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31A-072 (2) . * Ali Co mmonwealth of Massachusetts , ; City of Northampton lo ;, Partial Certificate of Occupancy f f p y In accordance with 780 CMR, Section 120.0 (The Seventh Edition of the Massachusetts State Building Code with 2009 IECC) :,', this Certificate of Occupancy is issued to the premise or structure or part thereof as herein identified. Identify Name of Building of Space Within, Building Owner, or Permit Holder Certificate No. Issued to Renee & David Dietz BP- 2011 -0072 Identify property address including street number, name, city or town and county Located at 222 Elm Street Northampton, Hampshire, Massachusetts Use Group Classification(s) Three Family Residential This Certificate of Occupancy is hereby issued by the undersigned to certify that the premise, structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the use as herein described and in conformance with any and all conditions as identified below. It shall be posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate, failure to comply with conditions or, tampering with the contents of the certificate is strictly prohibited. Conditions of Use Three Family Home - Partial for third floor and egress only. Safety and Structural Systems must be maintained. Name of Municipal Charles Miller '' Date of Final Map /Plot: Building Official Inspection 06/03/11 Signature of Municipal Date of 31A -072 Building Official d4 Issuance 06/03/11 • the Cowrns:n•ea4sh o f,tlfassachusetts • r<A� 1. 7 ..c� of industrial a1t'txtt'ssrrts • 71};11.• r1 Office of invest igaltiorts ' -y AN_ - • 600 Washington Street = z" Boston, MA 0211.1 - • .— te : "Y..� • www.m€ssgov /dra . • •Workers' Gsunpelasation nonce Affidavit: Builders/ ContraciorsiEElectrician .sfPiumhers A i, 'cant , ormat - 'lease .Print . l . - game Orgat> ticeinudividnal):. ' (i 0 R . • • Addnes- MIL t CityIStateiZip: w r .r.... 4 ' • . �►1 o #: " . I L5 Are you an employer'. Check the appropriate box: , The ef*eke t (regtuired) d 1.0 1 am a t giisyer vrnl�h 4.. Li I am a general contractor and I ] N r ,call aadinl tined.* have hired die sub- contractors on 2.0 I ant, a sole Eic onr or par r- listed on the attached sheet 7. mo de . ship and have no eatplaye These sub- ,.ontractors have. . .8 0 zw . working for in any capacity. employees and have workers' g ❑ Building addition [No workers' comp ins . uince comp. b e.t r e q u r e d . ] 5. igit W are a c ., r tiro and lb 10,0 EieStrical repairs or addmcrts t ' 3.0 I aru Isomer weer doing all work officers have w. - ed. dick - 1 L El Plumbing repay or additions . mapelf. Arworgers' coo*• right of exemgilcin per MGL 12.0 Root . insurance r yt j . E. 132, i 1(#). and we have no • employees. [No workers'. 13.0 Other • r ., t11017 axle reqnaedd 'Any applicant that theatasbak all Ullat 4 fal out the ;Mica Wow ShOw+itg their workers' easuponsttioa policy Wormed= t othuli anti: who subunL His attvt thong tY tea doing all evert and diet hive outside contactor must avbmon a wow anSdavir indicatthg such ICoserscLOs that c wJcthia Lox meet cEggehed an addi shoot shorting the cons or the sulivocaractors and sum whether or not those cattier have • • esuployees. If the subtoonnitors ha+ro yyrca- „ 3' lalasselaneide their Fotic'Y auntha- !mn an employer that is providing workers' compensation insu ante fir my esepioyeea: Iterow is the policy and job site iirforrntaian. . • Insurance~ Company Nano: Policy # or Self ins. Lic. #: .. Expiration Date: • • • lab Site Atkh+ess: City/State/Zip: - • • • • Aktach a ems, of the ^werikers= conipens po e9 n p age - (sha+wing the pulley number and expiration date). Failure to secure coverag as required under Section 25A of MGL c_ 152 can lead to the iatposition of crit m iL penalties ofa faro up to S1,500.00 endlor ore -year imprisonment; as well as civil peaaides in the form of; STOP WORK_ ORDER =de fine of Up to $250.Q12.1. dui against the vioisior. Be advised that a ectiyof this stattsmcnt may be fora dot to tlis O fi'ce of . ._:ti • .:. , . of the DIA.tr ""Rr. co �. - - vedSca ; out. !do hereby a under 1m , r • , annl pies of penury that the Information p ed above is true and Tarred • Si. A Ili - ,r_71-r7 ts- ip , l • --�� _ r T o , .. Do not rerstetn. arm is - - - -- ?a y ci 7 or town ofJ1cfat 0 City or Town: • Permit/license # I Issuing Authority (circle ens): - 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Piwubing Inspector 0 d. 