25C-209 ACORD_ CERTIFICATE LIABILITY INSURANCE DP 10 sg DATE(MMWDIYYYY)
CONSA50 07/01/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
iRM Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Barry M. Stephens, CPCU HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
75 North Main St.-P'O Box 564 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
East Longmeadow MA 01028
Phone:413-759-0010 Fax:413-759-0017 INSURERS AFFORDING COVERAGE NAIL#
INSURED INSURER A: cmtsal znx= c.companlos 20230
INSURER B:
Construct Associates, Inc. INSURER C:
36 Service Center Road INSURER D:
Northampton MA 01060
INSURER E:
COVERAGES`
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.
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDM� DATE(MRAIDD/YY) - LIMITS
GENERALL16BLITY EACH OCCURRENCE $500000
A X 'COMMERCIAL GENERAL LIABILm CLP7834317 07/01/08 07/01/09 PREM,sES(Eeoccurence) $100000
CLAIMS MADE OCCUR MED E)P(Anyone per) $5000
PERSONAL&ADV INJURY $500000
GENERAL AGGREGATE $1000000
GEN'L AGGREGATE LIMTT APPLIES PER: PRODUCTS-comp/op AGG S 1000000
X POLICY PR LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
A ANY AUTO SAPS614614 07/01/08 07/01/09 (Eaaccidert) $1000000
ALL OWNED AUTOS .BODILY INJURY $
X. SCHEDULED AUTOS (Per person)
X HIRED AUTOS BODILY INJURY $
X NON-OWNED AUTOS (Peraccidert)
PROPERTY DAMAGE $
(Per acciderd)
GE LIABLRY AUTO ONLY-EA ACCIDENT $
Y OTHERTHAN EAACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLAUABLTTY EACH OCCURRENCE $1000000
A X OCCUR F cu1MsMADE CXS7834319 07/01/08 07/01/09 AGGREGATE $1000000
DEDUCTIBLE $
X RETENTION $0 $
WORKERS COMPENSATION AM X.TORY LIMITS ER
EMPLOYERS'LIABILITY
A WC783431818 07/01/08 07/01/09 E.L.EACH ACCIDENT $500000
ANY PROPRIETOR/PARTNER/EJECIJTIVE
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500000
ItM describe urMer
SPECIAL PROVISIONS below E.L.DISEASE-POLICYLIMIT 1$SQQQQQ
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS./VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
PRooro o SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE 7tEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Proof of Coverage WOSE NO 09UGATM OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTA[TVE8.
17IRMInsurance REPRESENTATIVE
Agency inc.
ACORD 25(2001/08) 0 ACORD CORPORATION 1988
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supelrvisor: Not Applicable ❑
Name of License Holder:. �� �t°-'� S y 5 16 U
License Number
Address Expirat on Date
'Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
i4j ' 6t .y� �c�. f c/,at/�`t� /S� d 1/-7
Co any Name Registration Number
Td, 5*—,��." , C" /---- Fed 1✓��...��.�- �� s--�� //0
Address Expiraffon Dat
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 build' g permit.
Signed Affidavit Attached Yes....... No...... ❑
11. - Hone Owner Exemption
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Efr Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[0]
Brief Descrip'gn of F�ropos ) "
Work: f'� c� d. A ; ✓ 1 tte�Y (� ✓'cs c r s�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached R911 -Sheet
6a. If se and or addition to existinct housina, complete the following:
a. of it inq%: 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. floodpiain 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
l IX ��_ �� �t..C� as Owner of the subject
property
hereby authorize
t c on my behalf, in aftati6rs relay e t rk authorized by this building permit applica on.
gn ture of Owner Date
as Owner/Authorized
Agent hereby eclare 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 e
d, if,_ r
igna a of Owner/Agent Date
Section 4. ZONI A Informs Must Be Completed. Permit Can Be Denied Due To Incomplete Information
x s ' g 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/Findin ver been issued for/on the site?
NO 0 DON'T KNOW YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO Q DON'T KNOW YES
IF YES: enter Book ( Page and/or Document #i
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 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,ex vation, 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.
f
Department use only
City of Northampton Status of Permit:
i_ _`�� �gi3ilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
OCT 1 4 KIN Room 100 Water/Well Availability
Nol'ttlampton, MA 01060 Two Sets of Structural Plans
phone_413-587 1240 Fax 413-587-1272 Plot/Site 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
^� G, dam- sk Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: J
Na (Print) , Current ailing Add ss:
La P
7 Telephone
gnature it z-
2.2 Authorized Agent. /
:57 36
Name(PA_ _,-_ Curren Mailing Address:
gignaturgV Telep one
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building S^ ��� (a)Building Permit Fee
2. Electrical p ,.� (b)Estimated Total Cost of
Construction from 6
3. Plumbing S-'�C1D �°' Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection _
6. Total=(1 +2+3+4+5) C / <o 6 t ` Check Number dff r
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
f
File#BP-2009-0412
APPLICANT/CONTACT PERSON STEPHEN D ROSS
ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224 Q
PROPERTY LOCATION 11 LINDEN ST
MAP 25C PARCEL 209 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: ADD 3RD FLR BATHROOM
New Construction
Non Structural interior renovations
Addition to Existina
Accessory Structure
Building Plans Included•
Owner/Statement or License 079160
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
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
O
Signature of Building Of icial 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.
f
BP-2009-0412
GIs#: COMMONWEALTH OF MASSACHUSETTS
w. 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-2009-0412
Project# JS-2009-000556
Est.Cost: $41900.00
Fee: $251.40 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq, £t.): 12066.12 Owner: WEINER THOMAS M&SUSAN K DUDEK
Zoning:URC(100)/ Applicant: STEPHEN D ROSS
AT. 11 LINDEN ST
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584-1224 O WC
NORTHAMPTONMA01060 ISSUED ON:1011712008 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD 3RD FLR BATHROOM
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 10/17/2008 0:00:00 $251.40284
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
�ND �ST NwEA�T�i F 'a'ust
O
COMA O CITY OF NOR i
p(p�S
aMlp ock:25C-209 pgRSONS CONTRACTING'
WITH UNREGISTERED C o(M L 0 '�42N)
ACCESS TO THE GUARANTY FUND
>t: DO NOT HAVE ERM��
rmit Bulldln,]C.. ILDIN� P
BV
'ate or�:_
BP-2009-0412
ernvt�J5-2009-000556
?ro'ect# N1 ED TO.
Est.Cost_$419oo.WO PERMISSION IS HEREBY License:
re=25� Contractor: 079160
cons=c:lass� STEPHEN DR O-S-
Us_e Gr°u 2 Owner: WEINER THOMAS ROSS SAN K DUDEY.
Lot size s .ft. : 12066.1 A licant: STEPHEN S
zoning:URC 10o i AT; 11 LINDEN ST phone: Insurance� W('
(4131584-1274
Anent Ads dry
36 SERVICE CENTER RD ISSUED ON:10/17/2008 0:0��:00
NORTHAMPTONMA01060 T�
�' OI_L��r►'ING WORK:ADD 3RD FLR BATHROO
TO PERFORM ,HE F
THE STREET Building inspector
POST THIS CARD SO IT IS VISIBLE FROM
Inspector of Plumbing Inspector of Wiring
Meter: Footings:
Underground: Service: Foundation:
Roug /l1ly1d� House#
h: Driveway Final:
Rough:11'I�-•r�� \ �/✓ l 6V
Rough France: ' f4 1
Final- �L7 i Q p tf�nal: 17-
P.�^'1 , Fireplace/Chimney:
Fire Dew tment Q g
Gas: Insulation:
o_l iZ�►� �a� ('O-C+65
Roub:l: Final: O 1'�
Smke.
Finai: UPON VIOLATION OF
D BY THE CITY OF NORTHAMPTON
IS PERMIT MAY BE REVOKED /
THIS
ANY OF ITS RULES AND RF,GUL _
Si nature:
Certificate of Occu anc Date Paid. Amount:
FeeT e-
10/17/2008 0:00:00 $251.40284
Building
413 587-1240,Fax'.(413)587-1272
212 Main Street,P Connn. ioner-Anthony Patillo
Building