25C-150 (3) ., � z p
ACORD . . �.<� � .. ` MM\OD$
YYl
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
WHITE JUBINVILLE INS AGC HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
39 LAMB ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO BOX 789 COMPANIES AFFORDING COVERAGE
SOUTH HADLEY,MA 01075
COMPANY
28SNF A CONTINENTAL CASUALTY COMPANY
INSURED COMPANY
B
KENNETH JOHNSON GENERAL
CONTRACTORS INC COMPANY
375 COLLEGE ST#312 C
AMHERST,MA 01002 COMPANY
D
`zc
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID
CLAIMS.
CO POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM\DD\YY) DATE(MM\DD\YY) LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $
CLAIMS MADE F--j OCCUR. PERSONAL&ADV.INJURY $
OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $
FIRE DAMAGE(Any one fire) $
MED.EXPENSE(Any one person) $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT _
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per Person)
HIRED AUTOS BODILY INJURY $
(Per Accident)
NON-OWNED AUTOS $
Id PROPERTY DAMAGE
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTOS OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
BUMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
A WORKER'S COMPENSATION AND STATUTORY LIMITS X
EMPOLYER'S LIABILITY U13-05021-846-08 04-05-08 04-05-09 EACH ACCIDENT $ 100,000
THE PROPRIETOR/ INCL DISEASE-POLICY LIMIT $ 500,000
PARTNERS/EXECUTIVE
OFFICERS ARE: Rl EXCL DISEASE-EACH EMPLOYEE $ 100,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
TII=ICATER Y.. �� "t", �: ., . fix... �...
,C
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS
CITY OF NORTHAMPTON WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO
MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
212 MAIN STREET ROOM 100 COMPANY,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
NORTHAMPTON,MA 01060 Dennis Chookaszis
AbRD 25-
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 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 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
Address understand the above.
(Home owner/resident's signature requesting exemption)
will call to schedule all required building inspections necessary for the building permit
sued to me.
ate
of work
location
The C"omnzonweaith of Massachusetts
Department of Industrial Accidents
,._ Office of lirvestigarions
600 Washington Street
Boston, ..4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
I Applicant Information 4 Please Print Leaibl
Name(Bu sin ess/Organizarion/Indi vi dual):
Address: C
City/State/Zip: Phone,-:
Are you an employer'Check the appropriate boa: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
� 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
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 10.7 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. o workers' comp. right of exemption per MGL 12 Roof repairs
insurance required.] t C. 152, §1(4),and we have no
employees. [.No workers' 13.7 Other
comp. insurance required.]
*Any applicant that checks box nl must also fill out the section below showing their workers'compensation policy information.
r 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. 1
Insurance Company Name:
Policy�;or Self-ins.Lic. #: Expiration Date:� i
y
Job Site Address: - yf *)1r1�>tt„ City/State/Zip
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 Lip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investivations of the DLA for insurance coverage verification.
I do hereby certz under the pains grad penalt' of perjury that the information provided above is true and correct.
Si Ynature: >� G (� Date: A41—d
Acne#:
Official use only. Do not write in this area, to be completed by city or town official
Citv or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
, I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) TR..fiing
Or Doors E:3
Accessory Bldg. ❑ Demolition ❑ New Signs [[I] Decks [[:] Siding [O] Other[p]
Brief Description of Proposed
W o rk:
s
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 exfstinq housing,complete the foil
owing:
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 IF
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
I. 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
k; IT V �'� as Owner of the subject
property
hereby auto `�.,
to act on b 1f, a neater r I tive to wo S horized by this building permit application. ��qq
a Q LJ
Signature o caner - Date
P kA A �y��� as Owner/Auth d
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 Name
/
Signature of Owner/Agent Date
SECTION 8 -CONSTRUCTION SERVICES
E.1 Licensed Construction Supervisor: Not Applicable ❑
iName of License Holder
License Number
Address Expiration Date
Signature Telephone
r
9.Reoistered Horne Im rovementContractor: Not Applicable ❑
Ke i/1
Combanv Name Registration Number
Address > Expiration Date
3 1 Telephone `
,M"-e-vis t 0 10®2-
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....... IN No...... ❑
l'1. Home Ownergeinptian
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
.t
'
^
'
'
`
Section 4. ZONING ALI information Must Be Completed. Permit Carl Be Den-led Due To Incomplete information
Existin- Proposed Required by Zoning
This column to be filled in by
Building Department
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
`
Open Space Footage %
(Lot area minus bldg&p�ved
#of Parking Spaces
(volume&Location)
A. Has aSpecial. ever been issued for/on the site?
NO 0 DONTKNOW M) YES 0
|F YES, date isoued /
IF YES: Was the permit recorded at the Registry ufDeeds?
NO �
DVNlRMUY Q YES
IF YES: enter Book ^ Page and/or Document#� /
B. Does the site contain a brook, body of water orwetiands7 NO DONTKNOYY > YES
0
IF has permit been or to be from the Conservation Commission?
'
'
' Needstobeobtained 0 Obtained 0 , Date Issued:
|
`
^ �.�
C) Doany�gnsex�ton the property? YES ��/ NO ��/
IF YES describe size' type and tocation: ' .
NO D. ���� p��c���or�����ir�� �����? YES 0 �
|FYES' describe size' type and location: | �
E. Will the construction activity disturb grading,excavation, or filling)over 1 acre orish part ofacommon plan
that will disturb over 1acre? YES [ } NO (� )
��
|F YES,then a Northampton GG�m lW§ff7 M��gerfient-PehnithnmtheDPVYisrequired
Department use only
City of Northampton Status of.Permit:
Building Department "Curb Gut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Weil Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-537-1272 Plot/S'ite Plans
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
Map Lot Unit
Zone Overlay District l
{A1\\*--t VJ lkAv1,- 0 LG Elm:St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i ►�i4 IN`u�y�r° wt�t S�! �LAA- o' 1 c o z-
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: �'� `� vU L
Name(Prin) ` Current Mailing Address:
L4A4ttO -4--OA
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION:COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
^ d Construction from(6)
3. Plumbing Building Permit Fee
0 µ �,
4. Mechanical(HVAC)
5. Fire Protection t'
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use.Only
Building Permit Number: IIsssued:
Signature:
Building;Commissioner/Inspectoro ui ings Date
i
`7
�I X20
APPLICANT/CONTACT PERSON Ken Johnson
ADDRESS/PHONE (413)292-3844
PROPERTY LOCATION 21 ORCHARD ST
"11 NWOUAQILI�' 1 _ .I."
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
uildin Permit Filled out
4 ee Paid .00
Typeof Construction: Roofing
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 155721
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
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.
1
BP-2008-0920
GIS #: COMMONWEALTH OF MASSACHUSETTS
Va :Blci j�t-'150 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-2008-0920
Project# JS-2008-001377
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group Ken Johnson 155721
Lot Size(sa. ft.): 6621.12 Owner: Muerle,Linda
Zoning: URB Applicant: Ken Johnson
AT: 21 ORCHARD ST
Applicant Address: Phone: Insurance:
(413) 292-3844
ISSUED ON:412212008 0:00:00
TO PERFORM THE FOLLOWING WORK.-Roofing
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 4/22/2008 0:00:00 $25.001197420
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo