18C-057 (3) 05/07,/220015 THU 10:02 FAX 10001/001
T ® DATE(MMIDDIYYYY)
A�RV CERTIFICATE OF LIABILITY INSURANCE 5�7�zols
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(les)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).
NTaOT House
PRODUCER NAME: --
King 6 Cushman Inc. PHONE t. (413)584-5610 NC N0;(413)564-9322
P.O. BOX 447 ADDRESS:
RIESS:
176 King Street INSURER(S)AFFORDING COVERAGE NAICA _
Northampton MA 01061 INSURER A:Liberty Mutual Group
INSURED INSURERB:Safety Indemnity Insurance Company 33618
David Fortier Builders INSURERC:
32 Laurel Street INSURER D:
INSURER E: -- -
Northampton MA 01060 1 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL155700881 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
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 HIPREIN IS SUBJECT TO ALI.THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID
INSR TYPE OF INSURANCE AD POLICY NUMBER PMfDDDY EFF MMiDONYYY LIMITS
LTR
FC-OMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A S•MADE OCCUR PREMISES Ea occurrence $
50,000
BES55722835 12/2/2014 12/2/2015 MED EXP(Any one person) $ 5,000
PERSONAL BADVINJURY $ 1,000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY❑PRO ❑LOC PRODUCTS-COMPIOPAGG $ 2,000,000
X JECT
$
OTHER:
-COMBINED SINGLE LIMIT g 1,000,000
AUTOMOBILE LIABILITY (Ea accident) —
ANY AUTO BODILY INJURY(Per person) $
B ALL OWNED SCHEDULED
AUTOS Ix AUTOS 6225303 10/8/2014 10/8/2015 BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE $
X HIRED AUTOS AUTOS Per accident
Uninsured motorist BI s Id limit $ 100,000
UMBRF.LI.A LIAB OCCUR ,_EACH OCCURRENCE _.
EXCESS LIAR `CLAIMS•MADE AGdREGATE
DED RETENTION $
WORKERS COMPENSATION I PTA UTE ER
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE ❑
NIA A
A (Mandatory n E.L.EACH ACCIDENT $ 100 000
OFFiCEtory In NMI M EXCLUDED? XWS55722835 9/4/2014 9/4/2015 E.L.DISEASE-EA EMPLOYE $ 100'000
H yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 141,Additional Remarks Schedule,may be attached H more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
210 Main St. ACCORDANCE WITH THE POLICY PROVISIONS.
Northampton, MA 01060
AUTHORIZED REPRESENTATIVE L
� u t
9-1
p 1988-2014 ACORD CORPORATION. All r4os reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025(201431)
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.
0,
Address of the work: iii ( .
The debris will be transported by: OA" , t
The debris will be received by: VfiL(. tz/
Building permit number:
Name of Permit Applicant ti�J� -i-��2� �t5•L
s ,,
Date Signature of Permit Applicant
City of Northampton
Massachusetts
{� { DEPARTMENT OF BUSLDING INSPECTIONS T ter'
212 Main Street • Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
w
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 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 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
1, 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
{ Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
-.-�
Name (Business/Organization/Individual): �;�
Address: L fit, �� S T
City/State/Zip:, I N �TztJ 11-1. 6 0 �!0 Phone #: ��I :3 � l Ca�' ��L, 5-
Are you an employer? Check the appropriate box: Type of project(required):
1.SQ I am a employer with a 4. ❑ I am a general contractor and I
employees (full andlorpait-time).
* have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp, insurance comp. insurance. 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions
myself. o workers comp. right of exemption� ' per MGL p 1 Z.® Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ OtherP fir'" ��,Z i-L4 Z r/1 U;14)N,
comp. insurance required.] -f t..
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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. j
Insurance Company Name: u I C r c. (jr• ;^
Polic #or Self-ins. Lic. #: i�3✓. " '`
y �.�r`� .-��ii/.;� Expiration Date:
Job Site Address: t! 2 ��S"KC i l``1 tr ;z 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 up to $250.00 a day against 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.
I do hereby certify undo-thepains and penalties ofperjury that the information provided above is true and correct.
; i
Sign ature: Date:
F'
Phone#: q('j r U S
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder: q �,�f f G \( A-- C
A/
License Number
_ 3A_ LA
Addgess i A. Expirati n Dat
Signature Telephone
9.Registered m
Hoe Improvement Contractor: ! Not Applicable £
Company Name Registration Number
Address Expiration Date
Telephonelug-
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!Ye ....... £ 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-vear 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 ❑ ReplacemenRindows Alterations) ❑ Roofing
Or Doors 7
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [[] Siding[01 Other[O1
Brief Description of Proposed / i��` -,°1 �' �'K' f �t �".4ftf`
'f t r� N 4�! /��, 1 1 a.
is V (�
Work: !�" t 1°J ( {�;�'( 6 a ' 4 Y` GM i G�.r�n1 X) • � ,�
Alteration of existing bedroom Yes_ No Adding new bedroom Yes X' No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
8a. If New and.or addition to existing housittg; coni aete the f6i16 inq:
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, 7,f-x cze(' as Owner of the subject
property
hereby authorize � e- /�a•t<t�2
to act on my beha , in all matters relative to work authorized by this building permit application.
-S 7
Signature of w r z Date
I, _,gs.Qw#-+er1Authorized
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 underthe pains and penalties of perjury.
Print Na
Signature o caner/Agent Date
Section 4. ZONIN7G All Information Must Be Compteted. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
nis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear F-71
Building Height
Bldg.Square Footage %
Open Space Footage r-, %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
�� ��
NO �_��� DON7KNOY/ �~/ YES �~�
IF YES, dateioued:/ �
IF YES: Was the permit recorded at the Registry nfDeeds?
��
NO �� D N7 KNOW 0 YES C)
IF YES: enter Book Pag and/or Document#
�~� �-� ��
D. Does the site contain a brook, body of water orwetlands? NO ��/ DONT KNOW �~� YES ��^
'
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained �~� Obta�ned «—\ Date � /
�~� ��. ' i
C. Do any signs exist on the property? YES 0 NO 0
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 0
IF YES, describe size' type and location:
E Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orimd part ofa common plan
'
that will disturb over 1acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ —
t �
'yam r
�' ""` Department use onlx
ki 4 t
t I
City of Northampton Status ofPermrt
� Ohl —8 ZQ� wilding Department Curb cutJDri�eway Permt#
l 212 Main Street SeweriSeptieRvaifabll'ty
Inspe��ons Room 100
E�eCtric.Ptu p'n� �� �iVaterl> ellRvatlablht
North p1On M�o1e6o Northampton, MA 01060 Two Sets ofStroctural Plans
phone 413-587-1240 Fax 413-587-1272 PIof/Slte Plans
other 5peci#j!_
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
,,, Map Lot Unit-
I �( )L lo sr"(- ct C) tx
;Zone Overlay Drsfr�ct
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
it/ L,,-2e - I7z �2a aG�/, G``°-
Name(Print) Current Mailing Ad ress:
3 Telephone
Signature
2.2 Authorized Agent: J
A4
Name(Print) ��. Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building (a) Building Permit Feb
2. Electrical (b) Estimated Total Cost of
Construction from 6 7
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
142 PROSPECT AVE BP-2015-1084
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C-057 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-1084
Project# JS-2015-002057
Est. Cost: $21500.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin DAVID FORTIER 008026
Lot Size(sq. ft.): 39900.96 Owner: CZELUZNIAK JAY
Zoning. URB(100) Applicant: DAVID FORTIER
AT. 142 PROSPECT AVE
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965
NORTHAMPTONMA01060 ISSUED ON.5 11112015 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF,INSTALL
REPLACEMENT WINDOWS, SHEETROCK REPAIR
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 Sisnature•
FeeType: Date Paid: Amount:
Building 5/11/2015 0:00:00 $70.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner