36-215 Construction Design
Mark Bonde Policy No# (Liability) MP020651 Finck & Perras Ins Agcy.
Gen. Contractor Policy No# (Wk's Comp) UB- 8139B27 -7 -07 413 527 -5520
General Liability Dates 8 -15 -2010 To 8 -15 -2011
Workers Comp 3 -13 -2011 To 3 -13 -2012
Gary L Kostek Policy No# (Liability) MP064863 Finck & Perras Ins Agcy.
Plumbing Policy No# (Wk's Comp) WC064863 413 527 -5520
General Liability Dates 6 -27 -2011 To 6 -27 -2012
Workers Comp 6 -27 -2011 To 6 -27 -2012
NRB Exteriors Inc Policy No# (Liability) CP49710701 Chaffee Helliwell Ins Agcy.
Roofing Policy No# (Wk's Comp) WC8738203 413 536 -0751
General Liability Dates 6 -07 -2011 To 6 -07 -2012 Workers Comp
3 -19 -2011 To 3 -19 -2012
Urban and Sons Insulation Co. Inc.
Insulation Policy No# (Liability) CPA018807913 McClure Ins Agcy. Inc.
Policy No# (Wk's Comp) WC8738203 413 536 -0751
General Liability Dates 6 -07 -2011 To 6 -07 -2012
Workers Comp 3 -19 -2011 To 3 -19 -2012
Aaron Morin Policy No# (Liability) 2008X0180 Meyer Agcy.
Heating & A/C Policy No# (Wk's Comp) 2008W6194 413 582 -0332
General Liability Dates 1 -19 -2011 To 1 -19 -2012
Workers Comp 3 -23 -2011 To 3 -23 -2012
Kurt Mengel Policy No# (Liability) Ross Ins. Agcy. Inc.
Electrician Policy No# (Wk's Comp) WC20 -20- 001319 -01 413 536 -8380
General Liability Dates 6 -02 -2011 To 6 -02 -2012
Workers Comp 11 -28 -2010 To 11 -28 -2011
Rod,s Drywall Policy No# (Liability) Ross Ins. Agcy. Inc.
Sheetrock Policy No# (Wk's Comp) 413 536 -8380
General Liability Dates 1 -16 -2011 To 1 -16 -2012
Workers Comp 1 -15 -2011 To 1 -15 -2012
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
H•
• V www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Leiibly
Name ( Business / Organization /Individual): n.lti'�r C 4 Cl...) TA 1;3
Address: `z 0 S
City/State/Zip: `° �� Phone tY P� ` �5 A�NP`CZ�= f � 1� P
Ci one #: V Zsii
Are you an employer? Check the appropriate boy Type of project (required):
I. ❑ I am a employer with 4. appropriate
a general contractor and
employees (full and /or part- time).
* have hired the sub - contractors 6. Q New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. - Remodeling
ship and have no employees These sub - contractors have 8. Q Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9. Q Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t 'Homeowners who submit 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 most 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.
Insurance Company Name: f4 t- NA 121"
Policy # or Self -ins. Lic. #: 1, 1 �j a 13 2 1 — 1 —01 Expiration Date: 3 • 13 $ 1 2.
Job Site Address: )-b L�Ltcc -1 City /State /Zip: d 16 bC
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 of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify un r the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: -2/0-- J
Phone #: 13 'Z: Ci ? , ( 1
Official use only. Do not write in this area, to be completed by city or town 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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name-of-License- Holder : NtZ.r ^ 2c.*- h F - (77 5
License Number
u — PA , R.R.- S . / • 5 - PT" 1.1 d- 1- 2-1 7_
Address Expiration Date
7 (rx u/3 5z9 Zt 7�,
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
esF CJ )k.15c7uCrtc513 1 b92Z '
Company Name Registration Number
2 -- e\--k 1 (a - Z -1
Address Expiration Date
170 t` f- Telephone 54
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 buildi 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 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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [0] Other [1
Brief Description of Proposed
Work: NT 7—EtAa
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 following:
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
1, 6-Trig' E L E! , as Owner of the subject
property ` , ^-�
hereby authorize ` -, f R K — Bow, D
to act on my beha 'n all afters elative to work authorized by this building permit application.
2S - l
Signature of Owner Date
a.rl--\ 0t4r , 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.
)J\ArcZK hF
Print Name
,, .mot t -
Signature of Sr -r/ • -nt Date
„
1
E' Department use only
" CD
RE V G City of Northampton Status of Permit:
Building Department 'Cut Drivewayllemit
juti 2 8 2011 212 Main Street Sewer /Septic Availability
Room 100 WaterNVeil Availability
of BUILDING INsfEonoNII rthampton, MA 01060 Two Sets of Structural Plans
Noanw+ - 587 -1240 Fax 413 -587 -1272 Plot/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
off- D bI / f , GC/i "— Map lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
-A ( V PALES 6 D if& a -
,t Name (Pent) Current Mailing Address:
Telephone
Signature
2.2 Authorized fluent:
M - ate ?)651,31)E 5 ' ,ck : ? E�57 rlr,,�, 4t
Name (Pent) u rrent Mailing Address:
� ' , 524 �:2J 76
Signature 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 ,�j
6. Total = (1 + 2 +3+4+5) q ec) Check Number t "`5 b
This Section For Official Use Only
Date
Building Permit Number: Issued:
Sign; :
Building Commissionerllnspector of Buildings Date
File # BP- 2011 -1100 `
APPLICANT /CONTACT PERSON MARK BONDE
ADDRESS/PHONE 205 PARK ST EASTHAMPTON (413) 535 -9529 Q
PROPERTY LOCATION 20 BIRCH LN
MAP 36 PARCEL 215 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /1 �`j9 oscs
Fee Paid �,7jJ
Typeof Construction:_REMODEL BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 67758
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INATION PRESENTED:
Appr oved 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
6%
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.
20 BIRCH LN BP-2011-1100
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 215 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 -1100
Project # JS- 2011- 001767
Est. Cost: $8900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK BONDE 67758
Lot Size(sq. ft.): 601 12.80 Owner: MALEK THADDEUS B & EUGENIE A
Zoning: SR(100) //WSP II Applicant: MARK BONDE
AT: 20 BIRCH LN
Applicant Address: Phone: Insurance:
205 PARK ST (413) 535 -9529 0 WC
EASTHAMPTONMA01027 ISSUED ON:6/30/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATH
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 6/30/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner