
Siare "Ttifephone
9 Q;Rett c El ne k; traclorr =. 'g: _ .. " Not Applicable ❑ .
Companv Name ` Registration Number
/t 0.04/vpht, F17 LAAd , o � f - ? 1 3.6 77
Address Expiration Date
)
Telephone O ir4 z „ �/ 1—
! - Z�I
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 buil ing permit.
Signed Affidavit Attached Yes No ❑
1; Ho Owner 4 I t r$ M l t §
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
completionbf 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 0
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] • Decks [E_] Siding [01 Other
�e 1sT 46 o f'4i4 . Nl'&c aus
. •ption of Proposed, Nt i,V -e f ,� e b u a l a(
Brief Des
Work: _ 4.1.18-.4. '6 Cr• - 4 ' 01% '...✓' A d ft P 4 - �to. .
Alteration of existing bedroom Yes / No Adding new bedroom Yes No
Attached Narrative atin g ffini hed ement Yes No
Plans Attached Rol Sheet O L 4 h /�e.c.c 4rt.. ai 'e„ U,l .141
sa: f ii ouse andor ack htion e iiiti t slnq om pl to foliownln : 4c . / off PN. r
(/1/
a. Use of building : One Family. Two Family 0;i4 a .sKJi0. ,
•
Other ^ �
,
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there d' gardge 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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
4, -
I. O _/' A -/.
w,4t- �r.x- Vl�+ - /JA'hi e l.J , as Owner of the subject
property
hereby authorize e., h w ids 14 d J • . Z I i"` ,/ Cirst '
to act on m half, in a attersAve to work authorized b this building permit pli tion.
Signature of Owner Date
1, £�1,. i) Je
, as er /Authorized
Agent he b declare that the statements and in rmation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under e pains and pe•alties of perjury.
. k J 1. •
Print Na
Si - ' re of Ow/WA. ent Date
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 I I € -- ---1 _
Frontage ( i i ____-- 1
Setbacks Front
Side L: ' R := L:' R:` ! ?
Rear E - - -
Building Height r----i ( i
Bldg. Square Footage [J 1 1 i I i j i
Open Space Footage l %
(Lot area minus bldg & paved 1 ,,____, ; .
parking)
# of Parking Spaces 4 i" ° '
Fill: 1 i 1
(volume & Location) I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW ,,/r� YES 0
IF YES, date issued:; I '
IF YES: Was the permit recorded at the Registry of Deeds? • '
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page; 7 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
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 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 Q NO
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
1 i : City of Northampton *.: .AV ,, �� �
Building Department . "� _ � ; ' � � . 4
DEC 1 4 2010 �_ 212 Main Street e 3 2 3x
Room 100 _ a - '.�
_ .. -- ------- 1 N rthampton MA 01060 rrig
._._. @'
8ne 416-587-1240 Fax 413 - 587 -1272 ° Y
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: d
53 w o- 1 i►'hw1 X Map r Lot Unit
/ d e r / 0 /kes Zone Overlay Distnct
Elm St. .District ? _ ` CB. District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: OW �` ii=r� " • QINAs.�J / /4 Z.1•0‘,
kJ. d Iw . .Vr — R .i, 4 w, d. /441•e_. 4 3 tj• 0 arw..e. l 2 0... d.
Name ( Pri ) l Current Mailing Address:
�{/3- s3 - /0J
x �L -- fartoile‘it Telephone
Signature
2.2 Authorized Agent;
/ it ', t,yi.JJ pp. 0,,e </t/� / Gam, , At4-, o /Ost
Name (P • t) J Current Mailing Address:
Si a re Telephone i p !/ 1f II - s j rs - 8 9 8'
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building'' Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 3
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) /g7 t� 9Qdr Check Number 1 1b 6
This Section For Official, Use Only
Date
Building Permit Number: Issued:
,�� sfi
/ Z,41 / :/6
Signature
Building! Commissioner /Inspector of Buildings Date
ri BP- 2011 -0549
GIS #: COMMONWEALTH OF MASSACHUSETTS
g :r ` 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-2011-0549
Project # JS- 2011- 000904
Est. Cost: $10900.00
Fee: $66.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KENNETH LYNDS 013668
Lot Size(sq. ft.): 14941.08 Owner: WOODMONT RD CONDO ASSOC
Zoning: URB Applicant: KENNETH LYNDS
AT: 53 WOODMONT RD
Applicant Address: Phone: Insurance:
P 0 BOX 448 (413) 584 -9282
LEEDSMA01053 ISSUED ON:12/14/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE 1ST FLOOR OF FRONT PORCH &
REBUILD
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 12/14/2010 0:00:00 $66.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner