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43-029 GERASTO-01 VCARRIER Aco CERTIFICATE OF DATE 0/11/2D/YYYY) LIABILITY INSURANCE ��- 1011/2015 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). CONTACT PRODUCER NAME: Valerie Carrier Whalen Insurance Agency PHONE -1000 FAX, -0401 (A/C,No (413 586 A c No): (413 j 585 71 King Street Northampton,MA 01060 ADDRESS:info @Whalenlnsurance.com INSURER(S)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 ICH PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WH 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. INSR 'ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD'WVD _ POLICY NUMBER �MM/DD/YYYYL MI M/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X ART-5056866-01 07/30/2015 07/30/2016 DAMAGE TO 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 ECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER'. _ _ _— -- ---- - AUTOMOBILE LIABILITY E COMBINED cdent) SINGLE LIMIT $ BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS — $ - PER OTH- WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y I N :ANY PROPRIETOR/PARTNER/EXECUTIVE .�1, N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? J (Mandatory in NH) E .DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E DISEASE-POLICY LIMIT $ . DESCRIPTION OFOPERATIONS I LOCATIONS/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 {��i City of Northampton 212 Main Street, Northampton, Na 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: 41.= V-1 D The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date i ` r� Signature of Permit Applicant City of Northampton Massachusetts _'_ s . 4 r DEPARTMENT OF BUILDING INSPECTIONS 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." 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 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 4ddress of work location The Commonwealth of Massachusetts Department of Industrial A ccidents > Office of Invesdgations 600 Washington Street r. Boston,M4 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual): �' ! L°(�le— Address: b / lva4© C f e City/State/Zip: l e)1'-e4Ct° X;.-O 1 G d Z Phone#: 32-3— 3 63 S� Are you an employer? Check the Fppropriate box: Type of project(required): 1.❑ I a employer with 4. 7 I am a general contractor and I mployees (full and/or part-time).* have hired the sub-contractors 6. 71 Ne construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for mein any capacity. employees and have workers' [No workers' comp, insurance comp. insurance.$ Building addition required.] 5. We area corporation and its 10.0 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.[1 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. lContractors 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 e pains a pen es ofperjury that the information provided aahove is true and correct Sim ature: Date: Phone#: 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 87 CONSTRUCTION SERVICES 8.1 Licensed Construction d up ervisor: / Pl , ' Not Applicable Name of License Holder: eT��� J 1 US ��-�K CY—toP4 O G 9 L // License Number 6� ��� U lC. cP ��vtonce Address Expiration Date Signature Telephone istered_Home'Im irovement"Contractor:_ _ Not Applicable £ rJ e LA r 6,A �� �.I°n l7 l 6.7 V Company Name -Registration Number 011AeJ-4d6eV<_ 7-0a Address ----�� Expiration Date Telephone�D� 1 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 thept i ding permit. Signed Affidavit Attached Yes....... £ No...... £ 71 = Home_4wner..Egempt J I on 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. CAR 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 buildins 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. i i _ I SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [C] Siding [❑] Other[❑] Brief Description of Proposed / Work: UCH e 6Q_Aro a!t'-,- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roil -Sheet New tiOuse and.or adciltion[to existlng=housinct,.comp fete_ he foalowlnc: 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 L Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. fioedplain 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 as Owner of the subject grope y hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Nner Date 1, �� � CJ`� e�� 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 der the pains and pen (ties of perjury. e—Lk Print Nam Signature of Ow /Agent Date 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 C i Side L:' ( R.:= L:i R:i Rear i Building Heights Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) r-? #of Parking Spaces F(volume&Locati ill: It W_.._._�.._.�.,.�......�.,,.....�......_.._,;_..._�.._...�,x._...,��....�,_..._..._.... It l on) -A. Has a Special Permit/Variance/Finding er been issued for/on the site? NO 0 DONT KNOW er YES Q IF YES, date issued:i IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book Paged and/or Document#s B. Does the site contain a brook, body of water or wetlands? NO _; DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: j R 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 O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. u - RECEIVED °jl peparfinent use only' „ 1 �i City of Northampton StausofPermit m -32 Building Department Ji 1 11111 t f 4 -{�-� i e �I ' - 212 Main Street SewerLSe t(e/ualfab llt _ - OR P i Y 1 1 DEPT OF BUILDING IN3PEG'T;ONS Room 100Vater/VIfe7�Avafla6ihty�` k NORTHAMPTON M1fA n7 orthampton, MA 01060 _ = Twa Sefls of S#rucf�ral Ptat}s phone 413-587-1240 Fax 41.3-587-1272 PIofISlte Plans ;1 j t _ APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE.INFORMATION. Thls secflorrfo be completed by office Property Address: - y�0 RD Map Lot nl Eim St.Dlstrlct CB Dlstnct - SECTION 2.-PROP ERTY OWNER.SH.IP/AUTHORIZED:AGENT-•. 2.1 Owner of Record: ©�QG T P t-tev,3 C 6AJ UX51 V�v ts►1 Name(Print) Current Mailing Address: G Telephone Signature 2. uthorized A ent:� 1 L I ` iL /�� l O( �' e d(�fif Name(P ' 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 Fee 2. Electrical / (b) Estimated Total Cost of Construction from 6):: 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) G U Check Number This Section For"Official Use Onl Date Building Permit Number. Issued: Signature: Building Commissioner/lnspector'of Buildings, Date File#BP-2016-0617 APPLICANT/CONTACT PERSON GERARD STORDEUR ADDRESS/PHONE 61 NONOTUCK ST FLORENCE01062(323)363-0659 PROPERTY LOCATION 400 WESTHAMPTON RD MAP 43 PARCEL 029 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid c Building Permit Filled out Fee Paid Tyneof Construction: REMODEL BATHROOM 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: o 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 Dela Signa ure of Buildi g 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. 400 WESTHAMPTON RD BP-2016-0617 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:43-029 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-2016-0617 Proiect# JS-2016-001035 Est.Cost: $5000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GERARD STORDEUR 108497 Lot Size(sq. ft.): Owner: CALCASNINO STEPHEN Zoning: Applicant: GERARD STORDEUR AT. 400 WESTHAMPTON RD Applicant Address: Phone: Insurance: 61 NONOTUCK ST (323) 363-0659 FLORENCEMA01062 ISSUED ON.1114/2015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL 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 Shmature: FeeTvpe• Date Paid: Amount: Building 11/4/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner