29-545 it 1'T/'7 1 ' ,+'RAT 1117.51 . FAX No, P . 20_�, ' I - I
ACORD
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIVYYY)
08/10/2012
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 CONTACT
NAME:
Webber & Grinnell Ins. Agency, Inc. PHONE Exit): 413. 586 I FAX 413 58
8 North King Street E-MAIL
ADDRESS:
Northampton, MA 01060 ( PRODUCER 00005763
CUSTOMER ID #. _ _
INSURER(S) AFFORDING COVERAGE I NAIC #
INSURED INSURERA: WCAR- A.I.M. Mutual
Stiebel Properties, Inc. INSURERS:
242 Suffolk Street
INSURER C
Holyoke, MA 01040 -4456 INSURER D:
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 2012 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 DDL al rIGT EFF P LICY EXP
LIMITS
LTR INSR WVD POLICY NUMBER MMdDD(YfYY) IMM /00/YY'YI
GENERAL LIABILITY
EACH oEcEiPRFfI L 5
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vrN VN 1010212011 1 1010212012 In r L MTs 1 Er`
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WORKERS COMPENSATION r — , ,...
I - - c V NIA - L _ACH__CIDE IT 5 -
an in N $ 500, ��
A FI d a o r in H P E a D., i C ERN E - L - I LC 500,000
P E I ict i,� t
r
(Mandatory � I
i` 500,000
�iBErbE POLICY aiT $
16E_ _ .API ON 5r APE ��:LIGh15 C .r_,. � -- '
I 1
i II DESCRIPTION OF OPERATIONS I LOCATIONS !VEHICLES (Attach &CORD 101, Additional Remarks Schedule, If more space is required)
l To provide evidence of workers' compensation coverage
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE /7 t. l ri . yNt : I
For Insurance Verification Purposes (Janet Sanuita, CISR /JAS
1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
SECTION 8 - CONSTRUCTION SERVICES
:.1 i ens • n t n !. • r: /� Not Applicable ❑
Ne of L
amicense Holder : Q, �. `� § ( " "kt\ b 1 t
License Numbe
l 9 1 ) 3
Address Expiration Date
Telephone
� 1 4 ; — L 7
• C 4 • - u: .t -. • r: Not Applicable ❑
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 ❑
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 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 assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Loc oning 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 ❑
Accessory Bldg. El Demolition ❑ New Signs [D] crs [0:4 Siding [p] Other [co
Brief Descriptio Propos �]� �
Work: ��C.l�.i -a S ] c3N\ S ,
Alteration of existing bedroom Yes _ No A •ng new bedroom Yes �_ No
Attached Narrative Renovating unfinished basement Yes )s; No
Plans Attached Roll - Sheet
6a. If New house and or addition to existina housing, complete the followina:
a. Use of building : One Family Two Family _ _ Other
b. Number of rooms in each family'vnit 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? _ _ Fireplapel or Woodstoves Number of each
g. Energy Conservation Compliance. _ asscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is co ruction 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.
Print Name
Signature of Owner /Agent Date
s
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
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 cial Permit /Variance /Finding ever been issued for /on the site?
NO DON'T KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
0 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, x vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• : Department use only
r ...
City of Northampton Status of Permit
( Building Department Curb Cut/Driveway Permit
;212 Main Street Sewer/Septic Availability
Room 100 WaterA#Vell Availability
I 0 2M2 ort ampton, MA 01060 Two Sets of Structural Plans
phone 4 3- 7 -1240 Fax 413 -587 -1272 Piot/Site Plans
Other Specify
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
f � V1 ,, r V\ s \ \ Map Lot Unit
` r1C+ m L t(° Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name (Pent) Current Maili ddress:
Telephone
Signature
_-_2.2 Authorized
3‘k.cRIA-• ,<-7 i
Current Mailing Address:
S', . re A Telephone
SECTION 3 - E' MATED CONSTRUCTION COSTS J
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building � p V c (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing LI-C 7 , C7C Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) 10•04( . L,` Check Number )9a'" 4)/
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0160
APPLICANT /CONTACT PERSON DANIEL JACKMAN
ADDRESS /PHONE 242 SUFFOLK ST HOLYOKE (413) 535 -1734 ()
PROPERTY LOCATION 35 INDIAN HILL
MAP 29 PARCEL 545 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out y�� , j ) t�
Fee Paid p/`�l 11
Typeof Construction: REPLACE DECKING & RAILS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 88226
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
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
1 g
V f'
Signae of Building • ' i•' .1 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.
35 INDIAN HILL BP- 2013 -0160
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 545 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- 2013 -0160
Project # JS- 2013- 000259
Est. Cost: $1400.00
Fee: $110.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DANIEL JACKMAN 88226
Lot Size(sq. ft.): 16378.56 Owner: STIEBEL PROPERTIES INC C/O STIEBEL PROPERTIES INC
Zoning: Applicant: DANIEL JACKMAN
AT: 35 INDIAN HILL
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 535 -1734 () WC
HOLYOKEMA01040 ISSUED ON:8/14/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE DECKING & RAILS
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:
FeeTyp Date Paid: Amount:
Building 8/14/2012 0:00:00 $110.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner