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POTATO BARN BOILER AND PIPING DIAGRAM Jason J. Burbank, P.E.
195 E. Chestnut Hill Rd.
NORTHAMPTON, Sheet 2 of 2
Montague, MA 01351 1 jt..*jA
MASSACHUSETTS August 12, 2008 413-367-2678
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POTATO BARN BOILER AND PIPING DIAGRAM Jason J. Burbank. P.E.. 31
NORTHAMPTON, Sheet I of 2 195 E. Chestnut Hill Rd.
MASSACHUSETTS August 12, 2008 Montague, MA 01351 Ot I AL
413-367-2678
WORKERS COMPENSATION AND EMPLOYERS' LIABILITY
INSURANCE POLICY—INFORMATION PAGE
INSURtR: POLICY NO: W1039542
MAIN STR) F'T AMERICA ASSURANCE COMPANY
4601 T'OUGHT'ON ROAD ITAST
SUTT;; 3400 RENEWAL OF: WC039542
JACXSONVILLE, FL 32:345-6000 NCCI Company No: 27103
Account No: CAC039542
ITEM 1 NAMED INSURED AND MAILING ADDRESS: AGENCY NAME AND ADDRESS:
HRUCn WHITTIER CORNERSTONE INS AGCY INC/RAIS
(SEE 10,XtD INSURED
6W MAX14 ST > NDT)
r
1, PO BOX 779
NEW SALEM MA 01355-9720 ATHOL, ,MA 01331
AGENCY PHONE NO.: (976) 249-3217
AGENCY NO.: ,.200664
LE44AL EAITITY: INDIVIDUAL
OT4ER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule)
ITEM 2. POLICY PERIOD: From 07-17-2006 To: 07-17-2009
Effective 12:01 A.M. Standard 7imc at the Insured's maiiing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listoo here:
MA
S. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of
liabiilty under Part Two are:
Bodily Injury by Accident: $ 100, 000 each accident
Bodily Injury by Disease: $ 500,000 policy limit
Bodily Injury by Disease: $ 100, 000 each employee
C. Other;hates Insurance: Part Three of the policy applies to the states, if any, listed here:
all states except: NA, OH, 14A, WV, WY
and states designated in ITEM 3A of the Information page.
D. This Policy includes these Endorsements and Schedules:
Sea Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for th s Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Flans. All information required on the Workers Compensation Classification Schedule is subject to
verlf"bation and Chang(? by audit. Please see Classification Schedule,
Total Estimated
Minirhum Prernium: $ 348 Annual Premium: $ 13,222
Audit Period: ANNUX:-
Date: 06-27-08 Countersigned by
WC 00 0 01 A Copyright 1987 Nmioml Councii on Coawrimtion Insane Page 1 of 5
AGwT COPY
Massachusetts - Department of Public SafetN
Board of Buildin- Re:;ulations and Standards
Construction Supervisor Specialty License
License: CS SL 101009
Restricted to: SF
BRUCE WHITTIER
61 WEST MAIN STREET
NEW SALEM, MA 01355
Expiration: 5/15/2012
('u nun ivsioner Tr#: 101009
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registratorv:. 161086
Ex@ 9/25/2010 Tr# 275394
j, Tyo- DBA
WHITTIER PLUMBING,&HEATING
BRUCE WHITTIER
423 DAINEIL SHAY HIGHWAY
NEW SALEM,MA 01355 Administrator
1,
I COMMONWEALTH OF MASSACHUSETTS
IN PLUMBERS AND I
7
LICENSED AS A MASTER PLUMBE
ISSUES THIS LICENSE TO
BRUCE W WHITTIER
61 WEST MAIN STREET
NEW SALEM MA 01355-9720 -
11809 05/01/10 454064 '
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 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 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 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 your) 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
` . The Commonwealth of Massachusetts
Department of Industrial Accidents
_❑ Office of Investigations
600 Washing
oton Street
Boston, MA 02111
w www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name(Business/Organization/Individual): �i�1/ Lir' T��"` d i {- UeA,4p
Address: Ll D�;(irNe, S Gc+�.
City/State/Zip: OW 0 J3 S T' Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).
have hired the sub-contractors 6. ❑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 S. ❑Demolition
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp. insurance.# ❑
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
.3 ❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ 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 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 thepolicy and job site
information. ,)
Insurance Company Name: Motit� ' )
Policy#or Self-ins.Lic. #: 1/U/&.1q Expiration Date: f
Job Site Address: V40,j0-ib- f City/State/Zip: 144 401446
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 5250.00 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 under the painji and ies of perjury that the information provided 113 )0 true and correct
Signature: hf t Date: %I/ %3 )0k
Phone ., ��`5 ��`� 79l9
Of f c•ial 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: S,�t c �� r,��� j �/���, Not Applicable ❑
Name of License Holder: !���� Ito- �"'�1 "'a,) P(��`' ' `4#,,6'
License Number
ly C l� �jnJ c-a 3 1�rvwi a� S > t lh ,,•t l: S L 10 1
Address `.� Expiration Date
�! S- 1 t S 1,;L0 l -X
Sign Telephone
W,, ,,7 q78 -5 k ti'- 781€3
9.Registered Home tmprovemenY GQntractor Not Applicable ❑
Company ame Registration Number
'e, Pi Ulm.ti; �� wy-4,"(`n 161096
Address Y 4¢L 5- 14t Expiration Date
N6w s'Aj-e " e14 v t3ss —spy -'zl3t�'
� 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...... ❑
1, -dome �tivner E-empt 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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
� 1
PDescription CRIPTION OF PROPOSED WORK(check all applicable)
[� Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 13
❑ Demolition ❑ New Signs [O] Decks [0 Siding[O] Other[O]
Proposed �"� WO�' �l[Z4 (�
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 existinct housing comalete the foifouvinQ
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? jj yypp
f. Method of heating? � T IW replaces 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
I. Pig �orm £S
as Owner of the subject
property
hereby authorize t2 � ��(T'T? F Q
to act on my behalf, in a matters relative to work authorized by this building pe it ap710 cation.
1 1
Signatureoff Owner A 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.
RUGS
Print Name
Signatur 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
LotSize __ _. .....r.,,.. ..__ '_.. ., _ .._...__._ _.. ,_) ..., ......
Frontage
Setbacks Front
SideL. ...,.__...... R. .__._ L: R ,.m._.,.., _....._
Rear
Building Height
Bldg.Square Footage % _. ___„_
Open Space Footage °
(Lot area minus bldg&paved
#of Parking Spaces
__.._._..._._ ....._.........
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/'on the site?
NO C DONT KNOW 0 YES 0
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 0 DONT KNOW 0 YES
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:
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, excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
c; .
Depttment userrC�t
City of Northampton E
Building Department irtz xtldyewa}r I=smrff3
212 Main Street Seuyer�SepfircAiarEbrl '
_ Room 100 Itta#ertue[Iva�ratit � ''
Northampton, MA 01060 Two Sets Q'StracturalPias *.
phone 413-587-1240 Fax 413-587-1272 PI>tf5►tePfans
Ofher Spee�fy
APPLICATION TO,CQNSTRUCT,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
vowel•GS A Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
7
Signatu Telephone 141 ?_„�^�J6
2.2 Authori nd�A7 J a
Name(print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit 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) �� L�d�rl,
5. Fire Protection aw/h
6. Totai=(1 +2+3+4+5) I Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2009-0519
APPLICANT/CONTACT PERSON WHITTIER PLUMBING&HEATING
ADDRESS/PHONE 61 WEST MAIN ST NEW SALEM (978)544-7818 Q
PROPERTY LOCATION 1 VENTURES FIELD RD
MAP 32C PARCEL 319 001 ZONE URC000Z
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: INSTALL WOOD BOILER W/OIL BACKUP
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101009
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
,RMATION PRESENTED:
_A,��' 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
Demolition Delay
7 0 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.
i VENTURES FIELD RD BP-2009-0519
GIs#: COMMONWEALTH OF MASSACHUSETTS
Nlan:Brgl<: 32C-"'19 CITY OF NORTHAMPTON
Lot: -001_ PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: WOOD BOILER BUILDING PERMIT
Pernut# BP-2009-0519
Project# JS-2008-001203
Est. Cost: $20000.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED 1'0:
Const. Clas;: Contractor: License:
Use Group_ WHITTIER PLUMBING & HEATING 101009
Lot Size(sg. ft.): 77057.64 Owner: JAMES BEN
- T r., Avr,licc�,l?t: \NHITTIER PLUMBING & HEATING
AT: 1 V E N i U rz— -it'i .v F,•-,
Applicant Address: Phone: Insurance:
61 WEST MAIN ST (9_7$.'_5-Az!-?8.1_R_0---------_ — ---Wgi-kers
Compensation
NEW SALEMMA01355 ISSUED ON.11/1812008 1);0(;,:00
TO PERFORM THE FOLLOWING WORK:I NS':�AL.L L B^+C UP
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. luilding Inspector
Lindergrc,md: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimneve)k( E^�4?�
Rough:
Final: Smoke:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. ,t'�v
Certificate of- y Signature: —
Fee'I'ype:_ Date Paid: Amount:
Building 11/18/2008 0:00:00 $120.001236
212 Main Street,Phone(4 1.3)) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo