06-023 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(les) must be-endorsed. If SUBROGATION !S'WA!VED, 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 !feu of such endorsement(s).
PRODUCER 1 NAME.
Martin 3. Clayton Insurance Agency, Inc. i r ac PHONE 413.536.080 � — N a! 413 ii 534.7874
1649 Northampton Street !R�E SG
P. 0. Box 989 INSURER(S) AFFORDING COVERAGE NAIL #
Holyoke, ! A 01041-0989 INSURER A : AIM MUTUAL INSURANCE COMPANY AIM
INSURED ,Q chard DaP «'3.Si INSURER 8, ? I
DBA: Pool Tech INSURER C: 1
P.O. Box 705 ;INSURER O: I i
Holyoke, MA 01041 I INSURER E : I _ i
F INSURER F
COVERAGES CERTIFICATE NUMBER: POOL TECH REVISION NUMBER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B LOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR T POLICY PERIOD 11
• ;NNCATED. NOTWI THST.ANDI NG ANY REC?IJIREMENT, TERM OR r ONDI'TION OF ANY CONTRACT RACT OR OTHER DOCUMENT WITH RESPECT TO 'NH ICI-1 T I YID I
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 13 SUBJECT TO ALL THE TERMS,
FXCI USIONS AND CONDITIONS OF SUCH POLICIES. LIMI IS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I
— ADDL SUt eki — I POLiCCY hEi- POLICY EXP
MR TYPE OF INSURANCE LIMITS
LTR � ( INSR� WVD I POLICY NUMBER �MM1D6/'YYYY) � (Mfd1DDIYYY�i}
GENERAL LIABILITY , I t At.rt OCCURRENCE $
I 1 I UAMAUE TO HEN t to I
1 COMMERCIAI. GENERAL t.IABIL.ITY ! 1 i !PREMISES (Ea occurrence) I $
i 1 CLAIMS -MADE (. j OCCUR { MED EXP ( Any one parson) 1$
I I 1 I
PERS w AL ^D INJURY $
i ! 1
f GENERAL A ^ t ELATE
GEN'L AGGREGATE LIMIT APPLIES PER: i 1 !PRODUCTS - COMPlOP AUUG $ 1
1I )PRO_ I i, .. I I$
I I I I
1 I POIMA i ) JEC e j I �i�
1 AUTOMOBILE LIABILITY I �(EE aB accident)
1NGLET1MIT I $
R{1 1 YINJURY (Per n_s P) ! $
I ANY AUTO 1 I
L OW
I I ALL I SCHEDULED I I I , accident)! _ _ $
I I T ^� !__i AUTOS
, , SCHEDULED BODILY INJURY ( Per
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I I I I NON -OWNED { rPRGPERTY-D $ _
HIRED AUTOS TOS /Per accident)
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I UMBRELLA LEAS I � <,.. I LA ^ CL' RENEE W
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CLAIMS -MADE 1 I AGGREGATE $
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.WORKERS COMPENSATION I y VWr6n02547O1 08/04/2012 � 08/0412013I X I vac sTATii I oT�-
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AND EMPLOYERS' LIABILITY Y I N I , _._
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. I ANY PROPRIETOR /PARTNER /EXECUTIVFr I wr s I I I I E L EACH ACCIDENT I $ $ 100,0001
r� OFFI .ER/MEiviBER EXCLUDED? I I I " v
(mandatory m NH) 1 1 I E t DISEASE EA E MPLO EE, 100,000
I 1
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It yes, describe under I ' I I r 0d0
DESCRIPTION OF OPERATIONS b &ox, E.L. DISEASE POLICY LIMIT $ SO0,
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DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEH /CLES (Attach ACORD - 10i, Additional Remarks Schedule, It more space Is required) j
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CERTIFICATE HOLDER CANCELLATION
I sunup S- D ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POI ICY PROVISIONS,
POOL TECH kfTHORIZED REPRESENTATIVE
P 0 BOX 705 ` r • , , i a � , " / J.
H 1
OLYE MA OIJ41
OK, . r .. - T ai rice - p --z' (�.., ( �( - ,
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C 1988 -2010 ACORD CORP ATION. Ail rights reserved.
ACORO 25 (2010(05) The ACORD name and logo are registered marks of ACORD
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City of Northampton `
Massachusetts , ti
DEPARTMENT OF BUILDING INSPECTIONS � j rn w;
v ' � t - 212 Main Street • Municipal Building -b :�*.
.`. -,4 Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner 4 • 4 Assistant Commissioner
A . 4
4, 4 4+ 4 Y 4, , 44 , +
4 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 tie, a one or two family dwelling, attached or detached structure
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 any 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 permits 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.
ome ow er / resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date 3-1?-0
Address of work location ✓? itCJ-.9,2I2 5,/
IE DJ, 74 0 ios3
The Commonwealth of Massachusetts
Department of Industrial Accidents
«, �. Office of Investigations W
600 Washington Street
,�. ; Boston, MA 02111
'''',t www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers /
Applicant Information Please Print Leaibl .
• 1 1 ,
Name (Business /Organizatio dividu T0 (744) _
Address: / , gel a( 7a5
City /State /Zip: /l o L yOt(E /14- Phone #: 1I / 3- 5.3 - 0 Z'o e
Are you an employer? Check the appropriate box: j � E re and I Type of project (required):
1. 111 I am a employer with 4. [ I am a 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2. n I am a sole proprietor or partner listed o n the attached sheet. 7. Ell Remodeling
, ship and have no employees These sub - contractors have 8. ❑ Demolition 1
for me in any capacity. employees and have workers'
working y p Y 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
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. ❑ Roof repairs
insurance d. uire
re t c. 152, § 1(4), and we have no
required.] Other fge0i.. Aeotr
• employees. [No workers'
comp. insurance required.] &IZO 041 b
*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 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.
Insurance Company Name: ,4Jii M v 1 v4 L 1,✓S 0, C� / + l
Policy # or Self -ins. Lic. #: V Wii✓ C (c OO Z 5 7 0 / Expiration Date: d r1Q ii/20/ 3
Job Site Address: 3 Lc/IA/4-4P sr City/State /Zip: 1.L711 n /,j C1 /0.5 3
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.
1 do hereby certi under 'ns and pena 'es ofperjury that the information provided above is true and correct.
Signature: f Date: ? /0 ' /3
Phone #:
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
. t.
8.1 Licensed Construction Supervisor: Not Applica ble ❑
Name of License Holder :
License Number
t
Address , ; ' ' „ > r Expiration £ a ' , i
Signature Telephone
9: Begin iid fion a lmproveinent,Contractor __ _.. .. Z2, _ „ , _,, ,Z_ w ,ei Not Applicable ❑
Company Name Registration Number
Address � , q , Expiration Date r
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c - 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 ❑
1.1.. ome Owner;= Exempti
. on
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
N rthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
N
Signature It--
s
W
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) .
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [0]
a 1 t f s. .
Brief Description of Proposed \ d � � _ Q 01 7
Work: �► CiC 7 G�J
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 hausinq;` 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 ORCONTRACTOR.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
1, J9/i6.5 , 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.
Ya/ 5 n AZ
Print Name
34-1 3
Sig y: - of Owner /Age Date
•
•
, ...
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
.1.
Building Department
$1 -
Lot Size I
_
■,, , , _ ...„,,,......„_ - .„..,_ „„_____
.
Frontage ,
Setbacks Front ) , 50 ' \
1
Side L:-- R:- - L R : c- -
/
Building Height ' i -----, 7---
Bldg. Square Footage
* 1 ,
1
Open Space Foot'age .t....._____ ' _ Vo ._._. : t --- 4 ,
(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 ( DON'T KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book , Page ; and/or Document # I .
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO a
IF YES, describe size, type and location: ! I
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO (OD
IF YES, describe size, type and location: ; I
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. • .
9.
Depa rtmeMt use only
Es �t lad
t
° l City of Northampton Status of Permit }
�� EV \i ''6-
h. _' ; r `'' u 3 tS rya d
Building Department Curb Cut/Drlyew Perme w
Q 201 212 Main Street SewerJSepticAvallabllity= #''
wit 3 a
` Room 100 WaterNVell Availability „;-
s Northampton, MA 01060 Two Set o f'Structural Plans « ,�
oeo 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans.° -, «
IJIN U k ?
��,;�_. « s « Other €pecify` * 1 * d a
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 :SITE INFORMATION
-..,, This section to be completed by office
1.1 Property Address:
� �
M a p Lot Unit
K n
Zo Overlay District
i El St. Distri ! CB D tricf
-/'
«
SECTION 2 - PROP ERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
9i`2 E S /-t. � ��
,1 > G C � 1 to 5 T j. �Ev S
Name (Print) Current Mailing Address: v 7 y'
t 7 ^� � �/ � Telephone
k ......,„ , Si• .ure .
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cos (Dollars) to be , Official Use Onl
completed by permit applicant
d"Permi Fee
3 i 6°c) 1. Building (a) Buil ing
t e,--"‘
2. Electrical (6) Estimat Total Cost of ,
Construction from (6)
3. Plumbing B P Fee
4. Mechanical (HVAC)
5. Fire Protection f '
6. Total = (1 + 2 + 3 + 4 + 5) Check Number ' # O .
This Section F or ly
Official Use On
Date -
Building Permit Number: Issued:
Signature:
Building Commissioner /inspector of Buildings :; Date .
File # BP- 2013 -0841
APPLICANT /CONTACT PERSON RYAN JAMES M & BRENDA M
ADDRESS/PHONE 56 LEONARD ST LEEDS (413) 586 -8285 0
PROPERTY LOCATION 56 LEONARD ST
MAP 06 PARCEL 023 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 0210 7n
Fee Paid ��
Typeof Construction: INSTALL 27' 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
INFQRMATION 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
3 /a' 13
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.
56 LEONARD ST BP- 2013 -0841
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06 - 023 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Above ground pool BUILDING PERMIT
Permit # B P- 2013 -0841
Project # JS- 2013- 001444
Est. Cost: $3000.00
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 40815.72 Owner: RYAN JAMES M & BRENDA M
Zoning: URA(100)/ Applicant: RYAN JAMES M & BRENDA M
AT: 56 LEONARD ST
Applicant Address: Phone: Insurance:
56 LEONARD ST (413) 586 -8285 ()
LEEDSMA01053 ISSUED ON:3/21/2013 0:00:00
TO PERFORM THE FOLLOWING WORK :INSTALL 27' 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 3/21/2013 0:00:00 $30.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner