29-267 (3) 52 LONGVIEW DR BP-2016-1519
GIS a: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-267 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: Ramp BUILDING PERMIT
Permit it BP-2016-1519
Project# JS-2016-002588
Est. Cost: $4000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NATHANIEL BRUURSEMA_
Lot Size(so. it): 19079.28 Owner: MCGRATH WILLIAM M$G RUTH E
Zunine Applicant: NATHANIEL BRUURSEMA
AT: 52 LONGVIEW DR
Applicant Address: Phone: Insurance:
57 SOUTH VALLEY RD (413) 326-4943
PELHAM MA01002 ISSUED ON:6/22/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:Install temporary ramp
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 if Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oils 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 6/22/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
r
Department use only
City of Northampton Status of Permit
'''`I 2 0 2018 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/tie/ell Availability
S7TIs Northampton, MA 01060 Two Sets of Structural Plans
aou
p one 413-567-1240 Fax 413-587-1272 PIoVSiie Plans,
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
/IA Property Address: This section to be completed by office
57 ),,.0/1_11) br• Map�........- Lot Unit
1 ocece,. t t `� 0 DG, Z. Zone Overlay District
tA
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
r�Owti@r of Record s i r 049 br /y n
,, �2� >� - N1cG�-�.�'�- 4. t"1'tM`i-irY.. .jt`ItixeLtCePkcefoet
Natint) Current Melling Address: ( 7L7 +,ZI 0'7
nature (.i V• c�- L. yt, Telephone CJ
4 2.2 Au, prized -.e.0
�� . • . � rs�, u � Si 5o ✓FLVa((5R0 �t o(o
N. :(Print) Current Mailing Address:
6I11) 3? 6' `19`!3
Signature Telephone is
SECTION 3-ESTIMATED CONSTRUCTION COSTS —1
Item Estimated Cost(Dollars}to be Official Use Only
\,/ completedbypermit applicant
V
1. Building q h 10q V i (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 6S
5. Fire Protection nnnnr /
6. Total={1 +2+3+4+5) LIM) Check Number 9/.5
This Section For Official Use Only 'Y
Building Permit Number Date
--
- Issued.
Signature
Bullding 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 rdrad in by
Building Dcpanment
Lot Size
Frontage
Setbacks Front
Side L._ R: L.II. R:I
Rear
Building Height
Bldg. Square Footage °o W
Open Space Footage
(ln,l arca minus bldg&paved
Perking) .....
ff of Parking Spaces
Pill
_Doggie&motion
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW O YES 0
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book Page! and/or Document Hi
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW a YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES O NO Q
IF YES, describe size, type and location:
0, Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre oris it part of a common plan
that will disturb over 1 acre? YES Q NO a
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) I / Roofing ❑
Or Doors 0
Accessory Bidg. LJ Demolition `'fP❑ New Signs IC) Decks i[] I Siding[0] Other(i(171]]
Pf De
Brief of Proposed 3e 4O L (J(4Atypic) ?r/"`9 i h 4'04 koust 61.4415,dde sit,
Alteration of existing bedroom Yes i No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga. If New house and or addition to existing housing,complete the following_
a. Use of building i 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 Woodstoaes 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_iNo
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 tellCity water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1(t� AI' P '\ . as Owner of the subject
propertyf. �,t/
hereby authorize 11 4 •f9'l br IA/r sai,`./t_
to act on my behalf,i all matters relative to work authorized by this building permitplication.
62c/( E,
Signature of Owner Dale
I, 1 I. 7 A.
i ,as Owner/Authorized
Agen'hereby declare tha he statem is and information on the foregoing application are true and accurate, to the best of my knowledge
and belief,
SI,,ned under the ppai or and penalties of perjury.
Print ��e -, —.-
t
"' Signature of�/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Liie.,nsed C rostra b. Sur I-[visor: 1,111
AA, � I Not Applicable £
Name of Ltcense Nettle[,: A PIA 1r. l�Viii5e v, t
_ ‘20 license Number
s Expirai'ion Date
d/33264943
S,-aiure Teteprtone
9.Registered Home Improvement Contractor: Not Applicable £
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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 Owner Exemption
The current exemption for"homeowners'was extended to include(Tuner-occupied Dwellings of one(I) 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 108.35.1.
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 hone in a two-year period shall not be considered a homeowner,
Such"homeowner"shall submit to the Building Official,on a fomh 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 of Massachusetts
Department of Industrial Accidents
‘.-, ii. Office of Investigations
- _ _f ' 600 Washington Street
'" Boston, MA 02111
yt:: wwucmass.govtdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organii'adonflndividua1):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. 9 I am a general contractor and I
�y employees(full and/or part-time).* have hired the sub-contractors h. ❑ New construction
2.[y I am a sole proprietor or partner- listed on the attached sheet, 7. n Remodeling
ship and have no employees These sub-contractors have g, n Demolition
working for me in any capacity. employees and have workers'
9. 9 Building addition
[No workers' comp. insurance comp. inswance3
required; 5. ❑ We are a corporation and its 10.9 Electrical repairs or additions
' .2 I am a homeowner doing all work officers have exercised their I t.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.9 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.9 Other
comp. insurance required.]
`Any applicant that checks box HI must also fill out the section below showing their workers'compensation policy information.
trio men iers who submit this affidavit indicating they are doing all work and then hire outside contractors mut submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate 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 oferfr nal penalties of a
tine 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 or
Investigations of the DIA for insurance coverage verification.
I dg hereby c fj under the pains and penalties of perjury that the information provided above is true and correct.
✓Signature: �1 r� Date: 6/z0/t6
Phone#: '0;46 q793
Official use only. Do not write in this area, to he 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
tsar
Massachusetts 'y.5. c
DEPARTMENT OF BUILDING INSPECTIONS Itt
212 Main Street • Municipal Building L t
Northampton, MA 010E0 '.Jy
S . Hyl<ten
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 784CMR 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
J1, 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
v 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: $2_ v'eu> aY {/orekce-
The debris will be transported by:'f/ �+, Fjrvvr5e�+-ti
�/
The debris will be received by: at(' P.(2_ctsC ' wS
Building permit number: / / n
Name of Permit Applicant (/ASW . rte( & rSe_ ,_
Date Signature of Permit Applicant
AS CERTIFICATE OF LIABILITY INSURANCE
DATE IMD 7
x/20/2016
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 as an ADDITIONAL INSURED,the policyles)must be endatsed. 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 endorsements).
PRODUCER IG2q�MTA
Mtt Heidi Wellman
Paddock Insurance Agency PMC N9 E�t1: (413)2535 FAAXitivc xpl 14131296-1135420 Gatehouse Road "AIL" ESB:BMellmanenathanagencies.com
ADDR
PO Box 48 INSUREDS)AFFORDING COVERAGE NAIGX
Amherst MA 01004-0048 *SURES*Western World
INSURED INSURER B:
Bruursema Builders INSURER C:
57 South Valley Road INSURER O: _... ._. _.. _ ..
INSURER E:
Pelham MA 01002 INSURER f: _. . ...
COVERAGES CERTIFICATE NUMBER:CL1662002041 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE PODGIER OF INSURANCE LISTED BELOW HAVE BEEN 15SIIED 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.
MSR - -. _ - __.. AGWESTER. _.- .- POLICY EFF 'DUCT EXP ... .. _
LIR TYPE OF INSURANCE INND•tWD POLICY NUMBER IMMRIQM1YYYI IMMNWYYYYI MEWS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 300,000
REISES(aENTED $ 100,000
A ("AIMS-MADE X OCCUR PREMI$E$(Ea wverercej
NPP8315044 5/4/2016 5/4/2017 MED ERR tiny one pawn) S 5,000
PERSONAL BADv INJURY 5 300,000
GE_N'L AGGftEG_4TE LIMIT PER: CENERAI.AGGREGATE 8 600,000
X...potty jFO .. inc PRODUCTS-COMP/OP AGO 5 600,000
OTHER: Employee dere% 5
AUTOMOBILE LIABILITY COMBINEO SINGLE LIMIT $
_ BODILY INJURY
PNBODILY S'AUTO INJURY(Per person) 5
ALL OWNED SCHEDULED BODILY INJURY(Po eccgsn0 S
AUTOS _. • AUTOS
N{D1IED PRO;04n DAMAGE q
HIRED AUTOS .AUTOS (PM accident). .__..
.. ._. _S
UMBRELLA lLte _OCCUR EACH OCCU_RR_ENCE .S ......
EXCESS TAB CLAIM.4-MADE AGGREGATE S
DED RETENTIONS 5
WORKERS COMPENSATION STATUTEPtR OETH
AND EMPLOYERS'WMLITY • - •
ANY TIN EL EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED' NI0. - -
IMAndMoryIn NNi EL.DISEASE-EA EMPLOYEE S. ,,.
Iv s Remote under
DESCRIPTION OF OPEMTIONRb&ow E L DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATORS I LOCATIONS I VEHICLES(ACORD 101,Amerman Armada BCMeus,my be•WCNed N roes,epe<a M nguimtll
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Ruth McGrath THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
52 Longview Drive ACCORDANCE MTH THE POLICY PROVISIONS.
Florence, MA 01062
AUTHORIZED REPRESENTAINE ,t�{
Heidi Wellman/HEIDI IA die 1Ik, kLyJ,� � —,,
®1985-2014 ACORD CORP TION. All tights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(20)a0n
j� ° g—C 02<cief40/1( airs'
' City of Northampton
rl Building Department
Plan Review
212 Main Street
1 1; Northampton, MA 01060
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