31B-078 14 SUMMER ST BP-2016-1459
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:31B-078 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2016-1459
Project# JS-2016-002501
Est.Cost:$8250.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Group: RONALD GROGAN 090818
Lot Siae(sn. ft.): 5357.88 Owner: GARBIEL JENNIFER J TRUSTEE
Zoning: URC(100)/ Applicant: RONALD GROGAN
AT: 14 SUMMER ST
Applicant Address: Phone: Insurance:
18 SUNSET AVE
HATF I E LD MA01038 ISSUED ON:6/8/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE SLATE ROOF & INSTALL ASPHALT
SHINGLES
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 6/8/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
/4.A^ Department use only
- -> \\ City of Northampton Status of Permit
`°.J Building Department Curbcut/Drlveway Permit
( 212 Main Street Sewer/Septic Availability
Room 100 Watermell Availability
\�a Northampton, MA 01060 Two Sets of Structural Plans
pgone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
> / Other Specify
-PLI ION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address. This section to be completed by office
/ SU/'f et La .r Map Lot Unit
Zone Overlay District
Elm St District CI3 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
NN/C /i'L egnh/ C /.1( T-.v 4V/? NdCYa/020/0y0
Name(Print) — Current Malting Addr7� I/g,
Ai/-5 11 y L
Telephone
Signature
2.2 Authorized Agent:
$ogc0 61 6ij,-) P O. £o,< 2&2 sv tont/ efevotoS3
Name(Print) Current Mailing Address:
q1.3 d59 5/,
Si. alure - Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building f g a 5-0 c/-i) (a) Budding 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 (1 +2+3+4+5) ,Check Numbe fj1 ffOZ Sro
This Section For Official Use Only
Building Permit Number: Issu
Dated:
Signature:
Building Commissioner/Inspector of Buildings 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 Depam enc
Lot Size _
Frontage
Setbacks Front ' r
Side L R
Rear
Building Height "
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved _. ..
parking)
#of Parking Spaces - -
Fill _.. _.
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW Q YES Q
IF YES, date issued:'.
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page ! and/or Document#I -
B. Does the site contain a brook, body of water or wetlands? NO i, DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q 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 Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO el—
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) n Roofing VC.
Or Doors C
Accessory Bldg. ❑ Demolition ❑ New Signs [Dj Decks [l7 Siding[CI Other[DI
Brief Description of Proposed
Work: ae 4.4°✓E Stark RtoF n o Tw.sTAc-c 4 Om9-c SHte'n-CS
Alteration of existing bedroom Yes V No Adding new bedroom Yes N
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Rall -Sheet
ea. If New house and or addition to existing housing,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 fl. 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, ITR NN/F,,,c 6'. dn' C ,as Owner of the subject
property
hereby authorize {.--/�
e N4 La G 2044.1/41
to act on rt7y behalf, I elative to work authorized by this building permit application.
/(/
Ar/8 /20/4,
Signature of Owner 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.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
`n^ �L Not Applicable E )`'
Name of license Holder:_ tf'^" 47.4420 t'JCtCx 6//06 CS 090 W/ b 10/
License Number
�. o, 8C) ?S"Z 60-1 7ZLY „✓1g iog3 33/3c/zoR
Address Expiration Date
2s5 _s///
ice`En Telephone
9.Registered Home Improvement Contractor Not Applicable E
Company Name Registration Number
Address Expiration Date
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
11. Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)families
and to allow such homeowner to engage an individual for hire who does nor 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 cal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
_. The Commonwealth of Massachusetts
eir.. Department of Industrial Accidents
Office of Investigations
d is 600 Washington Street
' Boston, MA 02111
C47 www.mass.gov/dia
Workers' Compensation IInsnrauce Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I
s have hired the sub-contractors 6. ❑ New construction
employees (hill and/or part-time).
2]4._I am a sole proprietor or partner- listed on the attached sheet. 7. E Remodeling
ship and have no employees These sub-contractors have g
❑ 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.❑ Plumbing repairs or additions
myself [No workers' right of exemption per MGL
Y comp. 12oof repairs
insurance required] t c. 152, §1(4),and we have no
employees. [No workers' 13.gOther
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:
Policy#or Self-ins. Lie. #: 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 fate
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 DR for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Date: .� /t/io,C--
.
Phone#: / c//3 2c5 ;cif
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
•rayr.,rare�•
P2assachussttsz� DSa3aThIEPIT OF BUILDING INSPECTIONS
<}S i 212 Main street o Municipal Building JJJ��rLif
,—A£ 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/footinqs (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 inspec . ns are made
I, understand the above.
(Horn owner/resident's signature requesting exemption) -
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date 4/5j /7 o f 4>
Address of work location / V 5 6.47 f/C2 S /
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: 14' Su w, aa ,c,c ST
The debris will be transported by: !J/cg. t KS
The debris will be received by:
Building permit number:
Name of Permit Applicant ReJ 6,9-1 t ,¢„..;
Date Signature of Permit Applicant
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYYI
`— 6/8/2016
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 Susan Fleury, CIC, CISR
King & Cushman Inc. PHONE FAX (413 584-9322_INC,No,EMI: (913)584-5610 _ of d,Nol.
P.O. Box 997 noortiss:SFleury@KingCushman.corn
176 King Street INSURER(S)AFFORDING COVERAGE NAIL#
Northampton MA 01061 _ INsuRER A MainStreetAmerica Group
INSURED
INSURER B:
RON GROGAN BUILDING AND RENOVATION INSURER C:
PO BOX 282 - -_-- -- _ --
INSURER o:
INSURERE:
WRATELY MA 01093-0282 INSURER F: I
COVERAGES CERTIFICATE NUMBER:CL166801504 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 - ADDL.SUBRI -- POLICY EFF POUCY EXP -- -
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDDNYYYI IMMIDDIYYYYI LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 500,000
A CLAIMS-MADE I ][ 1 OCCUR PRPREMISES OREccEO 500,000
1RT999414 6/7/2016 6/7/2017 MED EXP(Any one person) S 10,000
- PERSONAL&ADV INJURY $ 500,000
�GEN'L AGGREGATE LIMIT APPLIES PER ''I i GENERAL AGGREGATE $ 1,000,000
17EI POLICY I PRO- I
TCT _ I LOC PRODUCTS-COMP/OP AGG ', S. 1,000,000
,I OTHER EmplPracliwsLit Ins 'IS 10,000
'AUTOMOBILE LIABILITY ' COMBINED SINGLE LIMIT I $
academy
ANY AUTO I BODLY INJURY(P person) IS
ALL OVtEDr .-fII SCHEDULED - -- -- ---
AUTOS .I AUTOS BODILY INJURY(Pm
atlenl)I $
HIRED AUTOS 1 NON.OWNED PROPERTY DAMAGE
AUTOS 1S
UMBRELLA UAB I OCCUR EACH OCCURRENCE $
EXCESS HAS
CLAIMS-MADE AGGREGATE $
DEO RETENTION S $
WORKERS COMPENSATION I 'PER 0TH I
WAND EMPLOYERS'LIABILITYYIN .._ STATUTE I ER _
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED' J NIA E L EACH ACCIDENT
(Mandatory in NH) - ' EL DISEASE•EA EMPLOYEE S
VI yes,describe under I
DESCRIPTION OF OPERATIONS belowI E L.DISEASE-POLICY LIMIT 15
1 •
1
DESCRIPTION OF OPERATIONS I LOCATORS I VEHICLES(ACORD'MtAdditional Ramada Schedule,may be attached Rmom 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
Building Inspector ACCORDANCE WITH TH 'e Cy PR+VIS
Northampton, MA 01060 a'. MAN
AUTHORIZED REPRESENTATM n IIS t ,N\1
ay Ar!`n l'11Cn l`(TDD(IDaTIf1M All•^1`�IeeeNed.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD V
INS025(201401)