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29-433 c....., ....) ._ \ 0 .8 ..,,, • , 81 r hi _______ 1 C k (..... . j ,..f.‘ : . ._..... (--- ,.„ 4 „........„.„ :„...„ ,„ ......., ,,, 9 , yi (:) 1 . ,.. _ ---Q. (NJ 6 ) s , 4 • • ACORD TM. CERTIFICATE OF LIABILITY INSURANCE ! DATE (MwDD/yyyr ' 04/01/2010 PRODUCER Phone: (413) 781 -2410 Fax: 413 -731-9539 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER OF NEW ENGLAND ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE • P 0 BOX 1175 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR WEST SPRINGFIELD MA 01090 -1175 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 1 • INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Arbella Indemnity Ins Co Teddy Bear Pools, Inc & TGH Leasing, Inc INSURER B: • 41 East St Chicopee MA 01020 INSURER C: • • INSURER D: • INSURER E: • COVERAGES • THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IS TO THE INSURED NAMED 'ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDIPON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 70 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFO 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. • 1NSRqaOD't, TYPE OF INSURANCE POLICY NUMBER . POLICY EFFECTIVE POLICY EXPIRATION LIMITS • LTR I INS , DATE (MMIDO/Yr DATE IMMJODIYY) Y GENERAL LIABILITY j STT8500042872 ' ( 04/01110 04/01 /11 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABtLITY DAMAGE TO RENT PREMISES (Ea occurence) I $ 100,000 CLAIMS MADE X OCCUR MED. EXP (Any one person) 5 5,000 A i PERSONAL &ADM INJURY �$ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG. $ 2,000,000 I POLICY I I PRO- I j LOC 1 -- - AUTOMOBILE LIABILITY • 31276400003 (, 07/01/10 07/01/11 yy COMBINED SINGLE LIMIT • ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY • (Per person) • $ X , SCHEDULED AUTOS . IA • X HIRED AUTOS BODILY INJURY 3 X I NON- OWNEDAUIOS (Per accident) $ • PROPERTY DAMAGE $ } j (Per accident) ' °' _ °'i ' GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ I ANY AUTO • J OTHER THAN EA ACC $ - AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ I OCCUR I CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION S I$ WORKERS COMPENSATION AND WC YLIM!T S 9104140409 04/01/10 04/01/11 TORY LIMITS [ j °T EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 5 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE 1 A OFFICtWMEMBER EJ(CLUDED? I E.L. DISEASE -EA EMPLOYEE IS 5CO a yes. describe under SPECIAL PROVISIONS below E.L. DISEASE- POLICY LIMIT $ 300,000 OTHER: DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS EE CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO WHOM IT MAY CONCERN TO CO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, IT'S AGENTS OR REPRESENTATIVES. • AUTHORIZED REPRESENTATIVE // S • Attention: , Irt1C ', ACORD 25 (2001/08) Certificate # 48028 • © ACORD CORPORATION 1988 Teddy Bear Pools, nc. .Y �. Known By Our Reputafion .— 41 E s S ee '' ;! X413`, 394-26,66 ®-' -200-554-BEAR Chkopee MA 01020-3562 j '� FAX ;A131) 59S-3823 Home improvement Cont. MA #11339/CT #52,3951 '',;;;.) :4* W W .ted ybecTo* Ojsoc 0,‘ a . r , i 3 f i ryr ' ' ,mss. ''„.., ,T,'''0- n m ° \ 1 *Mt, . .. 'r A ',: D , . _,„,,,,,i,‘, : u . �. i p .,m y a ii k t., l&'' , x t 'a .. .4 * . AVA , ': ' 4s.L f. .� 4 , — _ e 7t P 1 :. it L li ' 2 t ; / ' 7s I . , & , Y W: ----------1-4, ,_ B oard o Building R egulations an S tandards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 111889 Type: Private Corporation Expiration: 2/8/2011 Tr# 279922 TEDDY BEAR POOLS & SPAS INC THEODORE HEBERT 41 EAST ST CHICOPEE, MA 01020 Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card )PS -CA1 0 50M- 07/07- PC8490 . - - V it ✓ A: .'4 "�,J w k.� e":. r�`V v y Vri Ti"v*,M,""t'!fV r � . �._ -- � :; v , R- , Y, r .,,, •t?' ;d•h Y' a. v. •,rr y v:. h • w,''v . r' ..'r. \•� ^. nC!" - , .v Rv 1 a i. .•h. M1• • ..rG.. ' •�Mii'. 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'•s r,'s 4 -...y F v, •a, -IA a 'r s '' s•, c r ,- f ,� ,, `� .- a •• 1- - •, r �„ �P s z 7 '�t VW STATE OF CONNECTICUT 4 WEEARTl ENT OF CONSUME PR ITECTION ,, ' Be it known that V 14 TEDDY BEAR POOLS INC r 4 EAST ST r , CHUCOPEE'MA 01020 " = is certified by the Departgrient-OfAsurrier Protection as a registered 1 HOME IMPROVEME=NT'-.CONTRACTOR "` �7n '� R ## ' H C `0 520951 ~ • -;g-kx:* :,,,,,t',.:,...st!,,,,,,;_i_.7...,„, TEDDY BEAR POOLS INC h , I1 a Effective: 12/01/2009r fir Ex pirat i on:11 /30/2010 C t ''''l , � F Jerry Farrell Jr., Commissioner `a ": a :> v:� . a air«+ x g ?" ; e'; ,,.. " _ ,„' •"" „ , y 'r :ate a .' ✓ .r - �'v � � V�s�. k, r '••ts .t .ti �J: /..: ,s,,. �.,.. >;;. : y,,.`, is l <x •.,yyF,� <. ti '�; p ,�, r •�e; 3., vp x,,.a �r � s., s+., o hJ'. . •,:' 3.:'. �• r .. ,« a ..n',: ,•rJ'a ,.s�., r .. Lvt..t'`�3s• ,�•,;.'@i1 • �" � Vii. '.• , ,F;. . ,: \a �, ... 'o-„�.s . 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S�z;'� a /� • n�'• j�,. e ,'•:.; 'vr. `. u„,% ;'" .. � 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 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 i.)ermits 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, r (cl > 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 me. Date C- 2 g Address of work location -,. , . ,.. The Commonwealth of Massachusetts ==— Department of Indus Accidents IP --r-. -- —f . " ---- fi Office of Investigatio' ns . 600 Washington Street 1.----.411=- .6 Boston, MA 02111 . ," - , www.mass.opv/dia . b ... • -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers .. , A 1 • licant Information ,„ Please Print L - • *blv Name (Business/Organization/Indivirinal): ".....kr,,,,Mit . • IF ■._ -IR-a - . • " Address: ,- - City/State/Zip: - Phone.#: Are you an employer? Check the appropriate box: Type of pioject (required): / • ?Z I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have hired the sub-conmactors listed on the attached sheet. 7. 0 Renaodeling • 2.0 .1 am a sole proprietor or partner- These sub-contactors have .8. 0 Demolition ship and have no ev-loyees eutployees and have workers' working for me in any capacity. 9. 0 Bullamg addition [No workers' comp. insurance 10.0 Electdcal repairs or additions 5. 0 We are a corporation and its require:cL] .• 3.0 I am a homeowner doing all work officers havetxercised their 11.0 Plumbing repairs or additions r myself [No workers' comp. right Ofexemption per MGL 12.0 Roof repairs . - insurance required.] t • c. 152, §1(4), and we have no ,....., employees. [No workers' 13-1--I Other CO. insurance required.] • *Any applicant -that checks beat Al must also fill out the section below showing tbeirworkers' compensation policy infonnation. - - t Homeowners yam submit this affida incficating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :Contractors that check this box must attached an milldam' sheet showing the name of the sub -contract= and stain whetheror not those entities have employees. If the sub-contractorshave employees; they must provide their workers comp policy number. .1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. - . - • - Insurance Company Name: • • Policy # or Seff Lic. #: Expiration Date: Job Site Address: City/StaM/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 Secii 'oflt?IGL c. 152 can lead th the imposition of riminal 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 te 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the °T _ _ i ce of Iiffeitlons Of thi DIA for insurance COveraii V;ii.ficitiori _ . _ _, ... 7. , , .,, .,, _ _ 1 ' der here.by__certi:fr under the pains and penalties ofperjury that the hvformationprovid.ediabirpaixtruaand.cop-ect. .. . . Signature: , Date : • . , , - . , . • • Phone li: - - Official use only. Do not write in this area to be completed by city or towrz 'official • • . City or Town: ' - Permit/License #_ ..... Issuing Authority (circle one): .1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical jri 5. Plumbing Inspector 6. Other . f- • Contact Person: Phone #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Re! i to •- d o , Im • rove • ent Con . tor• Not Applicable ❑ // � i� ,, r ~ S// � ! Com . v N ame / Registration Numb- 0 V /f 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 ❑ 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 on 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. H omeowner Signature • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [CO Brief Description of Proposed / / ( / Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the fo]Iowina: 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 , 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 , 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 penalties of perjury. A-- /17 - u1 c ' Print Name /Signature of Owner /Agent Date a9'3 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 e 4 Frontage /erl" Setbacks Front *17 Side L: R: L: R: 3 Rear Building Height Bldg. Square Footage Open Space Footage c Yo (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) 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 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q 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 ® 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 ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r F; Department use only City of Northampton { „ S a tus of I ermit: Building Department : i2_-L- -- eorbCt t/briveway Permit 212 Main Street Sewer/Seplic Availability ,. i O Room 100 M AY 2 8 20 aterrl I1 Availability , Northampton, MA 01060 Two ;ts of tructural Plans phone 41-587 Fa c 413t681-1272 , P e Pla s APPLICATION TO CONSTRUCT, ALTER, RE RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 7.1 Property Address: This section to be completed by office 5 E I' , vi 1 ..-- 12-J . Map Lot Unit a r e.J ^ Lk_ 6 Q l V o -L Zone Overlay District ' Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 171 ame (Print) Current Mailin Addre N13� r 2 H 4, Z, Telephone Signor ure 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Rem Estimated Cost (Dollars) to be Official Use Only completed by permit applicant Building $ 77 S 0 3 (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) Check Number /;1 16 #30 This Section For Official Use Only Building Permit Number Date Issued: Signature: Building Commissioner /Inspector of Buildings Date Y File # BP- 2010 -1082 APPLICANT /CONTACT PERSON KOCHIS ANN M & MARILYN KUSEK ADDRESS/PHONE 58 ELLINGTON RD FLORENCE (413) 584 -2442 0 PROPERTY LOCATION 58 ELLINGTON RD MAP 29 PARCEL 443 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid /0 3 Typeof Construction: INSTALL 18' ABOVE GROUND POOL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 ---.4 " ------P 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. vicitsma tf BP-2010-1082 GIS #: COMMONWEALTH OF MASSACHUSETTS k: 29.443 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- 2010 -1082 Project # JS- 2010- 001586 Est. Cost: $7503.00 Fee: $30.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TEDDY BEAR POOLS & SPA Lot Size(sq. ft.): 13111.56 Owner: KOCHIS ANN M & MARILYN KUSEK Zoning: URA(100) //WSP Applicant: KOCHIS ANN M & MARILYN KUSEK AT: 58 ELLINGTON RD Applicant Address: Phone: Insurance: 58 ELLINGTON RD (413) 584 -2442 0 Workers Compensation FLORENCEMA01062 ISSUED ON: 6/3/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 18' ABOVE GROUND POOL 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 6/3/2010 0:00:00 $30.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo , • • . '''",'". •', 44 • 0 4A,s 4 " 4, 1, 1 . 4 1# 11 t1 • ' . • • , . . . , . , • • • , . . • • ., . ' • 3424 Funaitart ihadirailty " - . Roos .. . ,,., ,..,.. , . < . • ,, ,. . ,,,,,, ...,,, . , ,, J. • . -,; iesAtheamostedEtivehitale 2: +MA ' 01607 ... . . „ . . . , ,, _ , ._.,,.. ., ., • '. .. '.- ..- --, -'... '-';i .4-, „ ,.: -.;; .."-..,.,',' - r , f,.. ,, ',' 4 — ' ' '. '''-- -.. , „, . . ' ., • . ; • , . 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Ib ,the • .. . us antedate aw roloseet Nit forth as is Apowilest or Mewed • - '..!. - . . . low, i'lfit .W,FOTt T . . t ... 4 . 414 UNTO A T M) TO OE 110b01__ war FROM fl i 'A ' 0 r YA,YRIs ENT VIERR A ' , Lli - - • MAD, WI OUT ;XsiTTINO mg ROME cararrliiMIPZIZ RallelEPTES YON RECOVERY OE ORTCRAMOLTM ' , • .....; , . . ,' - r - , Costotere WWI sod oedemata& iluit Wu Agommief is the COOSC atineratto britvom Customer ot• the Products sod Imago:WO RAU taw .* mipers0eistptiot oiewistoo mit rogratertulia, biased 164 Of W116101, re ' m co =tasks:la saki hatelistion, This Agetoroset earbiotlie Reined or smendsd tams* a mama signed ry Comoros siid The Buu Dap CUMUMIN meameledgea sal agmet Mat Culimagf,E it a aid, aniitirmapdt, voluntarily arm the onus of sad tat ntesived soapy of this Agreement. 1:4491.41 1 li " . ' ( I — / 4 ie x abratit l i tintiVP56 2,1,. .. 6 8666% OW 66141$ C44644161174 IP ... . '''''''''".^..'...`""°...."'"°"".."""'"....'"'. . TeibPhOne Na• „.........,,,,,..,., , . ........,....,••••••••••, :1666111616r6 fitgastItte Dag Ulm Comultsat maLLADLE; cams= MAY CANCEL TIES . or sesdam3 ' ,. keILEEMENT VOTTROCT PENALTY OR ORLIOATIOPII • 111 DELIVERWO witrinor NOTICE TO THE ROME • . )POT lY Atuniacin. ON THE TEEM IRISIMS6 . • ' ' )AY Ate STONING TEE AOREDIENT. ;TATE SurpLemeNT Armarito ITR,ETO :ONTAINE A FORM TO LE IE ONE . ;PLOY/Cm-LT PRESCRESED BY LAW IN ArsTomul srAn. NOTICRI AMMON& MAW ASV CONallierni AM aTATIlb OF TO *MIMI MR Olet AM. 'ART m1110 CONTRACT 41-10 c-tW What - Branott Fie Yallim Cusionar ' • 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 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 occupancv 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 ermits 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 me. Date Address of work location •,- — - , • -• , The Commonwealth opfassachusetts Department of Industrial Accidents I ... ....,......... 1 . = gri Office of Investigations • 600 Washington Street —•=1:4 =e. V I -f— Boston, MA 02111 - K--Y O - ' www.mass.gov/dia , • _.. -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information • Please Print Legibly Name (Business/Organization/Individnni): — 1 - 5e- fl 744 • • Address: 9 tcq 0 C, pfnb<4 /e1 nel Z iI) , - . 1 , , City/State/Zip: (trk t-, 6,--_,..307 Phone.#: Or (a Are y pd an employer? Check the appropriate box: Type Of project (required) 17 1.9ri am a employer with 1 DO 4. 1:1] I am a general contractor and I 0 : New employees (full and/or part-time).* have hired the sub-contractors 6. construction sted e 2.0 I am a sole proprietor or partner- li on thattached sheet 7. DR.emodelin . ship and have n.o ez.ki—loyees These sub-contractors have 8• 0 Demolition • worlang for me is any capacity. eirffilPYtre§and have workers 9. . Bulldog- addition # - Rio workers' comp-. insurance required] - 5. D We are a corporation and its 10.E1 Electrical repairs or additions 3. D I am a homeowner doing all work officers have4xercised their . 11.0 Plmning repairs or additions , b myself [No workers' cOmp. riert Of exemption 'per MGL 12.1:2 . - insurance required.1 t • c . 152, *1(4), and we have no employees. [No workers' 13. Odier 0( • comp. insurance requiredj • - *Any applicant that checks box #1 must also fiII out the section belowshowing their cornpaisation policy information. 1 " Homeowners who submit this affidavit indicating they are doing all work and then !tire outside contractors must submit anew affidavit indicating such. :Contractms 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 mustprovide their workers' comp. policy number. lam am an employer that is providing workers' compensation insurance for my einployees. Below is the policy and job site information. Insurance Company Name: . .Vt .k kiy 1(4 ---k KID ' . • . Policy # or Self-ins. Lic. #: --24 c-Q Expiration Date:-:fla____ I :7 A .i Job Site Address: E 1.--1. i ly ,L 0,c otrstafrizip. _____cl Attach a copy of the workers' compensation poll eclaration page"(showing the policy number andeapiration date). . • . _ _ , Failure to secure coverage as required under Section 25A 'Of MG-L c 152 can lead to the finpOsitiOn of ii ii Penalties of a fine up to S1,500.00 ancVor 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 Eiriitliatimis Of the 1' or insurance coverage Verification. _ .. ._ . , . - ., _ do . h . I erettycertz der and enalties ofperjtay that the information provided.a.boveiu!rue_and_corrpet„ _ Signature: ( ' I 4/..r i L. Date, iip 1 . ,, - Phone it: - L i 5 ---( ' -:-. 3 - - . Offic.itzl use only. Do not write in this area, to be completed by city or townafficiaL • • • City or Tovvri: .- Permit/License # ' Issuing Authority (circle one): .1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricaljnspector 5. Plumbing Inspector 6. Other . . . Contact Person: Phone #: r , • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ / Name of License Holder : T if l d14 \J.! f J License Num T 7 �� Addres arm Expiration Date • Signatuie Telephone 9.:Rettistered3. Home Itngrc ettient oritraa r . 4 -vatalzt Not Applicable ❑ Company Name Registratio Num er Address Expiration Date — �i�% r �It /rL 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 ❑ i 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 W' ows Alteration(s) Roofing 0 Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [D] Brief Description of Proposed f r-- Work: 11� 1 1 1 l t� ��l `Z( ` ► c i C I Alteration of existing bedroom No No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet ate" � � �.,�_� rur �� '"�'i'�� �_�� � �?��" a��� sa . Me ii % . Iii ,. ati . d aiFM ilrti e�i it it fi foil ring: 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 J k. Wifl building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ( D ) * 2 c , 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. 1� Signature of Owner Date 1fI as , 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 p -• penalties of perjury. Print Nam MN i f ) Signature of • ner /Agent Date a . 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 , t I' t Frontage . _ ' i t i Setbacks Front 1 i 1 ----- i , Side L: ' R . _ i L:1 1 R:l Rear = I i Building Height 1 t Bldg. Square Footage = = % , 1 = [ J Open Space Footage ii % (Lot area minus bldg &paved 1 ._ parking) # of Parking Spaces ,._ Fill: I � (volume & Location) i ..... L 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:1 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book 1 = Page! 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q 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 0 NO 0 IF YES, describe size, type and location: € 7 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: . 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. City of Northampton n t` sa, Building Department 212 Main Street Room 100 51,Q ate N CV 1 I46rtham MA 01060 phone 413 - 587 -1240 Fax 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 Map -`, Lot = Unit ) ` Zone Overlays District Eim St. District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Vpyjfi • Name (Print) Current Mailing Addr s : .14 c Telephone Signature 2.2 Authorized A. =� Name (Print • L/ Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building iQ l (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) 99 [ -- Check Number 3 This Section For Official Use Only Date Building Permit Numb .sued: /111W-40eir F A Signature' '/ ✓ ' Building CommissioneNlnspectar ofiBuildings Date • 41, BP- 2011 -0480 GIS #: COMMONWEALTH OF MASSACHUSETTS c 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-2011-0480 Project # JS- 2011- 000786 Est. Cost: $2497.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 13111.56 Owner: KOCHIS ANN M & MARILYN KUSEK Zoning: URA(100) //WSP Applicant: HOME DEPOT AT HOME SERVICES AT: 58 ELLINGTON RD Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 - 9401 WORCESTERMA01607 ISSUED ON:11/23/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT DOOR 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 11/23/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 sue www.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /organization/individual): l; 1''O 11 1) & 2E0NA �& N (T i » L = 1 c Address: k •-• �vJ City /State /Zip: S1 An'lt i�Cv t'L r K( A btu 11 Phone #: } I" 5-2c) Are you an employer? Check the appropriate box: Type of project (required): 1.5 I am a employer with � -- 4 . 0 I am a general contractor and 1 ; employees (full and/or part- time).* have hired the sub- contractors 6. 0 ltiew constriction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. N1 Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition working for in employees and have workers' rIting arty capacity. ir�ure.# 9. 0 Building addition [No workers' comp. insurance comp. required.] 5. fl We are a corporation and its 10 .0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 1 1.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance ] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp insurance required.] =Any applicant that checks box #I nest 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. �y Insurance Company Name: Vi Nt' i - � �` Yt a l l`I SU 42 rtt A �s C` f l i 1 [} (' L Policy # or Self -ins. Lic. #: 0 `7 ' Z Cv 5 rE Expiration Date: ' 1 2 1 1 11 Job Site Address: t`i Ll I (V1 (I r n ore Yl Lc, City/State/Zip: 0 10 'Z Attach a copy of the workers' c 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.(X ) 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 do hereby certify un and penalties of perjury that the information provided above is true and correct. c- i Signature: Date: I Phone #: LI 1 3 5 2ci - O1+L1 Official use only. Do not write in this area to be completed by city or tmm 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 #: 0 ( s SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) 1 i/4 I to .rcito fibici_c License Number Expiration Date Name of CSL- Holder 2 , TC 0/0_6 e c ) ' 5I ((VAt,vt � List CSL Type (see below) Address Tme Description (% Unrestricted (up to 35,000 Cu. Ft.) R Restricted 1 &2 Family Dwelling Signature M Masonry Only 05-1-1-4 RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Igrovemeiit Contractor (HIC) 6 - HIC Company Name or HIC R Nartie Registration Number Address 1 113 5`2A -- O Expiration Date Signature Telephone SECTION : WORKERS' COMPENSATION INSURANCE AFFIDAVIT 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 12 No . ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT /o OR CONTRACTOR APPLIES FOR BUILDINGPERMIT I, AIC S,� / , as Owner of the subject property hereby authorize INP to 4( aV e'c'J7 navy de rir✓ to act on my behalf, in all matters relative to workduthorized by this building permit application. 42 0 . K - 9/(191 it Signature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION 6 ort �Y r�r. C'f.,? ac h r as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf_ 7 r -YJI Print Name 1/6 Signature of Owner o . 'ra Agent Date (Signed under the pain and penalties of perjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned, provide the information below: Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for "Total Project Cost" The Commonwealth of Massachusetts �Q Boated of Building Regulations and Standards FOR ` 7th MUNICIPALITY D: Massachusetts State Building Code, 780 CMR, 7 edition US E �Q Building. Permit 3plication To Construct, Repair, Renovate Or Demolish a Revised January One- or Two - Family Dwelling 1, 2008 This Section For Official Use Only Building Permit Number: Date Applied: r ,. Signature: Building Commissioner/ Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property )n10-1,(1 Address: ` 1.2 Assessors Map & Parcel Numbers t b 4 i, { P nc-e 1.1a Is this an acepted street? yes , / no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public ID Private ❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP'` 2.1 Owner' of Record: . NI c hG Kg o0s1� -t l°t E I ► v1 ttn N e (Print) Address for Sery e: �! j l ne- Q .ices--le- - 2- 10 _ c t S s I Signature % Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building Owner - Occupied Er ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other El vJ?a teiVI(4 1Qrt / Ivtbti((tiht V1 Brief Description of Proposed Work A � � C eit� t use, S Vk C v4 C - t - o (t 4 h c, - � u l z - 1 S AL rcre 4 enV i' c~f rt 1 t VL a 41 tit 19t I c21 , 10-0,.Pc_ - t dog✓ i< / t vi Stk. l 4 t Act-3r ✓` (4Ct ee- d- c v Vlr c, S-e4 i d i, 4ti '�- SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials) 1. Building $ -7> co o i 1. Building Permit Fee : '$ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ ❑ Total Project Costa (Item 6) x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ 311 D Total All F• s Suppression) l Check N. v • heck Amount Cash Amount: 6. Total Project Cost: $ 7i t» � � 0 Paid in Full ❑ Outstanding Balance Due: File # BP- 2011 -0239 APPLICANT /CONTACT PERSON SEAN JEFFORDS ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416) 529 -0544 PROPERTY LOCATION 19 ELLINGTON RD MAP 29 PARCEL 433 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 6(28610d/ r 6 - Fee Paid J Typeof Construction: INSTALL ATTIC/BASEMENT INSULATION & REPLACE FRONT DOOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 074539 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 V IC 0 Signature of Building Of icial 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. 19 ELLINGTON %) r - BP GIS #: COMMONWEALTH OF MASSACHUSETTS lap :Block: 29 - 433 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-2011-0239 Project # JS- 2011- 000402 Est. Cost: $3000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEAN JEFFORDS 074539 Lot Size(sq. ft.): 10018.80 Owner: KOLOSKI GERALD C & NANCY A Zoning: URA(100) //WSP Applicant: SEAN JEFFORDS AT: 19 ELLINGTON RD Applicant Address: Phone: Insurance: 13 TERRACE VIEW (416) 529 -0544 WC EASTHAM PTON MA01027 ISSUED ON :9/17/2010 0:00:00 TO PERFORM THE FOLLOWING WORK :INSTALL ATTIC /BASEMENT INSULATION & REPLACE FRONT DOOR 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 9/17/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner