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35-205 (9) 1250 BURTS PIT RD BP-2017-0327 GIS a: COMMONWEALTH OF MASSACHUSETTS Map:Block:35 -205 CITY OF NORTHAMPTON [At-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Deck BUILDING PERMIT Permit s BP-2017-0327 Project if JS-2017-000536 Est.Cost:$1865,00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN NADOLSKI 104006 Lot Size(sq.&): 62290.80 Owner: MILLER GEORGE A&THERESA Zoning: Applicant: JOHN NADOLSKI AT: 1250 BURTS PIT RD Applicant Address: Phone: Insurance: 167 JOSEPH AVE (413) 246-1080 WC W ESTF I E LD MA01082 ISSUED ON:9/1212016 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE VERTICAL SUPPORT RAILINGS REPLACED 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: FeeTene: Date Paid: Amount: Building 9/12/2016 0:00:00 565.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0327 APPLICANT/CONTACT PERSON JOHN NADOLSKI ADDRESS/PHONE 167 JOSEPH AVE WESTFIELD (413)246-1080 PROPERTY LOCATION 1250 BURTS PIT RD MAP 35 PARCEL 205 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT .a es Fee Paid UJ Building Permit Filled out Fee Paid TvoeofConstruction: REPLACE VERTICAL SUPPORT RAILINGS REPLACED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 104006 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 •emolition Delay t7/SW • `'g �ffic . 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 40K Contact Office of Planning&Development for more information. w /40ld -4Cc Department uce`only Oiy of Northampton Status of Perrot Nit Building Department verb Cut/Driveway veway Pe m - 212 Main $r=1 Curb Availability Room 100 'Water/Well A/allab t; Northampton. MA 01060 iTwaSets of Stceraal Plans phone 413-587-124D Fax A13-587-1272 Ploeste P aas JOtherSpeclfy APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DNfELLING SECTION 1 -SITE INFORMATION Th:s daemon tc be completed by office 1.1 Property Apd dress Pit �('{ - /(,ta/tso lid" f t I r0_'^ 'Map - i of Unit T 1(lr � Milt OI�� Zane Overlay District Elm St District s CE District - -I SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 2e, nty, pLA (�k �� ` hef jYtu1ts&._ar ut (er g Sarrt ci cF sa -ifil i,u- PLIA666 Current MedinaAo ass31.113 3 , S• kelli hi 6 `t 2L-N, TelephoneSignat re - 2.2 Authorized Acent: 4 K NQ 4o 7 Name(Pon. Current Mailing AdoTaaa. Signature Telephone I SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars/to be Offlc;al Use Orly completed by permit applicant I 1. Building (a) Building Parma Fee 2. Electrical (b) Estimated Total Cost of Construction from(5) 3. Plumbing F Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection �7 f E. Total=(1 +2+3 +4+5) Building Permit Number: �� / �('�� Check Number. �� 6 This Section For Oficial Use Only Date Issued: Signature: Il I Building Commissioner/Inspector of Buidings Date Etna// Section 4 IONINI0 AU information Must Be:fleeted_d. Pe mi Be Denied Due i o Incomplete aJon l Existing IProposed I Required by Zoet ThisI t II tic I leDe°ervn_nr ) Lot Sze Frontage I ...._ _ -_.___ --- -�'I Setbacks From - __ - - .__ Std L. R._.. Li ._._ R: _ Rear : _ -:.. Building Height Flag Square Footage / )I Open Space -. Footage 1 r( hem� 8 - _ _ I I 1 of Perking Spaces ----- .-- I i l I Fill: .ue2 Locadoc. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO (0 DONT `✓ KNOW' YES 0 IF YES, date issued:, IF YES: Was the permit recorded ??at the Registry of Deeds NO 0 DONT KNOW 0 YES 0 I IF YES enter Book Page and/or Document c B. Does the site contain a brook, body of water or wet:ands? NO 0 DONT KNOW (3 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity oisturto(ciearing, gradino, excavation, or filing)over 1 acre or is it part of a commer Alen that win disturb over aste7 YES 0 NO 0 IF YRS,then a Northampton Storm Water Management Permit from the DPW is required ' `, SECTiON 6-DESCRIPTION OF PROPOSED WORK(check a/I applicable) New House ❑ Addition ❑ Replacament Windows Alteratlom(s) ) I Roofing Or Doors C .Accessory Bldg. H Demolition New Signs [r-'7 Decks I2re Siding IC] Other]C1] Brief Description of Pmposetl ' ,t 1 O ,// (� ,Q" �.,, Work: u ✓''!M�-� SM^yr �rtr�^i✓-S S, Iw.ee{Fa - Alteration of existing bedroom Yes No Adding new bedroom Yes No N Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ea. If few:hoase zndorao't9otiohta axis. nc housliia: co^talec=_ the fofPaurPeuq: 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? 7 P? d. Proposed Square footage of new construction. Dimensions e. Number of stories? 1. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 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 OW NERS AGENT OR CONTRACTOR �APPLIES FOR BUILDING PERMIT 1 1 \LI/ I /I.VI:(Jil/— as Owner of the subject property //�� tt I� ( (� hereby authorize l U NN"A t v�tdl p to a n my behalf,iti ell matters relative to work authorized by this budding per liccattioon. Siggnature of Owner "b�^ Date , as Owne•/Authohzed 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. T e (St) Mal \e/ Prime m eI I (4,1 Signature of Owner/Agent pate SECTION a- CONSTRLLCFION SERVOQE$ S.1 Licensee Co st-ue:icn Supervisor Not Applicable f. j None :'Jcans,odder ,y1 B L4 /1/10>dl.Sj4t DA(, ed 9 6 A`i _ «n der / I /(..al d o5e X71 / z t� � ei ° 'e(y ! l � G 1dai/7 AddroExpiration Date ....... • C t/1...c 43 rot y /08a Sig,l ure Telephone 9.Reaistera ,Home Improvement Contractor. Nat Auoncable E --../ 1nitL1 G rhit0\a' /& isfiD --- Company ' SC f/. :^ Registration Nu her 1 Name11 (n ? ,J o j0 a.at'J Address Expiration Date q ,,i/,� yv %�G II// l.tl "' t ... Telephone`' z& ���� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.P.151,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. FailJre to provide'this affidavit will result in the denial of the issuance of the bui ding permit {{ Signed Affidavit Attached Yes _ No i i 11: -Home Owner E±emption The current exemption for"homeowners"was extended to include Owner.eccuoied Dwellincs of one(1) or two(2)families and to allow such homeowr-er to engage an individual for hire who Coes not possess a license,provided that the owner acts as supervisor.CMR 780. Sixth Edition Section 205351. Definition of Homeowner:Person(s)who own a parcel of lend on which he/she resides or intends to reside, on which there is,or is intended to he,a one or two family dwelling,attached or detached structures accessory to such use end/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such•nomeowmer"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 ander the buntline 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 net resulting in Death)of the Massachusetts General Laws Annotated,von my be liable for persons) 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 ofMassacaucetts General Laws Annotated. Homeowner Signature '', The Comtnonvesith or.101assachnsens -*j—a Department ofIra7yt.traal Accidents Office ofInvestigations • Iwti 1'1 600 6U0Was,rargtor5trept Boston, :WA 02111 MI)VW.m. asz.govAlia Weaken' Competcsattou lInsurance AIDEc.1t: PLi7r]ers/6 traetsc /#f. nsfcian .,/PLuifl erg AntalficaPit Informat ©n Please Pant Leall l 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. n I am a general contractor and I 6. Li 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 8. LJ Demolition worldne for me in any capacity. employees and have workers' 9 Buildc.a addition [No workers' comp. insurance comp. insurance.t ❑ required.] 5. ❑ We are a Corporation and its 10._ Electrical repairs or additions 3.P I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myseff. [No workers' comp. right of exemption per MGL 152, §1(4), and we have no 12.H Roof repairs c. insurance required.]' 7 13.17 Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. !Ho meow-hers 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'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 0 Insurance Company Name: kJ DmA" Cl) ) Policy#or Self-ins. Lic. #: Lk-) \ C 3 l 7 B 13 Expiration Date: 1l /t S' j o/0 Job Site Address: I?& 13J'2-4r 9, Ift) City/State/Zip: P1 o"...career— 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 e. 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 S250.00 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 the pains and penalties o perjury that the information provided above is true and correct. Si:mature. Q . L �{� Date: 7/A4 <p Phone#: '-/l3— cL(Q. 1 —/ © ryc 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 #: , fi ,r s Obnor aE- f 12 Main Street o Municipal Bufldinn + A/ iNSPECT_0R Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER E)GMPTION ACKNOihrLEDGEMFNT I The State of Massachusetts allows the homeowner the right under 780CMR 508.3.4 to act as his/her I construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a ore or two family dwelfleeg, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two- s year period shall not be considered a home owner." i 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/footinas (before backfill). sonotube holes (before pour), a rouo.h buildinc inspection I (before work is concealed). insulation inspection (if required) and a final buildino 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 Math l Street, Noinhamvton. i•-_i 01060 Solid Waste D''1sposai AfIIGaUL 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: IdSb /DU ( 19tk ✓e-1 The debris will be transported by: JaC,- N-boisici The debris will be received by: (c-- w� L,.P ear Sr^,us L/eJ y.✓c/ o.e ✓SH- Building permit number: Name of Permit Applicant moyc Date q\ & I (0 Signature of Permit Applicant /-....1 W&ICO-1 OP ID: DS A`ORn CERTIFICATE OF LIABILITY INSURANCE DATE 082016 G9rasnDl6 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 INSURE/0S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(es) 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). 4pPRODUomnO Lussler Ins Agcy Inc NAME J Raymond Lussier Ins Agcy Inc 181 Park Avenue,SURa 8 JA.w Em:413-7375359 ,No):413-732-2027 PO Box West Sp4ifnge99 dd,MANT090-0499 ADDRESS:tnfiD@lussieflnsurance.COm _ J Rmcnond Lussler Ins ARC).Inc 1NSCREAMI iF FORDING COVERAGE NAIC4 INSURER A.Wesco issuance Co �.. . 25011 NFIRED W&I COIISLTUCINNi inc. ISMER e'. 37G St Jacques Ave — '— Agawam, MA 01001 INSURER c 1_ INSURER D' I INSURER E: INSURER F: _r COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO ME INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWV ITHSTANDNG ANY REQUIREMENT,TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO INH CH THIS CERTIFICATE MAY SE 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. INGR TYPE OF _—.._. . LTR ryyly/yy POLICY NUMBER IMMNpIYYY✓J (MMTpKWVIF LIMfII COMMERCIAL GENERAL LIABILITY : I I I I,, . .__ _uE S EC E CT I I I )— v____r„ ,.are. r._ MED c%r'(Any ore Fersom 5 n_CNAL'fl ADV Cann' , _CS v3V Gw X.DRE.s DTra I I AUTOMOBILE LIABILITY IICN3 ED SIJGiE LIN � LIABILITYiIT �I. ��N.REL quios ,—ut NDN OWNED t i I PF FTZ E s I UMBRELLA LEAS JC EXCESS WB 1F VENd]E } - JED RETENTION$ WORNERS COMPENSATOR I I A FLP I C n. I MC EMPLOYERS LIABILITY y N I T L _1- _ A nOwrrs A FT VE fIINIA I WWC3171813 12/18/2015 12/19/2016.EL CCDENT �$ 500,000 F Lon *d+l ` III 500.000 fires.des e under .. rv_.0 ow E L e.,E FVLw LIMIT -a 500,000 DESCRIPTION OF OPERATORS I LOCATIONS I VEMCLES (ACORD 101,Additional Remarks Schedule,may be attached If more Race IS required) CERTIFICATE HOLDER CANCELLATION NORTHAM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF NORTHAMPTON THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WIN THE POLICY PROVISIONS. BUILDING DEPT 212 MAIN STREET • AUTIURVEOREPRESENTATNE NORTHAMPTON, MA 01060 s 144-4-19 ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 12014/01) The ACORD name and logo are registered marks of ACORD