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CAMPS CONSTRUCTiOl.1
STEPHEN CAMP
AS EAST ST.
EASTI-IAMP1ONi MA-0107 Undersecretary
'laas Dem of Sfety
Board of ch Bui Rc�„uiations ent and Puhii S tan
Construction Sup License
License: CS 82531
Restricted to: 00
iiii
STEPHEN P CAMP ' `
46 EAST ST '
EASTHAMPTON, MA 01027
� - -- -- Expiration: 11123/2011
( Tr#: 8573
■
ACORD CERTIFICATE OF LIABILITY INSURANCE DATI
04/05/:
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORM?
James J. Dowd and Sons Insurance Agency, Inc, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFI
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTENT
PO Box 10300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BEOO1
USURERS AFFORDING COVERAGE
Holyoke MA 01040
I • INSURERA: NorGLTARD Insurance Company
Stephen P. Camp INSURERS:
46 East Street INSURERC:
INSURER D:
Easthampton MA 01027 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIP
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PE
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH PO
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTWE POLICY EXPIRATION LIMITS
LTR DATE (MM/DD/YY) DATE (MMIDD/YY)
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (My one fire) $
CLAIMS MADE Fl OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
POLICY PRo
JEcT [1 LOC
AUTOMOBILE LIABILITY COMBINED SINGLE OMIT
■ ANY AUTO (Ea accident)
III ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
. HIRED AUTOS
BODILY INJURY
NON•OW ED AUTOS (Per accident) $
PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
OCCUR I I CLAIMS MADE AGGREGATE $
DEDUCTEILE $
RETENTION $ $
A WORKERS COMPENSATION AND STWC131305 04/04/2010 04/04/2011 X ITORV I J ER
EMP UABILITY-
E.L. EACH ACCIDENT $ 10 (
E.L. DISEASE - EA EMPLOYEE $ 10 (
E.L. DISEASE - POLICY LIMIT $ 50
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISItN s
CERTIFICATE HOLDER I X J ADDITIONAL INSURED; INSURER LETTER: — CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT
FA/LURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPOI
Stephen Camp Construction
46 East St.
Easthampton, Ma 01027
(413)527 -7124
Submitted To : Joe Squires Phone- 584 -0192 626 -7207
Address : 36 Grant Street Date - 6 -30 -2010
Northampton, Mass 01060
We hereby submit this estimate for - Vinyl Siding
My price is for installing 3/8 " backer board and vinyl siding on
The second floor of the building.
(All metal trim is complete. )
Color will be customer's choice.
Price = $ 3150.00
Contractor Supervisors License number 082531
Home Improvement contractor Registration number 135204
I propose to supply materials and labor -in accordance with above specifications.
This proposal may be withdrawn
By us if not accepted within 30 days Authorized Signature ,,,,I
Acceptance of proposal Signature AP ;'7„
" i
.
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 /footinss (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
ilsermits 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 of Industrial Accidents
t' _',5, M Office of Investigations •
±: _��=
600 Washington Street
_ y
• ,74-F:1:47--
_ I
Boston, MA 02111
www mass gov /dia •
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/individual): 14-0,
Address: e- :,5'' ` 7`' ,
O iry?
City /State/Zip: 5// - -z<., , Phone. #: X2- 7 - 7 J Z
Are you an employer? Check the appropriate box: Type of ect roj
. I am a general contractor and I project (� _ /
1 4
I am a employer with ❑ g 6:
employees (full and/or part-time).* have hired the sub- contractors ❑ New construction
2_ ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any a loyees and work e y t3' 1: Butt a
[No workers' 'comp insurance -. comp• msnran t_.. ._ �__
required.] 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have-.exercised their • 11. Plumbing r
r ❑ ing epairs or additions
myself [No workers' comp. right of exemption per MGL 12.D.Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. o workers' . 13.0 Other
Py
comp• insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing t eirworkers'- comnpensation policy information:
t Homeowners who submit this affidavit:indicatrag they are doing ail work and then hire outside conttacters 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 whetherar not those entities have
employees. If the sub- contnato s 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: 4/9 / 4 '!-x'4: 7 i 2 . 7.- $ C�
•
Policy # or Self-ins. Lie #: „ l 1 h� Expiration Date: C( G' --" 2_Gp`
5'✓`6
Job Site Address: l0 . ,''' � I v 1-tsf ' C
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'ofMGL c. 152 can lead to the imposition of ciimini1 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 $250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Office: of
Tnvestieations of the'DIA for insurance coverage verification _ . ..
do hereby certify under e p and
_ I o . f p
P .fP� that the ui ormation rovidedlrbavE issrue_aud..correct �.. . _
Sienature: /"� Dater l /�. ,
Phone
Ai:
2
Official use only Do not write in this area, to be completed by city or tow
n offici
City or Town: # ,,_
Issuing Authority (circle one):
1. Board of Health 2_ Building Department 3. City/Town Clerk 4. Electrical,Ins ppector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
a
SECTION 8 — CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
,., f la� g Ma Applicable ❑
� ��� � -x N ot A PP
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 ❑
. ,`. em
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all .applicable)
New House [] Addition Replacement Windows Alteration(s) Roofing ❑
Or Doors U
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [I=] Siding g Other [0]
Brief Description of Proposed
Work: ' 5hd1 1/114 / 5o,9 114 ce6,74-fi �lr�
Alteration of existing bedroom Yes _ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
! E . Vx „ w i
.� � ... a "4 �@ � � ®. q'"a' � -a. 411
a
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
l , 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
L c/17 , as Owner/ thoriz
Agent hereb eclare hat the statements and formation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
��,.. %41111111'J — /
Signatur .f Owner /Age 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
Frontage r, I ! 1
Setbacks Front = = ,
Side L:= 1 R: L:! i R:= _.I i
Rear =
Building Height 1 I f . 1
Bldg. Square Footage 1% 1 1 f I
Open Space Footage %
(Lot area minus bldg & paved ~ i £ ; j i
En L --....
parking)
# of Parking Spaces
Fill: I q
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:; I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I P ag e i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES ® NO 0
IF YES, describe size, type and location: I
1
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location: s ,
I ,
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.
- r t ` \ _ \ it H of �(orthampton ''
\� � •`. \-'- — 43tttldir D P� t •
i ' J
212 Main Street ,� f; e
WG 1 8 2010 Room-100
∎, Northamp on, A 01060 � :. `, 1
phone 413- 587 -1 40 Fix 413- 587 -1272
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
,,, - _C` -. eS7` Map ` Lot Unit
e 9 h ,'� / ✓ Zone Overlay District
[/ EIm;St= Dlsstrict ' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: �1
±p ..G $ a i ✓'e-- ZS 6.1 n C a 141 A- c..-e-
Name (Print) Current Mailing Address:
>t V^
Signature
2.2 Authorized A ent:
-t-V1'4'11 ke ‘ .. ,,•-• t - .57 7‘ - / - 1 )1, ,V1■ 2 1?)4e.42
Name (Print) '} Current Marling Address:
Signatur t Telephone
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)
5. Fire Protection /
6. Total = (1 + 2 + 3 + 4 + 5) .3 CD 0-- C heck N umber / 6/d
This Section For Official Use Only
Date
Building Permit Number: '
Signature:
Building Commissioner/Inspector of Buildings Date
#xF
, y 6 — GRANT ' BP- 2011 -0125
GIS #: COMMONWEALTH OF MASSACHUSETTS
k NMap:B1ock :25C 100:' h 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 -0125
Project # JS- 2011- 000216
Est. Cost: $3150.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN CAMP 082531
Lot Size(sq. ft.): 8799.12 Owner: SQUIRES JOSEPH D
Zoning: URB(100)/ Applicant: STEPHEN CAMP
AT: 36 GRANT AVE
Applicant Address: Phone: Insurance:
46 EAST ST (413) 527 - 7124 0 WC
EASTHAMPTONMA01027 ISSUED ON:8/18/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 2ND FLR VINYL SIDING
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 8/18/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner