17C-040 (2) A ORD_ CERTIFICATE OF LIABILITY INSURANCE OP ID Sg DATE(MWDDNYYY)
• CONSA50 1 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, CPCV HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
75 North Main 3t.-P 0 Box 564 ALTER THE COVERAGE'AFFORDED'BY THE POLICIES BELOW.
East Longmeadow M& 01028
Phone:413-759-0010 rax:413-759-0017 INSURERS AFFORDING COVERAGE NAIL#
IaUIRED- INSURER A: Central snsutanoa cwpanias. 20230
.INSURER S:
Construgt Associates, Inca INSURER C:
36 Service Center Road INSURER D:
Northampton MA 01060
'INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIE POLICY PERIOD INDICATED.NOTWITHSTANDING
G
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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL TIE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR .NM TYPE OF INSURANCE POLICY NUMBER DATE(MMdDD/YY) DATE(MMDDfM LIMR'S
GENERAL LIABILITY EACH OCCURRENCE $500000
A X COMMERCIAL GENERAL LIABILITY CLP7834317 07/01/08 07/01/09 PREMISES Ea $100000
CLAIMS MADE X❑OCCUR MEDEXP(Any-ompwson). $5000
PERSONAL BADV INJURY $500000
GENERAL AGGREGATE $1000000
C—ENM AGGREGATE LIMIT APPLIES.PER: PRODUCTS-COMP/OP AGG $1000000
POLICY Ca"T LOC
AUTOMOBILE LIABILITY.
A ANY AUTO BAPS614614 07/01/08 07/01/09 Ea acNECIcidart)SINGLE
( $1000000
(Ea
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per PAN $
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (PeracCdert)
PROPERTY DAMAGE $
(Pereccidert)
GARAGE IJASILfTY .. AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
E(CESSAIMBRELLAUABILRY EACH OCCURRENCE $1000000
• X7 OCCUR, F�ctAmsMADE CXS7834319 07/01/08 07/01/09 AGGREGATE $1000000
$
H DEDUCTIBLE - $
x RETENTION $0 $
WORKERS COMPENSATION AND X TORY LIAA ER
• EMP0YEW LIABILITY WC783431818 07/01/08 07/01/09 E.L.EACH ACCIDENT $500000
ANY PROPREETORIPARTAER/EXECUTIVE
OFFICEWMENBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $500060
If yes,describe IXldef
SPECIAL PROVISIONS belm E.L.DISEASE-POLICY LIMIT $500000
OTHER
DESCRIPTION OF OPERA71M/LOCATIONS I VEHICLES.I EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS.
CERTIFICATE HOLDER CANCELLATION
PROOFOO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF.,ne ISSUNG INSURER WILL ENDEAVOR To MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDIER NAMED TO THE LEFT,BUT FALURE TO 00 SO SHALL
Proof of Coverage IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE RRSURM ITS AGENTS OR
REPRESENTATNES.
AUTHORIW.REPRESENTATIVE
IRM Insurance Agency Inc.
ACORD 25(2001M) OACORD CORPORATION 1988
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: '� Not�A—pplicabblle ❑
Name of License Holder: �' 2� ✓� �`� v `� (7 1( e e^
License Number
Address Expir ion Date
Signature Telephone
9 ea stered Home Improvement Contractor. Not Applicable ❑
gn5,r ll�re` , y7
Comifany Name Registration Number
Address AA Expiration Defte
Cold l Telephone S 8y'r'C
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 buildin ermit.
Signed Affidavit Attached Yes....... No...... ❑
11. -Home 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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[tom] Other[a
Brief Description of Proposed
Work: c�
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 existina housina, com fete 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
I, --n V L, I Y L �4�-�d'� as Owner of the subject
property
hereby authorize
to act on my behalf, in all matted relative to work authorized by this building permit application.
Sign ture f 0INner Date(
as Owner/Authorized
Agent here 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
2 l L J
Si ature wner/Agent Date
NNW
Section 4. ZONING All Information Must Be Completed. Permit Can Be D ed 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/Finding r been issued for/on the site?
NO Q DON'T KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Regis of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , 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,grading,exc tion,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.
Department,use only
� `�, ��: - City of Northampton Status of Permit:
Budding Department curb CuUDriveway Permit
0 ,212 Fain Street Sewer/Septic Availability
Room 100 WaterNVell Availability'
Northatrlpton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans'
Other Specify
APP-LiCATION 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
7 � �1-e 4--t-" Map 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_M igg Address:
D j/d'Vr t j
Telephone
Sig atu
2.2 Au/tlj, riized Anent: *�
ST�fi` ` 1 1.✓ C L53S Ll 5�7 L'.'!_ t .c > u'� �
Name( nt) Current /
Maili ng Address
y
Signature Telephone z V
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building S-V.c,�.p ,':'b (a)Building Permit Fee
0
2. Electrical �)", 4-0 (b)Estimated Total Cost of
Construction from 6
3. Plumbing VS-00 8*0 Building Permit Fee
4. Mechanical(HVAC) 0 v 0-0 -.
5. Fire Protection
6. Total=(1 +2+3+4+5) (p 7,-,5-()(), Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2009-0973
APPLICANT/CONTACT PERSON STEPHEN D ROSS
ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224 Q
PROPERTY LOCATION 71 SHEFFIELD LN
MAP 17C PARCEL 040 001 ZONE URA/URB(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
Typeof Construction: RENOVATE KITCHEN,BATHROOM&MUDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 079160
3 sets of Plans/Plot Plan
THE F ALLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INPFIRMATION 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
2 1220e
Signature of Building Official ate
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.
.y BP-2009-0973
GIs#: COMMONWEALTH OF MASSACHUSETTS
'' i�t Z"-1111' 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-2009-0973
Project# JS-2009-001405
Est. Cost: $67500.00
Fee: $405.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq. £t.): 20298.96 Owner: MALKIN ANYA
Zoning:URA/URB(100)/ Applicant: STEPHEN D ROSS
AT. 71 SHEFFIELD LN
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584-1224 O WC
NORTHAM PTONMA01 060 ISSUED ON:512112009 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE KITCHEKBATHROOM &
MUDROOM
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 5/21/2009 0:00:00 $405.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo