36-140 (8) 256 BROOKSIDE CIR BP-2017-0379
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 36- 140 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:window replaced BUILDING PERMIT
Permit# BP-2017-0379
Project# JS-2017-000627
Est. Cost:$3500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grout): GENE BOROWSKI 106527
Lot Size(sq. ft.): 15071.76 Owner: HOUGEN SARAH
ZS : Applicant: GENE BOROWSKI
AT: 256 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
117 SUNNYMEADE AVE (413) 687-3777 WC
CHICOPEEMA01020-1780 ISSUED ON:9/21/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 32" X 57" CASEMENT WINDOW WITH
BLOCK WALL IN BASEMENT
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 9/21/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File ft BP-2017-0379
APPLICANT/CONTACT PERSON GENE BOROWSKI
ADDRESS/PHONE 117 SUNNYMEADE AVE CHICOPEE (413)687-3777
PROPERTY LOCATION 256 BROOKSIDE CIR
MAP 36 PARCEL 140 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OU _
Fee Paid airana1,
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL 32"X 57 CASEMENT WINDOW WITH BLOCK WALL IN BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106527
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 'NATION 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
D'r ••litionD—ff
/ �
Signature of Buil.ing iffrcial 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.
Department use only.
Cityof Northampton . •
P Status-of Permit - El '
Building Department curb Cut/Drrveway Pertntt
sql212 Main Street SeWer/SepttcAvai[ability
Room 100 DWa er/WellAvailabtib
ciz./ Northampton, MA 01060 Twp Setsof Structural Plans
a" phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans `'
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
21.5-4 ed r%5 Lie C/Ac La, Map Lot Unit
Ala Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:/ /�
a�/ ro/a4!�/ /14; �t S6 �rm�Sr�e C eci
Name(Print)/� Cr Current Mallin A dress.
Y CELVLeV �O^<il -c
Telephone (LLS) .�C)—r>svO5—
Signature
2.2 Authorized Agent:
CV's eA .^tx,ck/ Be-sir] ®o/%let /17 Ja //j y%�_ e_ %c acre, t
Name(Print) ACurrent Mailing Addreas.
ESTIMATED
(Y/3') / se-7- 8 77.7
Signature' Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building / f{ 3 S4
epe' (a) Building Permit Fee
2. Electrical 'k1 (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 Number 787.3 (
This Section For Official Use Only
Building Permit Number: Date
Issued:
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 Department
/eGYyLot Size I__. _. . _.._._...
Frontage 'Iy/ _ I.
Setbacks Front - 3d
ie
Side L:2�' R:i_- L. R L _ I ___
s
Rear L_____.
Building Height y 7 ( 1I
Bldg. Square Footage - ` °/o ( —
Open Space Footage __ %
(Lot area minus bldg&paved , _
parking)
d of Parking Spaces A/ r�_i -_ I
Fill-
(volume&Location)
A. Has a Special Permit/Variance/Finding�/ever been issued for/on the site?
NO Q DONT KNOW l� YES Q
IF YES, date issued:'
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO Q DONT KNOW ( YES Q
IF YES: enter Book Pagel ! and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 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 ( Y
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: II
E. WII the construction activity disturb (clearing, grading, exc tion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
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 n
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [17] Decks [O / Siding [O] Otherr,[],lf
Brief Work;
Description of Proposed 'Tny 1 J/ 3X S
5_/! ' //CRS
/C S�nn-' .L(. ,q 4x� C 1 a Of
Alteration of existing bedroom Yes No Adding new bedroom Yes No LYLY.0
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If.New house and or addition to existing housing, completethe following:
a. Use of building :One Family I Two Family Other
b. Number of rooms in each family unit: -5 Number of Bathrooms "2-
c. Is there a garage attached? /i/C� //
d. Proposed Square footage of new construction. Dimensions 3 x S a/c ne�Lw l
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 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
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature off Owner / Date
I, „/ 1— 'c/I • , as Owner/Authorized
Agent hereby drrr777,,,FFF___lare 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.
/� 11 !
Coei re ^ K.
Print Name
•
•
i i //
a ,
Signature of Own.- /Agent Date
•
SECTION 8-CONSTRUCTION SERVICES
-91 Licensed Construction Supervisor - -- — _.-_ _ _. __Not Applicable ❑ _ .._..
Name of License Holder: G r ✓�+ r'G e < _ .- C S— X6( 5 27
License Number
1/7 Sv� . , C ,� /7 �.� za „7.2,/, 7
Adbressa / / .f Expiration Date JS Cyr ) aj 3 r77
igna Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
74/67
Company Name Registration Numbeff
//f/a0i7
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 builds permit
Signed Affidavit Attached Yes No 0
11. Home Owner 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 pennit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not esulting 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 of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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: >LC�'L �--er,ce_/ /17c
The debris will be transported by: As, --e
The debris will be received by:
Building permit number:
Name of Permit Applicant e eodrodc,S)
Air t.
/
Date Signa' re of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
l Office ofInvestigations-
•t
Investigations 1 Congress Street, Suite 100
Boston,MA 0 211 4-2 01 7
� �` www-mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /J Please Print Legibly
Name (Business/Organization/individual): /met (IC// lase�f C'�S
Address: /7 S0. ,r f/�Qfl f ff-
City/State/Zip:L' c Lio Phone #: �4'/3) I ' 7 377?
Are an employer? Chick the appropriate box:
Type of project(required):
1. I am a employer with ' 4. ❑ ]am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
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 ❑ Demolition
workingfor me in anycapacity employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp.insurance.•
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 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.0 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.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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'comppolicy number.
Jam 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.#: [Ce 7 e.. 7 /�/ Expiration Date: /jr/�23 //
7
Job Site Address: ...2s-4...2s-4 �6e4S r� PCrf'/� tatuv City/State/Zip: /��q Gs'3§1d‘�
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.
J do hereby certiO undo the pains and nettles of y rjury that the information provided above is true a d correct.
f /9 SienaNre: �. - Oz., Date: ?
Phone#: (y/3, ��S� • 7 7
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#:
-NOTE-
THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED.
BUILDING LOCATION ACCURACY IS NOT GUARANTEED
NOTE:
SUBJECT TO EASEMENTS AND 90
RIGHTS OF WAYS OF RECORD. .`16•
50/ 1,
BOOK 8945, PAGE 267
PLAN BK. 69, PG. 121&122
LOT #110
m ; a
co' i
i 23/0
eny{'rc'cpf k//6. A
CB/4ce ,
Onz„11 •
L=11 : . 50 '
BROOKSIDE CIRCLE
TO: MERRIMACK MORTGAGE COMPANY, LLC &
CONNECTICUT ATTORNEYS TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES,
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY #250167
_ —NOTE—
SURVEYOR .Q J-n THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
tNw �krs , —MORTGAGE LOAN INSPECTION PLAT—
.Ko
., NORTHAMPTON, MASSACHUSETTS
RANDALL ., PREPARED FOR
E.
IZER SARAH & EDWARD HOUGEN, & MARY & PETER CURRO
72 SCALE: 1"=4O' AUGUST 24, 2016
��NO Suav�t HAROLD L. EATON AND ASSOCIATES, INC.
- - -- REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET — HADLEY — MASSACHUSETTS
A u CERTIFICATE OF LIABILITY INSURANCE DATE(MWDOHr(t)
0210312018
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: H the certificate holder is an ADDITIONAL INSURED,the poHcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
she terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate dos not confer fights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 4317817075 4137817076 I
NAME
Eric
Fred c Froebel Ins Inc g.s,,uEm,4317@17075 IIA .NO:4137817076
321 Park Street _ooPPss'
West Springfield, Ma,01089 INSUREN6}AFFORIXNGCOVERAGE RAMP
INauRFR A:Nautilus
INSURED INSURERB1 Travelers
Eugene Borowski/Beyond BuildersINSURER C:
117 Sunny Meade Ave nauRERD:,,,,, _
Chioopee,Ma. 01020 INSURERS: .,,
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 PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT DR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY SE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED eY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. •
IHS' ADEL SNSR POLICY EM NEAT warm
TYPE OF INSURANCE ]y¢D 4ND POLICY RUM/Mt IMMNDIYYYYI MYYY4
1 COMMERCIAL GENERAL LURILOY EACH OCCURRENCE 11.000.000
A CMMADE / OCCUR PREMISESS((EaLN
TED
WSoccia®I s 100,000
__ NN540774 01/2212016 01/222EX
017 MED P WI,cmPeron) s_5 fl0O
PERSONALSPDV INJURY 1 1,000,000
GEM AGGREGATE LOAM APPLESPER: CENER+s ACOREGATE s 2,000,000
RPOLICY I I jEC { LOC PRODUCTS.COMP/OP AGG 8 2 000 000
OTHER: s
AUTOM080.EIIASIUTY •,iLL4{�^U t
ANY AUTO 90DILY INJURY(Per Palm) 1
—'ALL OWNED SCHEDULED SODLYEBfURY(Per&vtey t
AUTOS AUTOS
HIRED AIMS AUTOS GROPPERTY E s ._
1
UMBRELLA OAS , _ OCCUR EACH OCCURRENCE S
EXCESS LIM CLAIMSMACE AVOREGATE $
PEP IRE MMnEHS S
WORKERS COMPENSATOR PLR
ANDEMPLOYERSuASILTr Yrx 1292018 01/23/2017 —" STATUTE FR
B ANaFFCERAAEMMSE�REXO EXCLUDED? Q NrA 2E67637 EL EACH ACCIDENT $100,000
Mand toy lip NN�H)) EL.OISFLAP-EA EMPLOYEE 1 100.000
0Eer
3[deserts0.19110N QP OPERA-MRSMWv EL DISEASE-POLICY tutu 1500,000
DEW/LIPTON OF OPERATORS I LOCATONSI VEHICLES(ACORD101,ALEMMnaI Wmap SoMaul%NVybe at4mad X Mere%aN.re AM1Pd)
CONSTRUCTION .
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Alit!)ItEpRE$/W ( /
•
Zr ')7ti 11988.2014 fACCORRDD CORPORATION. All tights reserved.
ACORD 24(2OWfs) The A0ORD name and 1090 are registered marks of ACORD