24D-239 (4) 176 PROSPECT ST-3A BP-2017-0533
GIS=: COMMONWEALTH. OF MASSACHUSETTS
Map:Block:24D-239 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Gatevo,�rv_r FIRE DAMAGE BUILDING PERMIT
Qern)it BP-2017-0533
Project e JS-2017-000867
Est. Cost:$60000.00
Pee: $390.00 PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
Use Group: CHAD O'ROURKE 103710
Lot Size(sq. f{.): 5795.36 Owner.SULLIVAN REAL ESTATE LLC
Zoning: URC(I00V Applicant: CHAD O'ROURKE
AT: 176 PROSPECT ST - 3A
Applicant Address: Phone: Insurance:
6 UNIVERSITY DR (413)348-4741 WC
AMHERSTMA01002 ISSUED ON:10/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE FRONT DOOR, REBUILDING FROM
FIRE DAMAGE - NO STRUCTURAL CHANGES
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring U.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: Houses 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:
FeeTvpe: Date Paid: Amount:
Building 10/19/2016 0:00:00 $390.00
212 Main Street, Phone(413)5371240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0533
APPLICANT/CONTACT PERSON CHAD O'ROURKE
ADDRESS/PHONE 6 UNIVERSITY DR AMHERST (413)343-4741
PROPERTY LOCATION 176 PROSPECT ST-3A
MAP24DPARCEL 239 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT rs
Fee Paid
�.i(]
BuildnG Permit F'lled out
!ok
Fee Paid
TvoeofConstruction: EPEPLACE F . .QOR.REBUILDING FROM FIRE DAMAGE-No STRU(" URAA
CHANGES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 103710
3 sets of Plans 1 Plot Plan ITHE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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 Weil Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolitia' De
__ ,,, e 1�1f- ate
/,1 • / fir 44
Signature of B . dins ditici/ r 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.
an -u 'Deparm n uredo
'r"ad Ohj of F)Cri aimpton Status or PaI-, .'
O 5r_iiGtP -U A'trnenlCurt,
cr' Cut Dr r ey y P rmi0
C .o $ I 1�� 212 Mai Street .S WerJ pi Av=dab I
Cp
Room 100 fff yafier^r) I A:+a I_bdi'
CI__i A 130-. h•r`tl ,.pr n, MA 01050 N S m s ru u(2i P is _ 1
/1I 4 — 5E7-124D Fax 4'13-OE71272
CtnerSp cry'
APPLICATION It CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Prooertv Address Thiofficee section to be completed by office
178 fRaspEcr SrRc
? r 3/9/.j 2an4� y Overt District '
(7 (glm St ostnt-4 CE District
ct - -a
SECTION 22-PROPERTY OWNERSHIP/AUTHORIZED AGENT
c 2.1 Owner of Record:
: S v L tr v4N PEAL E cr, r£ LLC . sSCI �y rCurreMatingy
✓� rfP✓t F r vD ce 0/0 CR
Mame Curren;Mag Address'
ip-s3 2- GL,7 i
AiiSi. .., _ Telephone i
Signa,{Gnn(re
``
2.2 Authoric= Aoen �� C. (�Ik.`lf1 a.--e-z-41.4 4,0 ,mil
��
4
J
rr
e(Phot) C;unerC h/.aitiny'P /drgess: lfy :44 r�
ture At A
Te@phone �+ - I
SECTION 3-ESTIMATED CONSTRUCTION COSTS
hem Estimated Cost(Dollars)to be Oficial Use Only
completed by permit a;ollcent t
'L Building �.. $2(000•00 �.Ca;BuiiT9?wm8r'se
I
2. Electrical yjOQC) oa I (b)siimated Total Cost of
L Construction from 16)
3. Pl robing I Building Permit Fee
I
/3 96 ,
Mechanical{HVAC1
i 5. Fire Protection _
5rrotai=( -2+3+4«5) } ,j72� e) 00 li CheekNumnery�t/3g0
This Section For Official Use Only
i E 9 caembuildin rmit Nuer: Date
L. Issued. __ _.
SIgr,atur=-
Building Commissinnedinspector of Buildings hate
'marl : 114S Xrree► 0"c*ioSe0y4tioo , ( ow^
se
iSection 4. ZONING Au lrsrmaWn Nos:Be Cons{e ed.Permit Can Be Denied Due To Incomplete Intelmahon
I Boost:t:mg Proposed f Rea:ired by Zoning
This column to tin o nllea by
I I Thi dap D°uortmonl
Let Size[F. n 1_ "_ ..
_ �-- ._. _ --II
Setbacks Prod '-' i�
I Side X R.� L: ,. R ,~Y
Rear :.._.__ ,._ _: -:
BulidWg 3etgct �.
Bldg Squaee Footage — _ % f __
..._.-
Oztascsmino bldg Spavea ._..-._.
bn1)
ofP0rL c Spaces ..._.„- .. .�
FEB
:asessece,ocatioa
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
4J
NO * DONT KNOW YES 0
IF YES, date issued_..
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book P �_ �- and/or Document i
B_ Does the site contain a brook, body of water or wetlands? NO 410 DONT KNOW 0 YES 0
tF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date issued: !~`
C. Do any signs exist on the property? YES . NO 40
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property 7 YES 0 NO
_—__s~^ ._...
IF Yes describe size, type and Ideation: �...�._..,.._._4
E. WtI the construction activity disturb(clearing gradino, excavation,or rlHnq over asks Br is it pert of a common plan
t”,twin disterbover i acre? YES 0 N0 4
IF YES,then a Northampton Sto:rn Water Management Perm,:from the CPW is required.
SECTION S.DESCRIP71OM OF PROPOSED WORK,Iche_ck ell anoticzbfe)
I
7
New House [] I Adie ort J Begtocer-e`1kk8jRtic$ros alit rauonfej 1 _ I Roounr- 1
1 Or Doors LLII , / �I
Accessory Bia�g. I Demolition Flew Signs fD Decks iCP Siding in) �erjCS
�. I
�-e .7. .
Brief besot-Oen or Proposed a r�"" Cu
Work: Rr bmf 111 1-1001 C- eta wl a ye '�i �/0� "'Y/Gf
Alteration of existing bedroom Yes j •Ji/ No ,Adding new bedroom Yes No /
Attached Negative Renovating unfinished basement , _Yes _No
Plans Attached Roil -Sheet
Sa If New house and oradddtlon to exisf&na horjsino, comoIete the followInQ.
a. Use of building:One Family Tom Faintly Other
4. Number of ooms in each faciily unit: Number of Bathrooms
c Is there a Garage attached'
d. Proposed Square footage of new construction. Dimensions
e. Number of stories,
t Method of heating? Fireplaces or Woodatoves Number of each
g. Energy Conservation Compliance. Massoneck Energy Compliance form attached,
h. type of construction_
i is construction vnthtn WO ftof wetlands? Yes V No. Is construction within 100 yr. floodplain Yes;No
j. Depth of basement or cellar floor below finished grade__.
Y Will bolding conform to the 3uild,rg and Zoning rrsgaiaiaons'i / ^Yes No
r
I. Sento Tank City Sewer C� Private well City water Supply etc--
--
SECTION
%'--SECTION 7a -OWNER AUTHORIZATION•TO BE COMPLETED WHEN '
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
� _._.�... �..
,,_�e c, T. So/1.��? ae Owner of the subject
prone ,y X. /t / np p
hereby aathodze 79 L �7 R IRC L'LDS
to act onmymyy chair,tn all matters !a to work authorized by this building permit ap 1n, tion
Signature of Owner Date ��/�C
SSt 7 C rt 44 of%} �'/y� /"
4Q (� 11. V ' G• asQwn '�$W
Age geby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
an. .eiief.
Signed under the pains and penalties of penury.
49789r—Fr0
Print Name
*, %stNAk 1°M-47
S,Ynature of Owner/Agent Date
SEC iON 8-CONSTRUCTION SERV/CES
al Licensed Constareteon Seiner risor. Not Applicable
Dame ei Lipson Hohfer 92 /9 / ,rie 1° h
License ur let
, 1 1i { /di
Ades
E..prJon Date
(0) 3w-VV/
Sion Telephone
S.Reaisfered Home Improvement Contractor ; Not Appih;aSie
SO�e S _ M S
Company Name Registration Number
one. ioS 48- Scw45 LLL _ 31
Address 1 SI007 Expiration Date
27 A4 ke De. 'Stick-4(+On MitTelephane G!!3=`ttiT7o17 nem / 17
— I
SECTION 10-WORKERS'CONIPENSAT1ON INSURANCE AFFIDAVIT(IM.C.L.c.152,§26C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wit'.result
in the denial or the issuance of the building permit
Signed Affidavit Attached Yes.. . E No E
_.ecce ._>.._
1�' - Nome Owner Exeitiptioa.
The current exemption for"homeowners"was extended to mcludo Owner-occupied Dwellings of one 0 no(-)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 he considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable ro the BuildingOfficial.that hefshe shall be
_responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site wilt be required from rime to time,doming and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workerff Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting m Death)of the Massachusetts General Laws Annotated,You moo be liable for personas)
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 Ordinance_,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature 1
F r.,_,i-C. , �virtii en c ti zi—Wa AeG'e.ros "
02-,fffiLeffITgaziwgs
i9£':;tie *glasr
' Bsc6r, / 74 0211".,,
WaBtkehs' Q'mcthpe.a„z,5eou iDataranttut ' . ^da r >-rh.sepg/CaA_
Au-tali-cant Iv:=ormtzt on Please PrT2t Leath v
Name (Business/Organizati cm/n avidual): 4( d/(Od+--if
Address: C Chntte-7' ,
City/State/Zip: A ;at &La/°e2 Phone#;
Are you an employer?Check the appropriate box:
l_f_ I am a employer with 4. I am a general contactor and Type of propeet,yeq,mi(required):
employees (full and/or part-time).* have hired the sub-coniraetors 0' New construction
2.rl I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contacs_s have g, — Demolition
working for mein any capacity. employees and have workers' p Building addition
[No workers' comp. insurance pomp. insurance.
required.] 5. We are a corporation and its 10._ Electrical repairs or auditions
13._ I am a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or additions
myself [No workers' cornp. right of exemption per MGL 12.E Roof repairs
insurance required.] t c. 152, 2:31(4), and we have no
employees.[No workers' 13._ Outer_
comp. insurance required.]
'Any applicant that checks box int must also fill out the section below show ng their workers'compensation policy inf rmatic.
'Ho meowners who submit this affidavit ir,dicating they are doing all work and then ere outside sovfractors ROOT DO brill a new affidavit iindioaling such.
'Contractors that cheek this box must attached an additional sheet showing thermic of the sub-contractors and state whether or not those entities have
employs If the sub-contactors have employees,they must protide their workers'comp.policy number.
Lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. p
Insurance Company Name: lap{ ,}tis1 it brA�tR
Policy#or Self-ins. Lie.r: Expiration Date: I
Job Site Address: G 11 !EG' •. 4.M t ten win City/State/Zip:se/8 0 G("1 _
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 51,500.00 and/or one-year imprisonment,as well as civil penalties in 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 he forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby cert),u der the pains and penalties ofperjury that the information provided above is true and correct
n
Sicmature: A Date..
Phone V4s1 i
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License n
Issuing Authority(circle one):
1. Board of Health 2.Bolding Department 3„City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone=:
� Y t t ,
212 POsin Street o RuflicTpal Building ‘,SAO
No soh-RAT:on, MA OA O60
'INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HONE OWNER EYIDEi.'TION 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 OPE or two family crwelfing, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in a taro-
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 buikdino inspection
(before work Is concealed), insulation inspection (if reauired) 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)
1 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 Malik Street, 'Northampton, JVLA 01060
`,olid Waste Disposal Affidavit-
In
ifdavr-In accordance of the provisions of MGL c 40, S54, ! acknowledge that as
a condition of Me 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: 17$" Remocc+ s-h
The debris will be trans:cited by: lee los k Sans At
The debris will be received by: 7yavtscel' ,S,Ja+426, 4,u{iett4 M4
Building permit number:
Name of Permit Applicant CL AA QRn rQ(1S
At 1 —_
Date Signature of Permit Applicant
LIBERTY MUTUAL FIRE INSURANCE
' Liberty Mutual. COMPANY
INSURANCE P.O.Box 8090
Wausau WI 54402-8090
Telephone: (800)653-7893
Fax: (603)334-8162
Email:IMS@LibenyMutual.com
September 22, 2016
BARCELOS AND SONS LLC
27 LAKE DRIVE
BELCHERTOWN MA 01007
RE: Other Stales Coverage Notification
Insured: BARCELOS AND SONS LLC
Policy Number: WC2-315-614108-016
Dear Insured:
Your workers compensation policy covers only states listed in Part IA. of your policy. If you are working in
states other than those covered by this policy and listed in Part IA, of this policy,please ensure you have the
coverage needed.
• if you are working in other states and have obtained workers compensation coverage,
please forward us a copy of your Policy Information Page(s).
• If you are working in other states and have not obtained workers compensation
coverage,please notify us in writing.
As a business owner, it is imperative that you comply with each state's requirement for workers compensation
coverage. It is our intent to cover the known exposures,only for states listed in Part 3.A of this policy. Failure
to notify us may result in claims not being covered.
For questions or concerns, contact us using the above email,phone or fax information.
Note: Liberty Mutual cannot combine the states of Indiana,Massachusetts,Mississippi,North Carolina,
Tennessee and Wisconsin with other states on an assigned risk policy. Contact your agent for additional
information.
Sincerely,
Jeff Eldridge
Commercial Service Operations
cc: AMHERST INSURANCE AGENCY INC
140068 0314 WC2-3IS-614106-016 Page t or I
Mick CL
THE TERMS AND CONDITIONS OF THIS QUOTATION MAY NOT COMPLY WITH THE SPECIFICATIONS
SUBMITTED FOR CONSIDERATION.PLEASE READ THIS QUOTE CAREFULLY AND COMPARE IT AGAINST ,
YOUR SPECIFICATIONS.
IN ACCORDANCE WITH THE INSTRUCTIONS OF THE BELOW-MENTIONED INSURER,WH/CH HAS ACTED
IN RELIANCE UPON THE STATEMENTS MADE IN THE RETAIL BROKER'S SUBMISSION FOR THE INSURED,
THE INSURER HAS OFFERED THE FOLLOWING QUOTATION.
Note-Your quote is only valid for thirty(30)days.
Date ssued: 11111/2015
Agency Name: AMHERST INSURANCE AGENCY,INC.
Producer: Mary Woodard
IMV Quote No: Q9314D O1
Assigned AUW
Underwriter:
Insured: Joseph Bsrcetas
Mailing Address: 27 Lake Drive
BelohertaWRMA01D07
Physical Location: 27 Lake Drive
Bslchertown.MA,01007
Carrier: Western World(AM Best Rating A+IX)Non-Admitted
Location: MA
Coverage: General Liability
Term: 12 months(11/11/2015 to 11/11/2015 )
Limits of Liability: $1,000,000-$2,000,000
General Aggregate Limit: 92.000,000
Product Completed Opertaions: S1,000.000
Personal Advertising&Injury 51,000,000
Limits:
Each Occurrence: 51000,000
Damage To Premises Rented 5100,000
To You:
MedicalExpense 56000
Professional Limits: NOT COVERED
Molestation Limit: Not Applicable
Deductible: 51,000.00
12:01 AM,STANDARD TIME AT THE LOCATION ADDRESS OF THE NAMED INSURED.THIS INSURANCE
QUOTATION WILL SE TERMINATED AND SUPERSEDED UPON DELIVERY OF THE FORMAL POLiCY(S)
ISSUED TO REPLACE IT.
Premium 5750 00
Policy Fee s95.00
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