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' - 17 - . /. 17 -- ��\` • / � �� w � � _ ... ._ ' 1 L _1: '4 ^2—— -----� w .. ~H. l' L. / ~~`~~^-/ pr,t...~^rrr"^" 1:.::::-......1.....1 \ __ �� _� _� � t �"�s Name | | �.0 `\ \ | • �--- usg�" • ' �� � v �u �°^n` ,, - pnpr"^�pr°w./^^ } 1 1+ ==r | �� �� -- �7 ���--- -- - ] L� ���� [] ' ( / | ` u * / / / / -___.___�_-___- -� [ [ ���-���e ' ,-_� __-�/ / | � ' -----�-- | -^ '-- . | �r�r±__----� ) ���.�s- [ , - . --� 1._ _ y —___— ' --� j- I rz,�[ r-L.,cc, r-t, e1 • .. ) ����. &�~ �___--- ' ___'___-__� ' ___ m~./w" \ � � ---------'----- ' ------- --'----'------'----'-- ' � ----- --'--- r --------�----- ____.....1 OP ID: RH ,d►coRO° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/24/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 413 - 594 -5984 CONTACT PHILLIPS INSURANCE AGENCY INC NAME: R omy Harrow 97 CENTER STREET 413- 592 -8499 A Nu, E :t), 413- 594 -5984 (A,C, No): 413 -592 -8499 CHICOPEE, MA 01013 E-MAIL romy @phillipsinsurance.com Chris is Rivers PRODUCER DIETZ -1 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED Dietz Construction Corp INSURER A : Travelers Insurance Company 7 Industrial PKWY INSURER B : Travelers Property Casualty 25674 Easthampton, MA 01027 INSURER C : Charter Oak Fire Ins Co INSURER D : INSURER E : ' INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR, WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 4TC0- 8665N798IND10 08/26/10 08/26/11 DAMAGE ( rE PREMISES (Ea REN ocanence) O $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 A X XCU 4TC0- 8665N798IND10 08/26/10 08/26/11 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY ^ PE O LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) B ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS BA8682N377TIL10 08/26/10 08/26/11 PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NONOWNEDAUTOS _ $ $ UMBRELLA LIAB X OCCUR . EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 2,000,000 B 4TCUP8665N798TIL10 08/26/10 08/26/11 - DEDUCTIBLE $ RETENTION $ $ — WORKERS COMPENSATION X S TATU- 0TH - AND EMPLOYERS' LIABILITY TWC ORY LIMITS ER C ANY PROPRIETOR /PARTNER/EXECUTIVE Y / N N / A 4TOUB8669N72410 08/26/10 08/26/11 E.L EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under D ESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 A Equipment Floater 4TC08665N7981ND10 08/26/10 08/26/11 Scheduled 1,386,500 Leased /Re 250,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Residential work, water & sewer lines CERTIFICATE HOLDER CANCELLATION DAVIDMD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David M. Dietz ACCORDANCE WITH THE POLICY PROVISIONS. 222 Elm Street Northampton, MA 01060 AUTHORIZED REPRESENTATIVE ���Fl S�ENTATIVE • —�"�? ' A�' l I ( %� • © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Versionl .7 Commercial Building Permit May 15. 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No Q SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, I Ark) l`YJ. ( ' �-' ` , as Owner of the subject property hereby authorize t CA'Iv(,,,) ) t r to act on my b- • . • all m -- relative to work authorized by this building permit application. / ` K, -3 , 2 "(/ SignIofOwner — Date 1 +V ..- be it) 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 ins a ; '. penalties of perjury. 00 ' �- ilk Print Name vs 1 O( 311 Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: �j J Not Applicable ❑ Name of License Holder : is e r +' ( ' v 51, `p)- License Number 1 6 CI 9-b v c L MA' 0 10 1-3 ' co l- / t i Address Expiration Date L(I.3-G4 1 0 Signature 24-A Telephone SECTION 13 - 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 X No 0 Version1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size ' atiL O Frontage Setbacks Front Side L: R: L: R: Rear Building height Bldg. Square Footage Open Space Footage (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 Q DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 3 YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO C DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q 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 ed 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 a IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations iG Existing Wall Signs ❑ Demolition 0 Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. Kc- �'`G � .�'4 ' c�� 4 tJ6. 1-'v i r� %v,j j ke el ac. e Of Proposed Work: l-k-Gat" +A Hcft i�uA ci Re' e l tec t ics; f e.vr k k *-ke nv A Q,t N fS el A f,pDIt twCc-s tr. fo kec, S t cow) F lac , 3 A ttt v -cj j .e.. SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential st R -1 ❑ R -2 '51 R -3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S -2 ❑ 5B U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA . BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) ifki G` �� 1St 2 nd 2 3 d 3rd 4 4 Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewa.e Disposal System: Public Private ❑ Zone Outside Flood Zone Municipal is On site disposal system❑ r Y •+ • Version1.7 Commercial Building Permit May 15, 2000 Department use only EIVED City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - 212 Main Street Sewer /Septic Availability Wit 24 2411 Room 100 Water/Well Availability ■orthampton, MA 01060 Two Sets of Structural Plans y . of BUILDING INSP= e 4 3- 587 -1240 Fax 413 -587 -1272 Plot/Site Plans NORTHAMPTON MA0i Oi ' — ' — " _ I Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office )- CL-vv -ST Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: - D A. [O1) i fiz � E Alec_ We: cr i M S b t r^cl.. (( ow Name (Print) _ �. Current Mailing Address: .4 1 1 0 -^ev∎) d t o G� Signature Telephone Le t:\ l j s F, .® N a-6 1 2.2 Authorized Agent: 14 &V "AU b 1 0:1" r € UrU A) ost• Name (Print) Current Mailing Address: S t L -..►IP 41PV0 I OW 0 10 Signature . ` 4,s4tif /. P M/A l Telephone L i 1 3-6 to ci SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building i 15 ; 000 (a) Building Permit Fee 2. Electrical 4 (b) Estimated Total Cost of I © Construction from (6) 3. Plumbing 4 lot a/l Da Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection '1 0, 0®U0' 6. Total = (1 + 2 + 3 + 4 + 5) ¶ 00 000 4� Check Number aQ / 4 D This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0762 APPLICANT /CONTACT PERSON HERMAN R DIETZ ADDRESS /PHONE 76 GUNN RD SOUTHAMPTON (413) 626 -3169 PROPERTY LOCATION 222 ELM ST MAP 31A PARCEL 072 001 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 $` 1 0 4 Fee Paid /LP "?�O Typeof Construction: RENOVATE 1ST FLR KITCHEN,2ND FLR BATHROOM & INSULATE ATTIC pole; A N New Construction FS w tLt.. QE — Non Structural interior renovations Addition to Existing q t,( -4 E S l Accessory Structure 1 ttWi" FE kW CV' Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO,VMATION PRESENTED: p prroved 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 16W 3/2_,S11( .c/ � % ' u � 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. • 222 ELM ST BP-2011-0762 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 072 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -0762 Project # JS- 2011- 001108 Est. Cost: $80000.00 Fee: $480.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HERMAN R DIETZ Lot Size(sq. ft.): 26266.68 Owner: DEITZ DAVID & RENEE W Zoning: URB(100)/ Applicant: HERMAN R DIETZ AT: 222 ELM ST Applicant Address: Phone: Insurance: 76 GUNN RD (413) 626 -3169 SOUTHAMPTONMA01073 ISSUED ON:3/25/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE 1ST FLR KITCHEN,2ND FLR BATHROOM & INSULATE ATTIC - ANY EXTERIOR CHANGES REQUIRE ELM ST DISTRICT PERMITS 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 3/25/2011 0:00:00 $480.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner