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24A-182 (5) �,...,, GERASTO-01 VCARRIER CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 10011!2/11/2015 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(ies)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). PRODUCER CONTACT NAME: Valerie Carrier Whalen Insurance Agency PHONE 413 586-1000 FAX 413 585-0401 71 King Street EA'a Lo,E■t): ) (AIC,No): ( ) Northampton,MA 01060 ADDRESS:info @Whalenlnsurance.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Utica First Insurance Company INSURED INSURER B: Gerard Stordeur DBA Gerard Stordeur Finishing INSURER C: 61 Nonotuck Road INSURER D: Florence,MA 01062 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -1NSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD _POLICY NUMBER - (MM/DD/YYYY) (MM/DD/YYYY) _ A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X ART-5056866-01 07/30/2015 07/30/2016 DAMAGES( RENTED 100,000 , CLAIMS-MADE OCCUR PREMISES(Ea occurrence) ', $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT $ OTHER: AUTOMOBILE LIABILITY (Ea accident)SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ .. $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? �.._ ] N/A (Mandatory in NH) E .DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate issued as evidence of coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main Street Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 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: The debris will be transported by: e-'Fi2.c`�`f�- : will be received b q// lee �'/X' The debris y Building permit number: Name of Permit Applicant Date Sign-ature of Permit Applicant City of Northampton Massachusetts 4s cf1, W;; Tye DEPARTMENT OF BUILDING INSPECTIONS Y 212 Main Street • Municipal Building �.-. Northampton, MA 01060 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." 1 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 i 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 i,,... _ • � 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): S U(d eCke- Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I employer with 4. ❑ I am a general contractor and I 6. ❑New construction ployees (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.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] 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.E Other ✓1 l 1- - ^- O comp. insurance required.] Fr'��G i °cr 0,1 *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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: 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 u the pain and aloes of perjury that the information provided above is true and correct. 5- Signature: Date: 0 - - 1 S J Phone#• `_7_2_7 — 3t3 3 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 Su ervisoor: Not pplicable £ q Name of License Holder: �! ��� � C� ir°(A �S ( OE � ` 7 0 Lice se Number -ter �cc c" �� - ✓l'1� f l Z - 1 -7 - zUIs> Address Expiration Date Signature Telephone err4_ «.. 9.R fire dHome rovement Contractor Not Applicable £rAeLv- ej ew,;J co,4, e��•�- S �rJ -- - i on 1 -71639 CowDanv Name U Registration Number a✓10 f 4-ck 5S&ee� Y-3 — 20I9 Address Expiration Date �lUl(°o1 cep C3 TeTeph�3 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-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 sponsibility for compliance with the State Building Code,City of Northampton Ordinances,State an Z ws and State of Massachusetts General Laws Annotated. Homeowner Signature, i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House F7 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [M Siding [0] Other Brie ri i Piro se � e� L cA — YJ G`��C W or ' P'1 p [�-- T CT `off �00/ O/t 601)f"F t�°N` 62c7� e Alteration of existing bedroom Yes No Adding new bedroom Yes No/ Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba. IfNew'house and or�adtlition to exlsting.h`ousna,'complete the follortiinc�: 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. flcodplain 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 N-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby a e rc&r to ac y be i all atters relative to work authorized by this building permit appli atio . nature wner Date I as Owner/Authorized 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. (5icr Print Name Signature of Owner/Age Date ^ ' F' Section 4. ZONING All 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 YO Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Sp at Permit/Variance/Finding ever been issued for/on the site? �� �� NO ^�� DON7KNOY� �_� YES �~� |FYES, dateissued: IF YES: Was the permit recorded at the Registry ofDeeds? NO ��� � DON7 KNOW 0 YES ' IF YES: enter Book Pag and/or Document �� �� �� B. Does the site contain a brook, body of water orwetlands? NO ��� DON7 KNOW «�� YES �~� IF YES, has permit been or need to be obtained from the Conservation Commission/ . Needs to be obtained �—� Obtained x~� Date | ued' v~� �~/ ' 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 0 NO vD`- � ~ IF YES, describe size, type and location: E Will the construction activity disturb(clearing,grading tion. or filling)over 1 acre orioit part ofa common plan ' that will disturb over 1acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. | ) ' �� — / = �' Deparfinent use only I F " i n r � yoQ k City of Northampton Status,ofPermtt F © Building Department Curb CutlDriye'uay Perini# �� 4; c� 212 Main Street Sewe rfSeptPcA?alfabllrty t Room 100 Water/UMfelGAvaila6lhty'`� k k r s I-" Northampton, MA 01060 7Waisofs of S#r' ctural P(a�ts f o hone 413-587-1240 Fax 413-587-1272 'P[of/Slte --i p = r k t Qther 5;peclfy��F a 15f ail 1 r r v i ION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION ='"' , This secfiorr to be completetl by office 1.1 Property Address: II - 1► i ` Zpne ' I " ' Overlay D�sfrict t' r_ - r u i _ I 5t District CB Dlstnct SECTION 2.:-PROPERTY OWNERSHIP/AUTHORIZED AGENT. 2.1 Owner of Record: Na a Print) Current Mailing Address: Telephone 171 Signature,/ (( �� 2.2 Authorized Agent, rC Nam t) Current Mailing Address: 32.3 - 3d3 �- 065� Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building v (a) Building Permit Feb 2. Electrical (b)Estimated Total Cost of Construction'from 6 `: 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number 4 to This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings; Date File#BP-2016-0452 APPLICANT/CONTACT PERSON GERARD STORDEUR ADDRESS/PHONE 61 NONOTUCK ST FLORENCE01062(323)363-0659 PROPERTY LOCATION 35 NORFOLK AVE MAP 24A PARCEL 182 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT —® Fee Paid 1,W Ea Building Permit Filled out Fee Paid Typeof Construction:_INSTALL GARAGE EXTERIOR DOOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 108497 3 sets of Plans/Plot Plan THE FqLkOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON MATION 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 y /� Sig of Builcling 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. 35 NORFOLK AVE BP-2016-0452 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24A- 182 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-2016-0452 Project# JS-2016-000748 Est. Cost: $1000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GERARD STORDEUR 108497 Lot Size(sq. ft.): 293158.80 Owner: UGONE JANNA Zoning URA(100)/ Applicant: GERARD STORDEUR AT. 35 NORFOLK AVE Applicant Address: Phone: Insurance: 61 NONOTUCK ST (323) 363-0659 FLORENCEMA01062 ISSUED ON.1011312015 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL GARAGE EXTERIOR DOOR 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 10/13/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner