32C-252 (5) From: 10/24/2000 09:32 #017 P-001/002
ACORD,. CERTIFICATE OF LIABILITY INSURANCE 10/2IWDD
10/24/2006 006
'RODUCER (413)569-2928 FAX (413)569-2949 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
E$G Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
617-F College Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. O. Box 259
Southwick NA 01077 INSURERS AFFORDING COVERAGE NAIC#
NSURED INSURERA:Nautilus Insurance Co
"-lark Dore Contracting INSURERB:Arbella Insurance Group 14168
442 Silver Street INSURER C:AM8rican Home Insurance
INSURER D:
kqawaz MA. 01001 INSURER E:
OVERAGES
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.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
VSR AWL POLICY EFFECTIVE POLICY EXPIRATION
-TR TYPE OP INSURANCE POLICY NUMBER DATE MMtDDIYY) OAT£ VI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
1£ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $O,000
PREMISES(Ea nce $ +
+A CLAIMS MADE F—RI OCCUR NC541790 08/09/2006 06/09/2007 MEDEXp(Any one on $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 3,000,000
GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-0OWjOP AGO $ 1,000,000
POLICY EC7 LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $ 1,000,000
ANY AUTO (En accident)
B ALL OWNED AUTOS 02551400003 6/12/2006 6/12/2007 BODILY INJURY
'1L SCHEDULED AUTOS
(Per person) $
HIRED AUTOS BODILY INJURY
NON-OVIME0 AUTOS (Per acddeM) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTOONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR FI CLAIMS MADE AGGI GATE $
$
DEDUCTIBLE $
RETENTION $ yy �7 TU
C WORKERS COMPENSATION AND T Y LI T - T
EMPLOYERS'UAB9JTY
ANY PROPRIETORIPARTNERIEXECUTNE E.L EACH ACCIDENT $ 1,000,000
OFFICERMFAIBEREXCLUDED? WC00894587000 6/10/2006 6/10/2007
E.L DISEASE_EA EMPLOYEE$ 1,000,00 0
If yes,desaibe under
SPECIAL PROVISIONS 4010w EL DISEASE-POLICY LIMIT $ 1,000,000
OTHER
3ESCRIPTION OF OPERATIONSA.00ATION$NEHICLEStEXCL.USIONS ADDED BY ENOORSEMENTISPECIAL PROVISIONS
59 Williams Stxeet, Northampton, X&
CERTIFICATE HOLDER CANCELLATION
413) 5 8 7-12 7 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of Northampton EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Linda Lapointe 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
?Northampton, MA 01060
FAILURE TO DO 9 HALL WPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER ITS AGE R EPRESENTA
AUTHORIZED R
(CORD 25(2001108) aACORD CORPORATION 1988
ti INS025(oi0®).w ELECTRONIC LASER FORMS,INC.-(SW)327-0545 Page 1 of 2
..
O O
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Grztr Vf XVrt4a111 xtVrn i r
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�I lASSACI(It8[tt8 -
DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
Nnrth,unpton, MA 01060 ,
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 1083.4 to
act as i:is/her construction sup, 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 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.
(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
�\30.rf1jullipfoil
A ' ` It l3EA(I�n r r If b
DEPARTMENT MEN"T OP BUILDr),\,C INSPECTION's
212 Train Strect Nfunieipal I;uildinc
Northampton, Suss. 01060
W()FUCER'S COi\[PENSATION -MSUR .NCF AFFM,-'�,VIT
(li crns.�Jpermi tirx)
���th a plZncipal place of business residence at:
— (phoney')
(su�x/dt}lstalcfrip)
do hereby certify, under tbe.pa_ins and penalties of perjury., -1?.1
I am an employer providing the followint %vorkcr's colnocns-nDon cove age for InY
elnl)lovccs worang on Oils job-
(Lfasw-axf= Comr,- ) (pcUc: Nona cr) -- (E-rpiraior, Dzr`)
( ) I a-m a sole proprietor, genera] conts-acror or homeowner (ci c;e one) and have hired
the cone aciors listed below wbo have the following workers coiperl_sadon policies:
(Nam-, ofCont7.laor) (Ir15L rail C Company/PGllCi NUM-'---:) (i_`->lid Datc)
(Name of Contractor) Oilslf-a.ncc ComoaawPo!.ie Nu-mc^_r) (Expo;ilon Date)
(Name of Conn-am ) (lcuwanc: Compan)-/Pob-c-r Nc,mbc.r) (Expimtion Dalc)
(Namc of Courractor) (Laszlran(-- Company/Policy Numbs) (Eapirttioa Datc).
(aa�ad-!i�ocal t'�ca,if nca-s�_-.cn a�c'u�inf«-m>;oo pcuia;..as w.L o�rrr-_c.o:�) a
{ ) I am a sole proprietor and have no one woi--iDg for me.
( } I am.a home owner perforuing all the work myself.
NOTE;p(esc be etrllC t*:z .i ]e Gem ovum w cmplay pe aai w d� �e� o r MpZir Boric on d..cU-�or
aoc mocc i), t 1cc lard in wtx o the hotDCOw pc raid,or oc the p ouoc! z�p�rtcnsl tbcGO�r no(C-Zrlly oc=:daoi to be
c piayc u--/—thew :c=-u--. ca An(GL1521a l(5)�appliaf3oo b-f.bomzo-=fcr c Lc=--x-or palail r=y c, tLc
1c7PJ n.a-'isc of es e-gloyx u.d-d-Wlk' 'a Coo3pom...tioa Aa-
I uadcztiad thud>copy of thi,-I—,nay Ix for---ied to the Dcperrmmd of lam, iJ A 6CO&oTjo of - -for the
cove-Fc vciroiioa A•rd nLt f:.iltac w U==)m0v,r undo soc<a 25A of M01-152 c.Icd to the ia,xui -of mmia pcaa -
coau:rz g oft Gnc of up to S 1500,00.nNor�.o�of up to ooc Yr end aril pmr.tio m form of.Stop W orl;Ord-.ad'
f=of 5100.00 i d--y t&aiaA me-
For dq.rti�=-sl u.c only .
0 Pc7mil Ntrmbcr
1`43p:1 Lot fit.
Z—,, of Li ccmi c� —Ie
a
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
ignature Telephone
7 _, • ,-� PP
Not Applicable ❑
Company Name Registration Number j
G
Ad ss Expiration Date
Telephoned
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...... ❑
� �
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-owna-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-vear 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
.. ay
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors r-1
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[O] Other[0]
Brie escription of Proposed
Alteration of existing bedroom Yes No Adding new bedroom Yes No � .1 c< 7
Attached Narrative Renovating unfinished basement Yes No 7wg e
Plans Attached Roll -Sheet
s�'[f°:Kew;~horas�a`nt� ra rliton�#a�existi-n ..:housiri corn tet�.the�:foltoin�rn
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=-=70_BE COMMF-7 D 1AENEN
OWNERS.AGENT.OR'CONTRACTOR�"APPLIES FOR-BUILDING PERMIT
as Owner of the subject
property
he by apthorize
to a t on my b� tiv to work authorized by this building permit application.
Si na re of Owner Dale
C
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 Na
Signature of Owner/Agent 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
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vuhunno/Findi ng ever been issued for/on the site?
���� YES v_���
NO �~�� DONTKNO� VV
IF YES, date iouod:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO ^_'� ) D
-NF KNOW .--
IF YES: enter Book Page, and/or Dnoumant#
B. Does the site contain a brook, body of water orwetlands? NO �-� DON7K0DVV 0 YES
IF YES, has permit been or need tobo obtained from the Conservation Commission?
Needs tobeobtained v�� Obtained /=\ Date\.� �_� '
C. Do any signs exist on the property? YES 0 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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orinit part nfa common plan
that will disturb over 1acre? YEG ���� NO �-���
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
J 1
Departr�en�iuse only �,� ,,
City of Northampton $tatus� t
Building Department
. .�'' 212 Main Street wecpt _ �E �
Room 100 a�7abt1�
Northampton, MA 01060 yrr ets trotuaat �rs
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1 -SITE INFORMATION
1.1 Property Address: This secfion to 6e;complefed by o'Ice
C"� r" ✓ t"A
q, t Zoe O�etlayDist�ct
EImSt-
SECTION District = �B Distr�et
.2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Recoordq::^
N me(Print) Current Mailing Adder:**-'-� Cam_
Telephone
S n ture .
2.2 thorized Aaent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3--ESTIMi4TED`C6NSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
.-Building -(a),Building Permit Fee
(�
2. Electrical (b),E$bmated Total Cost of
Construction.fromw 6 ,
3. Plumbing Building PermiYFee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This SectiomFor Official'Use Oil
Date
Building Permit Number: Issued:
Signature:
Building Commissionerlinspector of Buildings Date
59 WILLIAMS ST BP-2007-0465
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 32C-252 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:roofing BUILDING PERMIT
Permit# BP-2007-0465
Project# JS-2007-000685
Est. Cost: $6400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CLARK L DORE CONTRACTING 128355
Lot Size(sq. ft.): 3615.48 Owner: BRODY JONATHAN
Zoning.URC Applicant: CLARK L DORE CONTRACTING
AT: 59 WILLIAMS ST
Applicant Address: Phone: Insurance:
442 SILVER STREET (413) 733-4080 O WC
AGAWAMMA01001 ISSUED ON:1012412006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 10/24/2006 0:00:00 $25.00524
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo