10D-026 119 ARCH sr BP-2017-0738
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:BIock: too-026 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Ctegorv:wipdowreolaced BUILDING PERMIT
Permit# BP-2017-0738
Proiect# JS-2017-001229
Est.Cost: $686500
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: COWLS BUILDING SUPPLY 098619
Lot Size(sq, ft.): 80586.00 Owner: VOGEL ALAN G&BETH J FISCHER
$orcins:URA 133 /WP .3 /URB 3 ' Applicant: COWLS BUILDING SUPPLY
AT: 119 ARCH ST
Applicant Address: Phone: Insurance:
P O BOX9676 (413)549-0001 WC
NORTH AMHERSTMA01059 ISSUED ON:12/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE 21 STORM WINDOWS
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 12/1/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
/7::tCity of Northampton
j-7
Building Department
212 Main Street
Room 100
/ Northampton, MA 01060
c-5Y phone 413-5874240 Fax 413-587-1272 _ '
, L CATION TO CONSTRUCT,ALTER,REPAIR, /RENOVATE1 '7OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION /C I / / — e 9
1.1 Property Address: ThissecYWn to be completed bleats
1 14 fRt-ciA-1 S' .. Leta-5,
Zone .Overlay DlstdM .'
lama.District CS histl(ct.:
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:macVs
%-, ct pr i Is n -ct-. Si-t ..Lei? AA5,
Name(Print) Current Mailing„Address:
A v iAik 'jc's.L< ✓ tiIZ . ySc, . iyti3
Telephone
Signature
Z.2 Authorized Aaent:f� p
Lata.,\ s l c AA;vx.� S.i roly '1 �-ti `svv.ci`4l`"la� J. P v-1 nel`5t
Name(Pi / Cunent£ding Ads
drs:
410r .
/� (./\---: 4r3 i 3cs}. 9C.1G
Sig : re Telephone _
§ECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by pemift applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(S)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) .,z
5.Fire Pl (1* 2 /' + A 1 /71 /()
B. iotas=(i +2*3+4+8) � 6, g IoS, Otl Check Namtrer. � b✓pj Zlf
This Section For Official Use Only
Budding Permit Number: Date
Signature: dile '/ �. ✓t— .
B 1irg Commissioner/Inspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Proposed Required by Zoning
alliall ...
11th column to be Deed in by
Building Department
IMMINIIIM allIIM E4W
Setbacks Front C.
Side L_1 RHE.J LC RC
i.r. L I= O
Bldg.Square Footage Eni . ®®
Open Space Footage r-�
on ea minus bldg 3 paved I I
#ofParki IS. ce
mi.. . .. .... , .._..._____.... as
mom
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES 0
IF YES: enter Book Page and/or Document# I
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained d , Date Issued:
C. Do any signs exist on the property? YES () NO O
IF YES, describe size, type and location; .......—
D, Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES,describe size, type and location:
E. Will the construction activity disturb(clewing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Stamm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK[check all annlidable)
New House ❑ Addition D Replacement Windows Alteration(s) n Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [p Siding[L7] Other[p]
SneE ription of Proposed_ r.. —
Wolk IZa ta.,... h,rwv 4 ykrl p,.,rjL � -(') UOv .`t t"1-UC Kira. lc
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
s'aIf NeW�louse•arY .gists 6Ro s1Ft1-'Cil"Dusmii4gmDkte' tl$eisiol'"gNtigp:
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? ._
d. Proposed Square footage of new construction. Dimensions
a. 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 Ta-OWNER AUTHORIZATION-TORE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPUES FOR BUILDING PERMIT
tLQ '"�_ ,as Owner of the subject
hereby authorize P eh t l Mcg':tY�
to act on my behalf, in all matters relative to work authorized by this building permit application.
/s t r fl ^. El_ 1475 (lb
I,___ , M OCin as Owner/Authorized
A hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed underthepains and penalties of perjury.
Offiln
Pint Name "' 7
l [I )9II �
Sign..m -, . 6 gdAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed ConstructionSupervisor: C ' Not Applicable ❑
(
Name at License Holder: RAO eft S7`R\a-rz (_5 -cpc 1Q6 (q
License Number
C-2(d Rnke<'‘-5\— 'fidSo„\-N-, \+oA1Qy \-MIfol ).a-I (I
AAdd , Expiration Date
/�(ilrr
..7--
a--AX— 111 ')N MI , (c7 175
Signature Telephone
''11 ##.Rwiste` •Flo tli�i lmonn'n'rMril,GOriti etGor•v-..-' . .„* -: .e a,t 7— . t Not Applicable ❑
Co�1.5 `\) vt\ti , Ylr.( )u p\y Is� 3104
Company Name J Registration Number
has 5 fed Rd . ��L � M gi� s�l1
dress Expiration Date
Telephone 4l 71. 30,4 0 3G
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,025C(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.
uiyil�
Signed Affidavit Attached Yes / No 0
i `K V't 'i-5i 11 1 A III
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 h,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 of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
ja a=n_ t Department of Industrial Accidents
;�;)I4l=(' Office of Investigations
=irti= 1 Congress Street, Suite 100
• _ 1= -" Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
{�
Name (Business/Organization/Individual): r ptti) S/n� VS v itln Su fie\1/
Address: ) '� (T� SII v ✓1 d.ar(o.r r� 1�d , /
City/State/Zip: A vim)h 2 Cr 1 L 1 _ Phone#: I-(i \ . i ( `.)., 610 3 Ca
Are you an employer?Check the appropriate box: Type of project(required):
1.101 I am a employer with 4. ❑ I 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 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.9 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
12.9 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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that cheek 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
Insurance Company Name: (S p e 'S 4 o c L e l7I
Policy#or Self-ins. Lic. #: 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 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.
I do hereby certify der the pains
nd penalties of perjury that the information provided above is ue and correct
Signature: / Date: ]] 12-- l
Phone#: L4 1 3 . 3 (,a) 01 D 3 G,
Oficial 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#:
Aco d CERTIFICATE OF LIABILITY INSURANCE °"h"' """
`....---. 11/21/2016
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 POUCIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREWS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polley(Iee)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).
PRODUCER woe;NAME: Cynthia Henderson, CISR
Webber 6 Grinnell _ �� (433)586-0111 FAX (6131586-6691
B North KingStreet IAD.coat ADDRESS;
chenderson8wahberandgrirMLell.ca
INSURERS)AFFORDING.COVERAGE MAKS
Northampton MA 01060 KNSURER A Netherlands/Liberty 24171
INSURED
INSURERS Excelsior/Liberty _ 11045
N.D. Cowls Inc. INSURER C Peerless/Liberty
PO Box 9677 INSURER OI4A E0ployers/X.I.1E.
INSURER E:
North Amherst MA 01059-0002 INSURER F:
COVERAGES CERTIFICATE NUMBERt4aater Exp 2017 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES 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 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 CONDNIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ADDL SUM POLICY Ef F POLICY EXP
TUR TYPE OF INSURANCE INSO WM Policy NUMBER IMW4M'YYYI IMLgayYYYI �_..LIMITS
R I COMMERCIAL GENERALUABIRY
r EACH OCCURRENCE 1,000,000
A CLAIMS-MADE Ri OCCUR DRE ?SES ETORENTED 100,000
DREAIGETO ENTER )
CBPR562731 11/21/2016 11/21/2017 MED DTP(Any OPE PAPAS 5,000
PERSONAL 9 Any INJURY 1,000,000
GEN.AGGREGATE LIMIT APPLIES PER'. GENERAL AGGREGATE 2,000,000
R POLICY Ter ......L-_J LOC PRODUCTS.COMP/OPAGG 2,000,000
OTHER
AUTOMOBILE UNARM (OMB aCoderASWGLE LIMIT 1,000,000
H ANY AUTO I BODILY INJURY(Per Putin)
All OWNED R SCHEDULED BAS569516 11/21/2016 11/21/2017 BODILY INJURYe�
URY PI
AUTOS AUTOS ( )
1-T HIRED AUTOS R AUTOS ED PROPERTY DAMAGE
E,
AUTgS
(Per MaduYJ
PIP-8ase 8,000
X 1 UMBRELLA MB R OCCUR EACH OCCURRENCE $ 10,000,000
C EXCESS LIAR CLAIMS-MADE AGGREGATE S 10,000,000
DED R RETENTIONS 10,000 408566562 11/21/2016 11/21/2017 S
WORKERS COMPENSATION PLR OTH-
ANDEMPLOYERS'M&IJT' YIN STATUTE ER
ANY PRCPRIETOPRARINFRRXECUTIE EL EACH ACCIDENT S 500,000
OFRCERMEMBER EXCLUDED, N/A
D -
(MMdWayInNEI SCC200200000262016A 1/1/2016 1/1/2017 EL DISEASE.EA EMPLOYEE 500,000
'DESCRIPTION Revlbe underEL DISEASE-POLICY LIMIT S 500,000
OF OPERATIONS bebw
I
DESORPTION OF OPERATIONS/LOCATORS/YEMCIER LACOR0101.Addition&Rave Schedule.maybe Method If more Waal N,pW,tl)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTRORIZED REPRESENTATIVE � �
C Henderson, CISR/CIN - :e�"—
-^ts- -
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025 tam ann
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: 1 VA S \ -
The debris will be transported by: C.n w
The debris will be received by: CrowtS (puwneci-ev-1
�
Building permit number
Name of Permit Applicant / , I nor-,r-)
N I -ql l �i� ,4•Aj
Date Signature of Permit Applicant