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24C-137 (2) I 1 FOURTH AVE BP-2016-1187 GIs#: CO MONWEALTH OF MASSACHUSETTS Map:Block: 24C- 137 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2016-1187 Project# JS-2016-001017 Est. Cost: $108130.00 Fee: $703.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID FORTIER 008026 Lot Size(sq. ft.): 4312.44 Owner: BENOIT JOHN E Conine: URB(100)/ Applicant: DAVID FORTIER AT. 11 FOURTH AVE Applicant Address: Phone: Insurance: 32 Laurel St (413) 586-8965 WC NORTHAMPTONMA01060 ISSUED ON:4/22/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT ADDITIONS, 6 X 28, 1/2 BATH 6 X 6, FAMILY RM 16 X 16, KITCHEN/LAUNDRY ROOM 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 4/22/2016 0:00:00 $703.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1187 4 N APPLICANT/CONTACT PERSON DAVID FORTIER ADDRESS/PHONE 32 Laurel St NORTHAMPTON01060(413)586-8965 PROPERTY LOCATION 11 FOURTH AVE MAP 24C PARCEL 137 001 ZONE URB000)/ 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: CONSTRUCT ADDITIONS 6 X 28, 1/2 BATH 6 X 6, FAMILY RM 16 X 16, KITCHEN/LAUNDRY ROOM New Construction Non Structural interior renovations Addition to Existinp- Accessoa Structure Building Plans Included: ,f Owner/Statement or License 008026 /W `�& 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 z Sig of uil in Oficial 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. f - Department use only ity of Northampton ilding Department Curb Cur�Drirce�vay Permt# �— t i APR " � 212 Main Street Sewerl5ept7c/�vaila6Eltty Room 100 1Nater/Uei�?+vatlabdity { ampton MA 01060 ow a S�#s o1 S#rsuctpFal Ptarrs phone 413-587-1240 Fax 413-587-1272 P[oflstte Ptans' "{ *r, j _.. r Outer Specify` 5� j APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This sectiorr to be complefetl by office 1.1 Property Address: ^' n Map Lot Unit �Ulz SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pr' t) Current Meiling Address -7-- •7 Telephone t� — S8`54{-- Signature l 2.2 Authorized Agent: � I 9 A In LAU i t , lUo 6�Q►�l°'fd�1. ��. al6(,4 Name(Pri Current Mailing Address: Ill- Signature U Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. . Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Buildingq32 �� (a)Building Permit Fee 2. Electrical (b)Estimated TotaI Cost of Construction`from*((5) 3. PlumbinL)5'00, Building Permit Fee � g )�0U, nU �� 4. Mechanical(HVAC) 1 d 5. Fire Protection Lj 3 oQ+ Q® 6. Total=(1 +2+3+4+5) 1' C3 $ t ©. Check Number r 17 This Section For Official'Use Onl Date Building Permit Number: Issued: Signature: Buildin.Commissioner/In.spector'of Buildings.'.., Date . � Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Tluis column to be filled in by 4 Building Department Lot Size Frontage Setbacks Front —10 Rear Building Height Bldg.Square Footage bil MI YO Wd 2-2-0 Open Space Footage % (Lot area minus bldg&payed &X Jj #of Parking Spaces (volume&Location) A. Has a SpecialPermit/Vahance/Rndingever been issued for/on the site? '«��x=� \V �A-1.NO DOHTKN� ��' YES �x~� ~� IF YES, date issued:! IF YES: Was the permit recorded atthe Registry ofDeeds? NO ��� � DONT KNOW 0 YES IF YES: enter Book Page[ and/or DocumenL# �� �� B. Does the site contain abrook, body ofwater orwetlands? NO ��/ DONT KNOW v�� YES v�� IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tubeobtained �~� Obtained �� Datebaued. ' �~� �~� ' v�� C. Doany�Bns� ex�tonthe pnope/�? YES ��' NO IF YES, describe size,'type and location: D. Are there any pnnpusedchanges tooradditions ofsigns intended for the property 7 YES 0 NO 0 IF YES, describe size' type and location: E. Will the construction activity disturb( hng.gradingvobon.or0|inQ)over1 acre orisitpa�ofacommon plan Uho�wi|/diatudbover1oons? YES � � NO �y� ' ^�/ ~-AW IF YES,then a Northampton Storm Water Management Permit from the DPW is required. - ^ '^ ' ' ! / > SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition Replacement Windows Alteration(s) Roofing ❑ Or Doors 177 1— Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding (0] Other[o] Brief Description of Proposed t / /] ► tea Work: 1'�y-� 0 f` d�� K JC C H Ad 3 0 t L"o I L S r) t rt Rh 0 w Alteration of existing bedroom Yes_ No Adding new bedroom Yes —No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa:`if New house and or.adtlitlon to exisfing"h"ous�ng complete th'e foflowinc�: 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? N o d. Proposed Square footage of new construction. f,(��( SSC• 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 3 i IC K 69-AArt 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 as Owner of the subject property v i hereby authorize �QQ 2 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date /Cr l t' p•QT t 1i;,fi aa;QwRer/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 pena[ties of perjury. Ul t- 0RTt Print Name Q k V Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: C6 O 0 i 63 0 License Number D R 0i J I'D 2�i ILA Address °� 1(4 Address / Expiratio D to Signature — Telephone 9.:R isteredHome Improverrient Contractor __. ,._._ _ _ Not Applicable £ Company NameII Registration Number II CAv � � ��� koltr41Ahl��dti �14, �t6a0 F7 /I "l !lr Address c� c Expiration Ctate Telephone 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 : Home Owners 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, The Commonwealth ofMassachusetts s 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): ��to 10 4, Address: City/State/Zip: Q 2Cw' Aprr,J d d Phone#: L d —3_1 " ft Are you an employer? Check the appropriate box: Type of project(required): 4. ❑ I am a general contractor and I 1.0 I am a employer with 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. F-1Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.$ 5. ❑ We are:a corporation and its 10. ] Electrical repairs or additions required.] 3.❑ I required.] a homeowner doing all work officers have exercised their 11.© Plumbing repairs or additions right myself. [No workers' comp. , 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: 0�1, Policy#or Self-ins.Lic. #: ,C w S S s a' $ 3 b Expiration Date: 9 1 Job Site Address: 6 UrQ�4rt U� City/State/Zip:6t-t(A;V Torn-', I/A.Q0 0 U 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. Ido hereby cer ' under e pains and penalties ofperjury that the information provided above is true and correct Simature: Date: CO E Phone#: Ito- 99i� Official 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#: _ City of Northampton _ Massachusetts I J .�V �I CV yyL DEPARTMENT OF BUILDING INSPECTIONS ay ^C: '•` f. i , -moi 212 Main Street • Municipal Building Northampton, MA 01060 s " 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 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 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: I Du el H u The debris will be transported by: �!�njj�/L The debris will be received by. 0 ('r Cl Building permit number: Name of Permit Applicant dxIli'�L t6 c. Date Sign-ature of Permit Applicant Ll gs- gq() %xk-o A y i 131 bA L 17 iia 0 LA T i1v VN _ _ �° 14 f i, C�s loacqo ITIIVYL '30 t CERTIFICATE 4F LIABILITY INSURANCE FD1o�9/2o15 D ) 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). PRODUCER CONTACT HOi3SB NAME: King & Cushman Inc. PHONE (413)584-5610Noll:(413)584-9322 P.O. BOX 447 E-MAIL ADDRESS; 176 King Street INSURE S AFFORDING COVERAGE NAIL k Northampton MA 01061 INSURERA:Ohio Security insurance Co. 24082 INSURED INSURER a David Fortier Builders INSURER C: 32 Laurel St INSURERD: INSURER E; INorthampton - Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1510901148 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. INSR rypE OF INSURANCE POLICY EFF POLICY EXP LTR POLICY NUMBER LIMITS $ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE rx-1 OCCUR PREMISES MeoocwrrrermS 300,000 EKS55722835 12/2/2015 12/2/2016 MED FXP(Ary one person) $ 15,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECTT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Expense Mod Factor 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE ClUr— $ Ea accideMM1___ ANY AUTO BODILY INJURY(Per person) $ ALL SCHED AUTOSM� AUTOSULED BODILY INJURY(Per accident) S HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS p� d�p $ S UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTION S $ WORKERS COMPENSATION O'1})_ AND EMPLOYERS'LIABILITY YIN _ ER ANY PROPRIETOR/PARTNER/EXECLMVEE.L.EACH ACCIDENT $ 100 000 OFFICERIMEMBER EXCLUDED? ❑ N 1 A A (Mandatory in NH) XWS55722835 9/4/2015 9/4/2016 E.L.DISEASE-EA EMPLOYEE $ 100,000 N yes,describe under DESCRIPTION OF OPERATIONS below I EL DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(ACORD 161,AdMonal Remarks Sctwdtde,may be attached V 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 Roger ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main Street Northampton, MA 01060 AUTHORIZED REPRESENT ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401)