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36-041 (4) SEP-29-2004 WED 10: 10 AM CRIMMINS GRAVELINE INS FAX NO. 4132532556 P. 01 C .CERTIFICATE OF LIABILITY INSURANCE 09/29/2004) PRODUCER (413)283-8378 FAX (413)283-2556 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Crimmins/Gravel ine Insurance Agency. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER-THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 1382 Main St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 90S Palmer, MA 010 69 INSURERS AFFORDING COVERAGE NAIC# INSURED Smith Buil ers INSURERA Cranite State Ins. Co.-ARWC 13102 DBA: David Smith INSURER 0: 161 Gi 1 bertvi I l e Road !NSURER C Ware, MA 01082 INSURER D: INSURER£. C THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTL"JITHSTANDIN 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, INSA OP' TYPE OF INSURANCE POLICY NUMBER POLICY£FFECTyVE POLICY EXPIRATION LUTS kwa GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY OIUJAGE TO RENTED ; F"- CLAIMS MADE 1:1 OCCUR MED EXP(Any ono Person; b PERSONAL.d ADV INJUR\ S GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG f POLICY PRO• LOC JECT AUTOMOBILE LIABILITY COMWNED 11SINGLE LIMIT s (£S�CCIIIOnI/ ANY AUTO ALL OWNED AUTOS BODILY INJURY S (Pb,P--) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY S (per ett�enlj NON-OVVnIED AUTOS P RDPERTY DAMAGE S (Per=:der+) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT f ANY AUTO OTHER THAN EA -- f AUTO ONLY: AGC S EXCESSAIMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE S f DEDUCTIBLE 9 RETENTION $ f t C WORKERSCOMPI:RSAI ION AND WC8277362 07X07/2004 07/07/200S 00S T1.�WC 0rH2 - p STAT lIyUITU A I f' EMPLOYERS'LIABILITY E.L.EACH ACCIDENT E 100;000- A ANY PROPRIE?ORtFARTtdaRtEXECUTIVE OFFICER/MEMOER EXCLUDED') E.L.DISEASE-EA EMPLO(Ef S 100iow if yes,drib.andM SPECIAi PROVISIONS below I.1 DISEASE-POLICY LIMIT S 500,00 OTHER DESCRIPTION Of OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 7 SPECIAL PROVISIONS 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WR?TTEN NOTICE TO'THE CERTIFICATE HOLDE i NAMED TO THE LEFT. BUT FAILURE TO 01iI1 -Imo'°_P NO n°yyPT10- OR LIABILITY Town of Nor t4hampton Attn: Linda LaPointe OF ANY KIND U^^. .�., xdl:r .� ..n __.�zTIVES. AUTHORIZED R "' - _ Northampton, MA V"' ACORD 25(2001108) FAX: (413)587-1272 OACORD CORPORATION 1989 omw i,.CGty of Narthamptan z Y � t 1�8'S4AthltSttfB - cwF DEPARTMENT OF BUILDIXTG INSPECTIONS INSPECTOR '212 Main Street • Municipal Building Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as l.is/her construction sups: ,s sor. The state defines "Homeowner" as, ",Person(s) who owns a parcel on which he/she resides or intends to be,a one or two fame - 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 f,,egulations. 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 buildinj 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 r j I .�'0 0Y of �icasi<rftnsctle' - o DEPARTMENT OP DUILDI7\'G INSPPCT101dS - j 212 Main Strcct INTunicipal Building — j Northampton, Afass. 01060 %vol CCR'S COLATENSATIO.N LNSURANCE A TIDA.ATI i i (li ce'usa'Jpertn�tfcc) V,ith a pn,,lcipaJ place of businesslresidence at: --- — (phonei') do hereby cerdi -, under dic.paif1S and penalties of perjury:, -'-h2i ( ) I am an employer providing the following!%:ortict's cotnocnsanon cove mge for my eluplovccs worUng on Gus job: (Lnsur_n=Comr,azy) (PeCie: ?�urnrr_r) -- (E:-pi>z on Dzt`) - ( ) I am a sole proprietor, general contractor or homeow' -ner (c c;e one) a.Dd have hired the cone-actors listed below vgbo have the foilowup, worke>'s comoensaaon pclicies: (I+anic Oi co-=Cior) (In2ranc:. Colnoany/11 ruc; NurLC:) (-EX)ir-au0n Datc) - (NaL1-c of COGIT-mor) (lnssrancc Comoan,,v?olic-; \t:mcrr) (Ex Dim6on Date) (Name of Conaactor) Onslraac Compan}-/Polio' Numb--r) (Expirzdoo Dale) (Nzmc of Coanclor) (In_suranc-c Comma fPolicy Numb,:r) (Expirtioo Dair). (aai[:1 vocal ifacocs.,to atc?ud;infoc�uaoc P--ta-i�6 to aL c�-r�z) O I am a sole proprietor and have no one working for me. ( ) I am.a home owner perfon=g all the work rnyseif. NOTE:ple be avruc it-..-t;.lo 6emco+•�crs wbo employ p�-ivas eo ba a rcpau work on i d—LLg of ant melt th_n Lbroc uara in t•3ieh Lt,bomcovwacr rceda o<ca the Qoundz p7jx a—the-•.o w- ooe C-­rlty o:,=.d-td to be -='Ploy—unc e the--k— - ., A�= GL'152.s l 5 t ( )�=y^ptinboa by a homcoavc Icr c ticz--=x p--it ray evidence the I�rLs of ea a y�loyx under d=Wock e,Coospoonatio¢Aa- I uodcniad th e a Dopy oCthu cIItcm�m,y t»for�vvrdad In tlw Dcga,tmco¢of In�asiicl Avadrrs�CHrion of 6= r+om for th. oov�bt vc'irc=tioa a_'1d ai--i L-i1Lm to ta=re fovery;c Undcr yzaIOa 23A of MGL 152 as led to the isGosi ioa of aimiwl pea&W- eoau;z 3g ora rmc orup to s13oo.00 and/or i=qriyocm of up to Doc yc end 6N-j pcnoja is t x form o(a Stop Wort Orde and a (t>z o(S 100.00 1 rLy•Faint me For&p.rtm only permit Number P., - Lot. Siin,-ttitzr of LicrnscclPccrttiticc x SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ �� SM►� C �b Name of License Holder: Vl 4T7/?/ License Nu ber Address Expiration Date lao L( P-1 If ature Telephone 9.,,Re'misfere ;. ma,bn' roverne :Contractors "' k Not Applicable ❑ a 6 �� Company Name Registratiori Rum er --_,_. Address Expira ion Date TJ � Telephone Q1:3 2O'�� l/ 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 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 buildine 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 r SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑. Replacement Windows Roofing Or Doors 1-7 Accessory Bldg. ❑ Demolition ❑ New Signs [EI] Decks [Q Siding[0] Other[O] eor ieif k:Description of Proposed O,� {t�s'T 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- out64h d n ddrtio�i t existir a tious�ng corxipfete`fhe; atfQ na 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. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION,-'TO BE COMPLETED WHEN OWNERS AGENT OR'COINTRACTOR APPLIES FOR BUILDING:PERMIT 6F I as Owner of the subject property � "b hereby authorize to act on iny behalf, in all matt e reI tive to work authorized by this building permit application. Signature of Owner Date I, 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 undexthe pains and penalties of perjury. ' Pri N 7 Signature of Owner/Agent V Date Section 4. ZONING All Informatihh 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:'..,. i Rear Building Height r— - - - Bldg.Square Footage I % —1 j Open Space Footage % (Lot area minus bldg&paved ! ' parking) i #of Parking Spaces Fill: (volume&Location) A. Has a Special Perm it/Variance/Findi g ever been issued for/on the site? N0 0 DON'T KNOW YES 0 IF YES, date issued:, ! IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book i Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO M DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q 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 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingpxcavation,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. City of Northampton S atr 1?ekt« Building Department erbt rye Penni 212 Main Street sewerset� ita6 Room 100er< eta �ab�ty � � Northampton; MA 01060 Tuyo Ses oStrucfurt Ptah q z : phone 413-587-1240 Fax 413-587-1272 PtotdSlte ?tans � a � � � . APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITEINFORMATION ����� This section to be comPteted byoffice 1 Property Address: © � ?1-T Pet ������� (efiap Lit Untt Zone Overlay D"strlct: Elet St Distract CB DIStE1Ct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone _ Signature �— 1413 - -' ` 2.2 Authorized Agent: Name Print Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building / G0® (a)Building Permit Fee 2. Electrical b (b)Estimated Total Cost of Construction from 6 3. Plumbing Building,;Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Ci "Q Check Number This Section'For Official Use Only Date Building;Permit Number. Issued: Signature: i Building Commissioner/inspector of Buildings Date 1053 BURTS PIT RD BP-2005-0367 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Bloek:36-041 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2005-0367 Project# JS-2005-0485 Est.Cost: $6000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID SMITH 126589 Lot Size(sq.ft.): 12501.72 Owner: STARK ROBERT E&STEPHANIE D Zoning.URA Applicant: DAVID SMITH AT. 1053 BURTS PIT RD Applicant Address: Phone: Insurance: 161 GILBERTVILLE RD (413) 204-1219 WC WAREMA01082 ISSUED ON.9129104 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• Receipt No: Date Paid: Check No: Amount: Building 9/29/04 0:00:00 2395 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 1053 BURTS PIT RD BP-2005-0367 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-.Block:36-041 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:- BUILDING PERMIT Permit# BP-2005-0367 Project# JS-2005-0485 Est.Cost:$6000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groun: DAVID SMITH 126589 Lot Size(sa.R.): 12501.72 Owner. STARK ROBERT E&STEPHANIE D Zoning.URA Applicant: DAVID SMITH AT.• 1053 BURTS PIT RD. Applicant Address: Phone: Insurance: 161 GILBERTVILLE RD (413) 204-1219 WC WAREMA01082 ISSUED ON.9129104 0.00.00 TO PERFORM THE FOLLOWING WORK:STRI & 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: .."ire De artment Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:(gK 10 . p l-O L{41`x"i THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT OF ANY OF ITS RULES AND REn ION i � Signature: Certificate of Occupancy - FeeType• Receipt No: Date Paid: Check No: Amount: Building 9/29/04 0:00:00 2395 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo