32A-196 e
22 PHILLIPS PL BP-2017-0004
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 196 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category,,,KITCHEN RENO BUILDING PERMIT
Permit# BP-2017-0004
Project# JS-2017-000010
Est,Cost: $188.00
Fee:S183.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
UysGroan: TED DECOSMO 078883
Lot Size(sq. ft.): 7666.56 Owner: STODDARD MIKE
Zoning: URC(I00)/ Applicant: TED DECOSMO
AT: 22 PHILLIPS PL
Applicant Address: Phone: Insurance:
49 COBBLESTONE RI) (4131475-2130
LONGMEADOWMA01106 ISSUED 01's':7/5/2016 0:00:00
7'O PERFORM THE FOLLOWING WORK:NEW KITCHEN CABINETS & LAUNDRY
CABINETS
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 7/5/20160:00:00 $188.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File d BP-2017-0004
APPLICANT/CONTACT PERSON TED DECOSNIO
ADDRESS/PHONE 49 COBBLESTONE RD LONGMEADOW (413)475-2130
PROPERTY LOCATION 22 PHILLIPS PL
MAP 32A PARCEL 196 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OW ®!J
Fee Paid 490• 7-
Building Permit Filled out
Fee Paid
Typeof Construction: NEW KITCHEN CABINETS&LAUNDRY CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accegsory$fracture
Building Plans Included:
Owner/Statement or License 07$$83
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ION PRESENTED:
pproved 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
mol' ion Delay
c /
Signature of Buildin Of;Mal 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.
City of Northampton Status of Permit: k. > „;D
Building Department Curb,CuuDrivewa Permit
212 Main Street Sewer/SeepticAvai=bi' , rigar
Room 100 Water/Well kraal ility :rGP
Northampton, MA 01060 Two Sets ofStruct rat •. ,.
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans DEPT,9;nmm/NG impala/it
Other Specify
APPLICATION 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
2Z Q1�1f(.ps OHHCa Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
2A Owner cif Record: �y._ '—
1,41 Pct///Ac�t 1! cVo.'i Cu , 21 P�11 I �S t"iLl[2.
....i
Name(Print) Current Mang Address:
X / &a) 32v 2Y37
1'elephooe
5 tore
2.2 Authorized Agent: g
"CJ U Ce.2.140 '1 (-p dTart<. _LcnnwterJJianI t iii/// D//ot
Name(Priest) Current Mailing Address: J
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Rem Estimated Cost(Dollars)to be Official Use Only
.completed bypermit applicant
1. Building y am.-000± 'firit) (a)BuildinPermit Fee
2. Electrical (b) Estimated Total Cost of
/�D P Construction from(6)
3. Plumbing .r -- Building Permit Fee
q _Cb 0
A. Mec tanlcal(HVAC) /srv�
5. Fire Protectio0, ter
,6. Total=(i +'2+3*4+5) ID cQq�n(,7Q Cck Number rLThis Section For Official Use Only ,,,
Building Permit Number: Date
at etl:
Signature:
Building Commissionerllnspector 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 colwnn to be fled u,by
Building Department
Lot Size . . .. _ _.
Frontage _. . . . _..
Setbacks Front
Side L - R L J R.
Rear _.
_._.
Building Height
Bldg.Square Footage
Open Space Footage / .. ..
(Lot arca minus bldg&paved ....
parking) ^. _
4 of Parking Spaces
(volume&Location) — __ ._. .. .. _. __... . ..
A. Has a Special Permit/Variance/Findin ver been issued for/on the site?
NO Q DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES O
IF YES: enter Book Page and/or Document g
B. Does the site contain a brook, body of water or wetlands? NO Q 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 0 NO 3cS1
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 10 NO .„Cifcr
IF YES, describe size, type and Location:
E Will the construction activity disturb(clearing,grading excavation,or filling;over acre or is it part cf a common plan
that vitli disturb over i acre? YES 0 NO Qcre
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)1 Roofing
Or Doors ❑ _
Accessory Bldg. ❑ Demolition ❑ New Signs 10] Decks [q Siding 101 Other[Cl]
Brief Description of Proposed /// ,,,/ //++
Work: AiineJ •• GLA 4 a S 'I' v 44 l ! ,a•
Alteration of existing bedroom Yes h No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes At No
Plans Attached Roll -Sheet ri.
sa If New house and or addition to existing housing,complete the following:
a. Use of building:One Family L/ 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 stones?
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. floodplain Yes No
f. 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,Ste Si0/T'LCGY/19 as Owner of the subject
property
hereby authorize K) o COS.s4—t'z
to act
tonymyy behelf,in ail matters relative to work authorized by this building permit application.
nature of Owner Da
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 belied
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: f Not Applicable
Name of License Holder': rte' A cessAt, GS_t/ ( �'> t3 J
License Number
'11 if" , 4y .e o�J/d aazo—zvr �
Atltlraes y` Expiration Date
.0r v/.3 `171--/ .30
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable £
cons.V-, a9
Company�� Name�t �/ /r/7 ',,' ,j Registration Number
`/ j C.-e�b ,s/ 'e t.�' k v act"U+s) }. 4(a/.f1.2 26 6 . ' .20
AAddressss(/��,r/' Date'y Y�, Expire on Da
l / Y Telephon /421t�t/
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.
Stoned Affidavit Attached Yes £ No...... £
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 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,von 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 o€
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
"P� Department of Industrial Accidents
Office of Investigations
k: =4,10
600 Washington Street
-z.irj Boston,MA 02111
-_,,2„1-1Y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
.-�
Name ($csinessiOrgantyadonrindivfdual): te-a Ceiskt.,w.LJ �
...-
Address: I e.1 Cobb4' CPCt.4 PI - ....
City/State/Zip:,,,, ton ineadii-,-/t$ Cl/aL Phone#?: /3� t" 1/.30 ,,,
Are you an employer? C t eck the appropriate box: Type of project(required):
1.J Sam a employer with 4. Li lam a general contractor and T
6.
mployees (full and/or part-time).* have hired the.sub-contractors New nvctlou
2. 1 am a sole proprietor or partner- listed on the attached sheet. Remodelideli ng
chip and have no employees have
sub-contractors have S. Demolition
workingfor me in any capacity. employees and have workers'
Y rip tY 9, L Building addition
[No workers' comp. insurance comp, insurance
porat
required.) S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.n 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp_ right of exemption per MGL 12 1 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other _
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
ilio rrmowners who submit this affidavit indicating they arc doing all work and then hire outside contractors,must submit a new affidavit indicating such.
teontractors 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. .11-6.2‘ / "" /"
Insurance Company Name: rmI(y ,�Y!'lS s--v/
Policy#or Self-ins. Lie. #: , Expiration Date:
y {
Job Site Address: 22 v Y.] r Bute_ „- City/State/Zip: 4 't1- ' NI 0/040
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 fforr insurance coverage verification.
I Signature:herr y9r I t P perjury information provided a¢rve is true and correct
Phone#, cern?un G ai u that the armati Date: - I.
- 2130
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
r
City of Northampton
Massachusetts ,J
$ y
rik7t'
, DOF BUILDING INSPECTIONSfr
212 Ham
� 212 Main Street • Municipal Building
Northampton, MA 01060 3 ry
INSPECTOR
Louis Hasbrouck Chuck Wier
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
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: 2 I'k; i s I UPS
The debris will be transported by: er
The debris will be received by: &t/c.stc , 74. , 3(
C
Building permit number:
Name of Permit Applicant 7j gyp rt.10-io
7 S /6 A
Date Signature of Permit Applicant
Jul 041601:48p Mason Agency 14135692308 p.2
A Oe CERTIFICATE OF LIABILITY INSURANCE DaTEINNvopn n
x7/0512016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NE ATIVELY AMEND, EXTEND CR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOS NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIS), AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTI ICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIO AL INSURED,the pollcypesl must be endorsed. If SUBROGATION IS WANED, subject to
the terns and conditions of the policy,certain polici may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsementtsi.
PROOUCER coxrac-
xT<HE-
DIANE LUA.SON AGENCY PHONE 413-'059-2332] FAX 415-569-2308
•iAm.vol°
FARM FAMILY CASUALTx' ADDDDRIESS.
504 COLLEGE HWY INSUREMLAFFORD1110 COVERAGE 1A1er
SOUTHWICK.MA 01077INSURER aFARM FAMILY CASJALTY INSURANCE '.3803
.
INSURED INSURER _._.. _
TED DECOSMO
«aXRERE.
452 MAPLE ROAD NSUIRD
LONGMEADOW,MA 0110E-3123 INSINSURERE,
LRER
COVERAGES CERTIFICATE NU BER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES CF INSURANC LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT,' RM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VWWTH RESPECT TO IMfLCH THIS
CERTIFICATE MAY BE ISSUED OR MAY FERTAIN, TAE NSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TC AJ. THE TERMS.
EXCLUSIOVSAND CONDITIONS OF SUCH POLICIES.LIMI SHOWN MAY HAVE BEEN REDJCED BY PAID CLAIMS. ",
INSR _IADOE3JBR —_-_-... PO'_CY EFF POLICY EXP — I.
LTR TVP OF INSURANCE ALSO'W✓O PC LICVNx4HER IMMIOWYYYYI I IMMTpVYYVI' I LIMITS
RAL GENE IAMLm 2 '5/ 9. 017 EAC-1.0 CL RE F S I 300.000 I
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I I 'F=_RSCN CV,P1JURr S '.000000
GEN LAGGREIATE LMT AP=UES,ER GENE PCL AGSRecs E G 2.032.000.
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DESCRIPTION OF OPEN➢ORE/LOCATIONS L VEHICLES IACONO I01,/gdIacm1 Remarks SMedjln,may be ma cuadxncre space is requ All
CARPENTRY-NOG
•
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN
CTY DF NORTHAMPTON III ACCORDANCE WITH THE POLICY PROVISIONS.
ATTN: 22 PHILIPS PLACE AUTHORIZE IALVE � ( ^
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01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(20141011 The ACORQ name and boo are reoistered marks of ACORD