24D-311 (2) VDAC
TRAVELERSJ' WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (7PJUB-0006042-0-1 5)
RENEWAL OF (7PJUB-0545N13-1 -14)
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
1 NCCI CO CODE: 13579
INSURED: PRODUCER:
DE',LONG CONSTRUCTION LLC WHALEN INS AGCY
76 BANCROFT ROAD 71 KING STREET
NORTHAMPTON MA 01060 NORTHAMPTON MA 01060
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05-26-15 to 05-26-16 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease: $ 1000000 Policy Limit
Bodily Injury by Disease: $ 1000000 Each Employee
e= C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
0=
D. This policy includes these endorsements and schedules:
oC SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
a�
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 06-01 -15 AR ST ASSIGN: MA
OFFICE: DIRECT ASSIGNMENT 701
PRODUCER: WHALEN INS AGCY 28LKF
005757
` City of Northampton
Massachusetts
W 1
R, DEPARTMENT OF BUILDING INSPECTIONS ai c
212 Main Street • Municipal Building
` Northampton, MA 01060 lsr'+.,... ..
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 buildinq 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
I, 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: 76 3A-4-c2-1-
City/State/Zip: ,e#Arr+nfiJ'✓ .A4 - 0"361" Phone #: q1 g--S<f 7-3 q S7
Are you an employer? Check the appropriate box: Type of project(required):
1.® I am a with o employer 4. E] 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 g• ❑ 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.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No 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.® Other
comp.insurance required.]
*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.
Insurance Company Name: -1;'4 1E4E,eS
Policy#or Self-ins.Lic. M 7-Pj U,3 `0 CT O 6 0 V z -° f Expiration Date:
Job Site Address: 7(,0 1 2`' R`:)• A City/State/Zip: 9
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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature .--R �- Date: /1''37
Phone#: C�i3 Y37
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#:
C
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: -76 3 Q �-��✓T ,�/o�'�i 'J� '�''� ' r�
The debris will be transported by: DVKcy
The debris will be received by: /i 7);r-
Building permit number:
Name of Permit Applicant
Date Sign-ature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder: Ed"7 I/n/d D L6-VI// 04 a1 C,S —d t{Z�dfa
License Number
7 /'w/Fnlc e 0 r 2�. y2�"�/��tm�raT1 ,ter4 . p 3%Z 5- l L o f b
Address Expiration Date
Signature Telephone
9. mpr e
Registered Home Iovment Coritractor „;; Not Applicable £
Company Name Registration Number
?& �g„Ir,ea�r �2"� . C//S/1a16
Address Expiration Date
14v,2fi/ :tO4J f4 . o s Telephone 457
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 Ham'me OwnerEExemption
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 [[] Siding[O] Other[tM
Brief Descri tion of Proposed
Work: /C Al4Ct 2e4'4-1' '.Y4 A%f#
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
8a:1f Newhouse and or'add'ition towexist'ing"h"ouslng;.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
l _ as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, Lam v�C4 L iH as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the Eesfof my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Its-12 0
Signature Owne gent Date
.
,
�
`
'
°
' . .
Section 4. ZONING AtI.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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
A. Has a Special Permit/Variance/Rnding ever been issued for/on the site?
»�-11�' YES 0NO 0 DONTKNOV
|FYE5, dateioued1 |
IF YES: Was the permit recorded at the Registry ofDeeds?
NO uuN7 KNOW YES
Page and/or Document#
IF YES: enter Book ag
B. Does the site contain a brook, body of water or*etkands? NO DONT KNOW 0 YES
IF YES, has a permit been or need tobe obtained from the Conservation Commission?
Needs tubeobtained »,� Obtained x�� , Date Issued:
�� ��
C. Do any signs exist on the property? YES «���� NO
IF YES, describe size, type and location:
posed YES NO "V*,'D. Aretheoeanypvo � 0
IF YES, describe size type and location:
( |
' ' . _________-_,
E. Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre urioit part ofo common plan
�otv�||disturb over 1 acre? YES � ) NO �0
' �~ _-
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
ah:;- _II r" ..ern Sn�y, 11epattme nt�J
of
'F r '
City of Northampton � tatus,of F'ermtt NSF fa k2 d F^r�x I'FI ti Y {? A'
.I
as a Isa�� s au���latnrf{ r
i �'i Budding Department Gt)r5 Cut/DXVa_w.aygT rPrlt#�=
9I Kt S-64 s$wk.A e xl�"�'s hn^",
�}I 212 Main Street Seyver/SgpftGA aira
(J l l JUN 1 6
Room 100 Watec/l/ItelGAvaalablllty,r i° i r �,Y
Northampton, MA 01060 Twals2#sdfS#ri�nral Plans r I'^ ^fiw}r '� ;i 1^
Elect c, Plumbing&Gas inspe h Y �' "' " y�r� �t a�aY i2a ti61 i
Northampton,MA D1060
jT
'ON e 413-587-1240 Fax 413-587-1272 Plo#1Stte Pians h h
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
office
1.1 Property Address: This secfion to be completed by
t 11
No1
M Mai• /QYJ�
wa�e�An��� ° y r
:Zone Overla District "
4 ,
t
Elm St Dlstnct District
. SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: '' /
i d m vyct —/). L °,/i"m'j 76 34 Are. o T 2 '44 .
Name(Print) Current Mailing Address:
CL� Telephone
Signature �/r3 6" Z-
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
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 Feb
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee �j S
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 7('vO v 0 Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
File#BP-2015-1299
APPLICANT/CONTACT PERSON ED LENNIHAN
ADDRESS/PHONE 76 Bancroft Road Northampton01060 587-0437
PROPERTY LOCATION 76 BANCROFT RD
MAP 24D PARCEL 311 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 4.6 4 14��
Fee Paid
Typeof Construction: REPLACE RETAINING WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 042506
3 sets of Plans/Plot Plan
TFOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
U ATION PRESENTED:
proved 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
D o " lay
, P,4� f' //!s
Signature of Buil mg Wicial 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.
76 BANCROFT RD BP-2015-1299
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma:Block:24D-311 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2015-1299
Project# JS-2015-002387
Est. Cost: $7000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED LENNIHAN 042506
Lot Size(sq. ft.): 17728.92 Owner: LENNIHAN EDMUND D&JENNIFER D ADDAS
Zoning:URA(100)/ Applicant: ED LENNIHAN
AT: 76 BANCROFT RD
Applicant Address: Phone: Insurance:
76 Bancroft Road 587-0437 WC
NorthamptonMA01060 ISSUED ON.611612015 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE RETAINING WALL
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 Sienature:
FeeType: Date Paid: Amount:
Building 6/16/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner