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25C-023 1 1as,aCItu.ett. - t)eI tit Public `+a 1� 1/42) Blurt/ nt Building Rcgulatiuns and `.4,intlartl. Construction Supervisor License License: CS 55955 Restricted to 00 DOUGLAS J FULLER 17 MOCKINGBIRD LN WESTFIELD, MA 01085 Expiration, 4/15/2012 ( mnri..i, rrrr' Tr• : 22177 /4 l '/ lY! /I1(;.J11 rAi �// / Office of Consumer Affairs & Business Regulation License or registration valid for individul use only tr before the expiration date. If found return to ? HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation 71' Registration: 165281 , Expiration: 1/27/2012 Tr# 293013 10 Park Plaza - Suite 5170 Boston, MA 02116 Type: Individual DOUG FULLER CONSTRUCTION ` DOUG FULLER 17 MOCKINGBIRD LN s <k� __ _ - -- WESTFIELD, MA 01085 Undersecretary vali bout signature - r ACORD TM. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 07/06/2010 PRODUCER Phone: (413) 562 - 2304 Fax: (413) 568 - 6708 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ROGER BUTLER INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 5 COURT STREET / P 0 BOX 816 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR WESTFIELD MA 01086 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # Agency Lick 1780920 - INSURED 1INSURERA TRAVELERS INS U RANCE CO DOUGLAS FULLER DOUG FULLER CONST ,INSURER B: ARBELLA MUTUAL 17 MOCKINGBIRD LANE WESTFIELD MA 01085 INSURER C: ASSOCIATED EMPLOYERS INSURANCE INSURER D: 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 ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION I LIMITS LTR INSRC DATE (MM /DD/YV) DATE (MM/DD/YY) GENERAL LIABILITY 6$02444 4 11/12/10 EACH OCCURRENCE 1$ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurence) $ 100,000 1 CLAIMS MADE )( OCCUR MED. EXP (Any one person) $ 10,000 A PERSONAL 8 ADV INJURY $ 1,000 000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 1 PRODUCTS COMP /OP AGG. $ 2,000,000 PRO- -- POLICY JECT LOC AUTOMOBILE LIABILITY 67413400001 06/07/10 06/07/11 , COMBINED SINGLE LIMIT I ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS ' (Per person) $ 250,000 B X HIRED AUTOS i BODILY INJURY _ (Per accident) $ 500,000 X NON -OWNED AUTOS PROPERTY DAMAGE $ 100,000 (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT 4$ i ANY AUTO OTHER THAN EA ACC 1$ , AUTO ONLY: AGG I $ EXCESS! UMBRELLA LIABILITY ' EACH OCCURRENCE I $ i -J OCCUR ( CLAIMS MADE AGGREGATE $ $ ' DEDUCTIBLE $ RETENTION $ $ WCC5006427 09/15/09 09/15/10 TOR Y uM TS WORKERS COMPENSATION AND OTHER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 100,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE - -- -- " -- - -- IOFFICER/MEMBEREXCLUDED? �EL. DISEASE EMPLOYEE i$ 100,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER: DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS THE WORKERS' COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR DOUGLAS FULLER CERTIFICATE HOLDER CANCELLATION CITY OF NORTHAMPTON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS BUILDING DEPARTMENT WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE NORTHAMPTON, MA TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE • Attention: Pauline Duzni 2 ski ACORD 25 (2001/08) Certificate # 5367 © ACORD CORPORATION 1988 P. 119.2 25C-027 50 100 100 200 100 50 25C -038 109.: 25C -025 50 25C -026 100 200 100 60 103 100 50 25C -024 50 100 25C -039 100 50 50 50 50 : �� ,)5 � 00 115 10( 25C -262 --- 25C -022 50 2 2 100 tti" 100 125 100 .Ii � 39 ' 50 9.2 25C -021 . 5C -023 127.5 Zi7,/ 50.1 ,1% 60 25C -020 • t om 119.2 2.8 100 13 c 59.1 • 50 50 25C -019 136 60.1 50 25C -018 1 240 138 60.7 80 25C -016 50 25C -138 238.2 V 25C -015 40 Q,�Z 71 59.4 � O 90 50 177.75 25C 232.5 80 187.2 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 Dour). 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, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date Address of work location . The Commonwealth of Massachusetts Department oflndustrial Accidents AN, t. _' 1i. — t Office of Investigations . 4 - -- 1= _ g �°�.= y 600 Washington Street t= a Boston, MA 02111 -z- www mass gov /dia • -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly uin Name ( Business /Organizationfindivmt): U_ 0 hod gut CALICj — ' ut 1 fh . Address: I I TY) c c. ,∎) 2 N �. t.. , A/. , • V City /State/Zip: We jT+e (8, 1V, /, .0169 Phone. #: 5% 7 "e -t 3so Are ou an employer? Check the appropriate box: Type of project (required): 4 1. I am a employer with 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 1 RRemodeling ship and have no loyees These sub - contractors have. 8. 0 Demolition working for -rue in any capacity. employees and have workers' 9. Burl °` addition [No workers' comp. insurance -- CoI»p. insurance _.. ___ .:. required_] 5. 0 We are a corporation and its 10 Electrical repairs or additions 3.0 I am a homeowner doing all work officers havexercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0. Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' il j Ail 1' 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 dais affidavit: indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees, they must provide their workers' comp. policy number. /am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: . 7 R U .`.I, Q ,S rr16042'1 VCE CO , Policy # or Self-ins. Lic. #: 1 k i. $'O 1 e2 0 Expiration Date: - /i$ / 0 Job Site Address: / .A (�00-64 (2 Z' U �'�� r �/,� y � • � IQ 'V CRP 11-t City/State/Zip: � i����La�s/��'.. �s . � /�"4 f'r'/ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage, as required under .Sectton25A'ofMGL`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 01A for coverage verification r ., _,_ .. , . , _ I do hereby ce under the axis and penalties o , formatron provided above ` _andcoriect_ __ .. �' P � P fPe that the in Signature: ' Date: Ul. /0 Phone #: c/a R 3 . . Official use only. Do not write in this area, to be completed by city or town offciaL City or Town: Permit/Llcense # �_ 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 #: i SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder : a �� 5 5 9 5 5 License Number It (1 oc it 8 . A_ c,AL. CAl e5` c � �5 /� Address Ex pir�fti Date -A,k- 5 -( 030 Signat t i Telephone B, Kett to eid4Nanie,fm#rra3nernen Orrtsrttt 12 } V—T ` YS'" 2 .,ai Not Applicable ❑ �1 4, ( it-r, / 5 8/ Company Nam f Re Number I .. 7 1A ( - k $ (1 fl^ �^ (�t,`i°57 / t" �8 /y„ y� �/► r / i , VO 7t// aAddresss I �� /� Exp Da e( �► —��. -/ .. Telephone r /d "5/13 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L, c.152, §25C(8)) 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 No ❑ 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 El Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [ Brief Description of Proposed / Work: ckaplAere f� Aka rt he-A. 40u) A • a0) Alteration of existing bedroom Yes Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes V No Plans Attached Roll - Sheet a l evil tls " t w c 'oliWiaii. ftifil iii. atii .I n 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. floodpiain 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. 1" \ 1 l \t\ \ ∎ � IN 1 m , as Owner of the subject property hereby authorize ()' ' it(4 r C.P5+ to act or alf, in all m- rs relative to work authorized by this building permit application. Signa • .r Date 6 1\Q\\(, Lim 6J\, , as Owner /Authorized Agent hereby declare that the statements an information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under t pains and penalties of perjury. /� /� C �` L V 06-Vim & Pri ame -1 —0 Si a ture of Oww Agent Date Sig 9 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 1 .,..3 .,..3 1 e 1 E •' I L i Frontage 1 50 r 1 1 5"0` 1; , Setbacks Front iR1 l 1 Side L:' R: L:4L R:L' Rear 111),` , . . Building Height Lis...f Ma 1 Bldg. Square Footage % ‘• i s 1 Open Space Footage (Lot area minus bldg & paved rifW. = E s.__..._ parking) # of Parking Spaces 1 7 " 1 Fill: ///s 1 � 0 (volume & Location) 1, I A. Has a Special Permit /Variance /Findin ever been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book P 1 Pagel 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ef DONT KNOW 0 YES Q 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: 1 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: 1 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. s g z ,, gy m r. ' � - \ - ,, 4 ' City of Northampton �r ''' Building Department a _ " af 212 Main Street , _ = 4 F. ` a Room 100 X416 . Northampton, MA 01060 _ , phone 413 - 587 -1240 Fax 413 - 587 -1272 m _ °A " ° d t _ x - . . ma y- .a � , .—, z, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR-DEMOLIS IA ONE(OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION �II QQ 11''11 r I Thi4 tion'fo gg Qompleted by office 1.1 Property Address: / /6 /v® - l' E /� 1A/ 4i/E. map Lw Lot . Unit Zane % Overlay District -- Etm.St. District CB. District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: PI 1c e((e L, Cali my u / e ./vo(r/lEedv t/4-(O F N. a (P.nt Current Mailing Address: , _ i1 i — i l 2 )( Telephone Signature 2.2 Authorized Agent: 0(5 i/ >.s z Puilei-- 1"1 rY10 st '(3 -a C,..+U, LJ 4PIeII Name Pri t Current Mailing Add r 6'16,1_- (11)30 .._ 3 `> — CiC,C f Signature y Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 5/ 9. (9, 205 r OD (a) Building ''Permit Fee 2. Electrical IC/ ryry o o (b) Estimated Total Cost of pC �QQ r Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = , + 2 3 + 4 + 5) �ZQ', 8170 , oo Check Number (��j l� _ L; This Section For Official Use Only J�pr Date u i ld i ng Perm Nu ber: Jssued: Signature: Building Commissioner /Inspector of Buildings; Date File # BP- 2011 -0018 APPLICANT /CONTACT PERSON DOUGLAS J FULLER ADDRESS/PHONE 17 MOCKINGBIRD LN WESTFIELD (413) 572 -4730 PROPERTY LOCATION 16 NORTHERN AVE MAP 25C PARCEL 023 001 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 7 �� Fee Paid Tvpeof Construction: CONSTRUCT 20 X 28 DET GARAGE New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included: Owner/ Statement or License 55955 3 sets of Plans / Plot Plan AtfrthA /O(,r ro P(61( (11 '�' THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON Ai r INFO ATION PRESENTED: O f PLANS' , 7J A pproved 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 dif 7/ 9/0 Signature of Building • fficial 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. 6 }F oar`° < BP- 2011 -0018 GIS #: COMMONWEALTH OF MASSACHUSETTS MAD:Block: 25C.023 ; 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 -0018 Project # JS- 2011- 000030 Est. Cost: $28800.00 Fee: $112.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DOUGLAS J FULLER 55955 Lot Size(sq. ft.): 16901.28 Owner: EASTMAN MICHELLE L Zoning: URB(100)/ Applicant: DOUGLAS J FULLER AT: 16 NORTHERN AVE Applicant Address: Phone: Insurance: 17 MOCKINGBIRD LN (413) 572 -4730 WC W ESTFI ELDMA01085 ISSUED ON: 7/9/2010 0:00:00 T() PERFORM THE FOLLOWING WORK: CONSTRUCT 20 X 28 DET GARAGE 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 7/9/2010 0:00:00 $112.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo