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31A-003 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: 7S�'?-� E�U-k The debris will be transported by: 440P ,L ou-1Q c2 The debris will be received by: Building permit number: Name of Permit Applicant `��1-�►�`/ Date Signature of Permit Applicant cn (n O fV(J) N—j O C) N � CD o m W N( a O- (0 CO ( V c>p_l y pO `n0 Dons (mm�o CM N*_ ° m n �uc m CD u°(o mM o=7,u -q5 m> , m -w al 3 WS 00 2 0 1 m q0) -IU - c5,M7 , o<3.= <(o �� Osu zmm Z)-.(D 0 �'Z, >-Ww � C) � D-Uc 03 -• -..nom mZN< - O u, tn, rw �5. 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Z � m �� �° m m m m Z O ?o n m (n w �� O O z <c � 0 "i >Cl) C (n F p z z m 0 z m� n z � � o CD - v� 0 o� .. � Cw < z O D D c CL C) m al t m � m � o s w m cn � p � a w z V x n z m (D `D D rn 3 0 � z z p a'm O CD vj fA * O O N D. 0 1 2 0 CD CD fD O � -� O 0. W 0 � i °1 00 Z D W C , rd n QV C O CD M m n C7 m CD. 0 O o° z CD R1 CD w D = a) _ r �cQ a�i r Z; m � m OD w -� -Office of Consumer Affairs&Business Regulation License or registration valid for individul use only :3 =HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ' Office of Consumer Affairs and Business Regulation Registration: 148688 Type: 10 Park Plaza-Suite 5170 Expiration: 10/18/2015 Supplement( 3rd Boston,MA 02116 _ LOWE'S HOMES CENTERS INC t JAMIE SPOFFORD 136 TURNPIKE RD. SUITE 100 < G<-x9 _----- SOUTHBOROUGH, MA 01772 Undersecretary ..Not valid without signature i" • •` v7 Ga IG:UV lowes 12345678910 >> Cowes 1916 ISO P 1/1 { Massachusetts-Department of Public Safety �T! Board of Building Regulations and Standards Conaruttion Sup.rvicor License: CS-103003 ^1 1 ` ♦F MICHAEL W fdti$G ANION. R ' 119 RICH STREET 1 . � ACAWAM MA 61001 ✓,�,... .lJ..c , ,", Expiration Commissioner 09/08/2014 ,aco CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOF 9/27/131 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS 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(ies) must be endorsed. if SUBROGATION IS WAIVED, 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 lieu of such endorsement(s). PRODUCER CONTACT NAME: Rejean J. Remillard Ins. Agy,- PHONE --V FAX N 23 Southwick St E-MAIL ADDRESS: Feeding Hills, MA 01030 INSURE S)AFFORDING COVERAGE NAIC ft _+NSURER A:National Grange-Mutual INSURED INSURER B:Acadla Inns_ CO Michael W. Burgamaster dba INsuRERc:Main Street American Assurance - Burgers Home Improvement INSURER D: 119 High St. 1st Floor -UR ---..._._....___..._�-.------. __. .._.-----•------_._.-- Agawam, MA 01001 INSURER E:---- - ------------ -- - -- --- INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATE X NOP^ATIASTANDING 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR! TYPE OF INSURANCE NSR i VV ID 1 POUCl NUMBER PM/DDNY F I PMIDIDDIY� LIMITS C i GENERAL LIABILITY IMPK6213N 6/8/13 6/6/14 EACH OCCURRENCE $ 1,000 000 K] COMMERCIAL GENERAL LIABILITY I i 1 DAMAGE TO RENTED $ 500,000 Cei 1-ii II Ed.QS6alU8 {CLAIMS-MADE I OCCUR _ME0 EXP(Any one person) __$_ _ 10,000 PERSONALBADVtNJURY $_-1 OOO OOO I _. �. GENERAL_AGGREGATE_..__ $.._-2,000,OOC___ GEN'LAGGREGATE L OTAPPLIES PER i i i I PRODUCTS-OOMPIOP AGG $ 2,000,000 }{ ; PoucY' .ECj I I LOC $ A AUTOMOBILE LIABILITY i I 6/10/131 6/10/14 COMBINED INGLELIM ' ;M1T3385E; � ANYAUIO BODILY INJURY(Per person) $ 100.000_ jo ALL OWNED x SCHEDULED ----•.......--- -`--- - --- -- AUTOS AUTOS i f j BODILY INJURY(Per accident), $ 300,000 NON-OWNED I PROPERTY DAMAGE X HIRED AUTOS X AUTOS ) PeracoidentLV^.._—_ 10O OpO _._ 1 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S. �— EXC ES S LIA --.—. .._. CLAIMS-MADE. A_GG_REGATE .--.- S ---- OED RETENTION 3 $ B WORKERS COMPENSATION ; WC-20-20-002804-01 10/6/13; 10/6/141 }{ WCYTATU-AND EMPLOYERS'LIABILITY Y/N 1 1 ANY PROPRIErOR/PARTNER/EXECUTVE I E_L EACHACGOEM 5 pFFICE RMIE MBF.R EXCLUDED� 1 N I AI (Mandatory in NH) i F E L DISEASE-EA EMPLOYEE $ if yyBS describe under ' DESCRIPTION OF OPERATIONS bebw E L DISEASE-POLICY LIMIT s 100,000 100,000 500,000 f DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Renerks Schedule,if more space is regrired) Lowe's Companies, Inc. and any and all Subsidiaries are named as Additional Insured as i respects to General Liability and AuLo Liability. I{ I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lcwe's Companies, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 1 Attn: Install Sales Insurance AUTHORIZED RE PRE SENTATVE P.O. Box 1111 7 N. Wilkesboro, NC 28656 © 1988-2010 ACORD CORPORATION. All rights reserved. %CORD 25(2010/05) The ACORD name and logo are registered marks of ACORD hone: Fax: (877) 411-7129 E-Mail: Departwnt of 1ndUS&ia1 Accidents Office of In estigadorzs 600 Washington Street BoSton, .11✓XA 02111 www.mas'xbor/dia ':Workers' Coinpensation Insurance Affidavit; l3uilders/Contractors Electricians/PloA licant•Infor.. ation mbers Please Prin LQ ibly Name(Busivass/organization/,[n&idtwl): Address: i t°t JA I 1. S+ 2X Ci /State/Zi ! A Ca0 12Q Phone#:_G41 Are.you an'etaployer?Check the appropriate box:, 1: I ana a employer with I, 4• ( I am a general contractor and I Type of project(required): j employees(full.,rad/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. M Remodeling I ship and have ao:employees These sub-contractors have i worlcirtg.for me in any capacity, employees and have workers' $. ©Demolition { [N.o workers'hornp. insurance comp,insurance.: 9• Building addition 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,,oiv ers'comp. right of exemption per MGL 12 Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] 4At1y appliutnT that oheeks bpi#1 mtt5t olso fill out the Section below showing their workers'compensation.policy informerion, Homoownors whq submit this attidavit Mica*they at doing all wort:and then hire outside eonttuctors must submit a now afrICUvit indicating such, %Conva=r:that;chackthis box must attaohod ail additional shoct showing the name of the sub-wntmtors and state whether or not th*sc wr hies have employees. If the,sub-connectors have employee:,they anus:ptp�de their workers'comp.policy number. ,r am an enipiayer Mat is pro�iing,yorkers'Compensations insurance for information. my employees. Below is#he.poluy and job site Insurance Company.Name:_Rc I Agz 12er+•ti Its.{ TnsLtz v ce Policy#or Self-ins,Lie *:__WC '28 0:L E:cpiration Date: tfi IXQ/y �.. Job Site Address: City/State/zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration datz). Failure to secure coverage as required under Section 25A of MOM 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 foam of a STOP WORK ORDER and a floc of up to$250.00 a Clay againg 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 certify under sh painsel amaides of perjury at the information provided 4bove is true and Correa 1 lure Dat : Phony#: Official use on1v. Do not write in this area,to be completed by city or town official l E l; City or Town: Permit/License# Issuing Authority(circle one): 13oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other 14 Contact Person: Phone - f{ 4/4 d OSI 9664 saM01 « 5 , SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: I l Not Applicable ❑ Name of License Holder: ��� W � Z��,� C's -- 10-5003 / I ''`^ , u ^ License Nu, er Lq Address Expiration Date Signature Telephone 9.Registered Home lmorovement Contractor.. Not Applicable ❑ ) q���� Company Name Registration N tuber Lo v) s oaf, c61►�2S C. 16 15 ao 1 Address Expiration Dat SV 1 UU Telephone. �� a a 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...... ❑ 11. Home Owner Exemy 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 La s ► State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ ReplacemerW' dows Alteration(s) Roofing ❑ Or Doors L� Accessory Bldg. ❑ Demolition ❑ New Signs [/r-3]] Decks [M Siding[p] Other[a Brief Deception of Pro os '` Work: 1�-�L�GV � 3�0�K— `G 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, `� � 7 '�J��--I"C as Owner of the subject property t hereby authorize T,G W G 5 Li r) LA ��Gr�•�1�C 1 0c to act on my behalf, in all matters relative to work authorized by this building pe mit ap lication. SF E eUi:-)TePC-V- I q Signature of Owner Da(e ;7as Owner/Authorized ief. re that the statements and information on the foregoing application are true and accurate,to the best of my knowledge Signed under the pains and penalties of perjury. \A L ` w S PcCr� " Print Nam Signatur o n gent Date , f 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 Side L: R L:, R: Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces - Fill: volume&Location A. Has a Special Permit/Variance/Ending ever been issued for/on the site? NO 0 DON'T KNOW 0 YES IF YES, date issued:; IF YES Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 NO Q IF YES describe size, type and location: D. Are there any proposed changesto 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 Q NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only Oity of Northampton 5 , s f perxr„t llding Department "errit�� 12 Main Street Sewer/Septic Avaitatiili Jr Room 100 WaterWell=Availability q�� as! pl mpton, MA 01060 Two Sets of Structural flans P mp h 413-587-1240 Fax 413-587-1272 Plott ite Plans oe'ctnc 17 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 "3 `C� Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: -C)E'O J z K)C)LA-K) 53 Name(Print) Current Mailing Address: �L Co O —r c a Telephone / // �/ � � Signature C� (� 2.2 Authorized Acient: Name(P Current Mailing Address: at Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building / CUB (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 6. Total =0 +2 +3+4+5) ?j�. O Check Number = This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 319 ELM ST BP-2014-1177 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma :Block: 3 1 A-003 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2014-1177 Project# JS-2014-001987 Est. Cost: $638.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LOWES HOME CENTERS INC 103003 Lot Size(sq. ft.): 14723.28 Owner: NOLAN DENNIS R&ARLENE T Zoning: URB(100)/URA(0)/ Applicant: LOWES HOME CENTERS INC AT: 319 ELM ST Applicant Address: Phone: Insurance: 136 TURNPIKE RD SUITE 100 (413) 588-0270 WC Southborough MAO 1772 ISSUED ON.5/8/2014 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE REAR ENTRY DOOR 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 5/8/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner