10B-025 (2) 7 MULBERRY ST BP-2017-1045
GIS a: COMMONWEALTH OF MASSACHUSETTS
Map:Block: loB -025 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Caleeory: renovation BUILDING PERMIT
Permit 4 BP-2017-1045
Project k JS-2017-001723
Est. Cost: $14000.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NATHANIEL BRUURSEMA 100441
Lot Size(sq, R): 8232.84 Owner: EAGER MAIWA S&ERIC DAVIS
Zoning:NB(100)IWP(IQQ) Applicant: NATHANIEL BRUURSEMA
AT: 7 MULBERRY ST
Applicant Address: Phone: Insurance:
57 SOUTH VALLEY RD (413) 326-4943 Liability
PELHAMMAO10O2 ISSUED ON:3/2212017 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIRING AND RENOVATING APT #3
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:
FeeTyne: Date Paid: Amount:
Building /22/20170:00:00 $100.00
712 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2017-1045
APPLICANT/CONTACT PERSON NATHANIEL BRUURSEMA
ADDRESS/PHONE 57 SOUTH VALLEY RD PELHAM (413)326-4943
PROPERTY LOCATION 7 MULBERRY ST
MAP 10B PARCEL 025 001 ZONE NB(100)/WP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid Building Permit Filled oute Paid
Typeof Construction: REPAIRING ANcrS!..Ps)OVATING APT#3
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 100441
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORM PRESENTED:
roved 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 Variances
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
Dem&iti. -0�
Signature of Building Official 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.
41051°... C# Version l.7 Commercial Huddle Pe nit May 15,2000
f�� DePartment use only --
/' City of Northampton status of
Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability ___
\F, Room 100 WaterM/ell Availability
\\V//
\ Northampton, MA 01060 Two Sets of Structural Plans_
phone 413-587-7240 Fax 473-587.1272 Plot/Site Plans
__ Other Specify __
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SEc1'1ON 1 -SITE INFORMATION
1.1 Property Address'. This section to be completed by office
-- H vus- ,tity ST. Map Lot Unit
t_S 2 , )-'ta'c Zone Overlay District
- - - --- --- - -- -- -- Elm St.District C8 District
SECTION 2-PROPERTY O WNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MRcZ4M 5, ea4E 35i ?L=am. Si- i sre ISO
Neale(Punt) Covent Mailing Address
T}rt-T-�At1�"!°r•1, flA 0toha -..
t (7 IvTelephone C0-tic, X3`-1- RI"-3 I
Slnnature _--_
2.2 Authorized Agent: j
C7 socALL. V.04
,---
Name{Print) Current Mailing Addr ss
`It732gg __
signature ___ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Ilam Estimated Cost(Dollars) be Cffiaai Use Only
to
completed by permit applicant
, 000 .- (a) Building Permit Fee
1, Building 4 5
2. Electrical # T (b)Estimated Total Cost of
I O0O� _Construction from(6)
3. Plumbing *9 t IvoBraiding Permit Fee
4. Mechanical(HVAC) ND/ -..
5.Fire Protection / -. /j �e�y�
6. Total ei(1 +2+3+4 +5) '} 1' li(1000 ' - Check Number / ,_
This Section For Official Use Only
_
—
Building Permit Number Dafe
Issued
Signature:
JBuilding Commissioner/inspector of Buildings _ Date
5 ICIU 19E7 tinct. 11i \AerS ‘el W-al ' , coat
allimusit
Version 1.7 Commercial Building Permit May 15,2000
IECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
;URIC FEET OF ENCLOSED SPACE
nterior Alterations 0 Existing Wall Signs 0 Demolition Repairs g Additions 0 Accessory Building
Sxterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing❑ Change of Use❑ Other 0
Brief Description Enter a brief description here. R-EfAdzt^-1 An/r7 2-E101/41kiV0E1 APT-41-3 i
Of Proposed Work:; 1 i5�''E7..-� vikcbo^, AnE2' ��/ >1661-5,
6 S OF Dw. (L ite Jj;
SECTION 5 USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A assembly A-t ❑ A-2 0 A-3 0 IA I ❑
CI A-4 0 A-5 0 18 ❑
B Business ❑ 2AI ❑
E Educational 0 _ `B t 0
F Factory 0 F-I ❑ F-2 ❑ I _ 2C ❑
le Kroh Hazard 0 3A I 0
I tnsstutionai 0 Id 0 1-2 0 1-3 0 38 I
M Mercantile 0 4 ❑
R Residential 0 R-1 0 R4 0 R-3 0 r- SA 0
S storage 0 B-1 0 s-2 0 5B 1 v
U utility ❑ Specig
M Mixed Use ❑ Specify. . _ . ... .._ ... .
S Special Use ❑ Specify: I
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group . . _ _._
Existing Hazard Index 780 CMR 34) , _ Proposed Hazard Index 780 CMR 34): .._
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1it
2.,n 271 .._.__. _... .__
_ _
3' ... .
Total Area MO Total Proposed New Construcihon(sg
Total Height(fp
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private ❑ Zone _ __ Outside Mood Zone❑ Municipal 0 On site disposal system❑
r
.. Version/.7 Commercial Building Perrnit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This whmn to be Elrod in by
Building Department
Lot Size ..
Frontage ..... .... ..
Setbacks Front
Side Li R._
Rear _. ._ .
Building Height
Bldg.Square Footage - era .__.... ....
Open Space Footage % _. __.....
Q..nt area minus bldg&paved _..
parking)
Ncif ParIang Spates ..—....:'
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES
IF YES: enter Book Page and/or Documents
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained fl Obtained Q , 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 disturb(clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES (9 NO a
IF YES,then a Northampton Storm Water Management Permit from the DPW is required
Verslonl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
. __.-. _ . ... . . _ _ -- . Nct Applicable 0
Name(Registrant)
--- �- - --- --- --- Registration Number
Addreee -._- _
_.-- _.. _
Expiration Date
Sancture Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibriity
Address Registration Number
Sienature Teiephcne Exp raton Date
Name Area of Responsibil ty
Andress RegTstratonNumber
Signature Telephone Expiration Date
Name --__ _--_- --_.. -. Area of Responsib0ty - ..
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Regisira&on Number
Signature Telephone Expiration Date
9.3 General Contractor
W &uYCso:Dia& $III Lee
Lfr .`_ _ - No:Applicable 0
Company Name'.
Respone ble In Charge at Construction
�7 .� �. ,„((7 �Q peitAA0, olo
Adores_
Z _ 13 za2CYFt4
Signature Telephone
r Version l.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) 0
Independent Structural Engineering Struofurai Peer Review Required Yes Ne 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
71%t S' CPS( .. . .... . _'..as Owner of the subject property
hereby authorize 1f -44-thatt—�l c ' &O ILT2 1t,CA, to
myto work authorized by this building permit application
act ohbehalf, ' atter I e S11-511
Signature at Owner Date
I, iia' .,,anLd rv,,,rS(,' Ll a ,__ .-, ,au 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 belief.
Signed under the pains and penalties of penury __ _.. ...
NeActtI<.(_IP: 44-cc 0.,
Print Oa ii + + - -. .. .
Z-- 7}1131)
Signature of OJJfier/Ager/q/ Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed ConstructionSupervisor Not Applicable 0
Name of Licens H1 oltler l ° J VIlice IML _ 6.9 FO c79 9.I
License Number
..._ _... _ .. ..._.. 3.z I A ..
.. _...i
Address Expirelion Date
H A26Y%Y3
Signature Telephone
SECTION 13-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.
Signed Affidavit Attached Yes 0 No 0
The Commonwealth of Massachusetts
a _ Department ofIndustrial Accidents
" —�- Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizarioMndividual): wOA CIA Ie /d/r3lrt-t �^
,Address: 7 oGrtin
City/State/zip: ' ( k, lnb,. • OO phone#: I ?2 3 2 L 99 Y 3
Are you an employer? Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. 7 I am a general contractor and I 6- New construction
,..{' employees(full and/or part-tune)." have hired the sub-contractors
2.u I am a sole proprietor or partner- listed on the attached sheet. i. D Remodeling
ship and have no employees These sub-contractors have g, E' Demolition
working for me in any capacity. employees and have workers'
9. Building addition
[No workers'comp.insurance camp_insurance.4
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.El I am a homeowner doing all work officers have exercised their 11.E Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.E Roof repairs
insurance required.]t c. 152, ss 1(4),and we have no
employees. [No workers' 13_E Other
comp, insurance required.]
`Any applicant that checks box,l must also tin 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,
[Contractus that check this box must attached an additional sheet showing the nava of the sub-conractors and state whether or not those rstit es have
employees. lithe subcontractors have employees,they must provide their workers'carp.policy number.
!am 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.Tic. #: Expiradon 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 le DIA for insurance coverage verification.
l do hereby car], under the pains and penalties of perjury that the information provide, above is true and correct
amre: • `" Date: 3 i I 7
Phone#: '
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#:
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: 3 Mvt_ YS ISS Wt-
The debris will be transported by: --DJs I nits NA
The debris will be received by: s� j,t,,, .,6‘
Building permit number:
Name of Permit Applicant MA2PN S .
Date Signature of Permit Applicant
A� CERTIFICATE OF LIABILITY INSURANCE
one d
pE1 a"
3/20/2014
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 policy{les)must be endorsed. N SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may requite an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Cecilia Chan
NAME _....... _.. _..."_.
Piddock Insurance AgencytAoN y_ 1413)253-5565 qct 413,256-en54
20 Gatehouse Road A :cchan@nathanagencies.cor —..
PO Box 48 iiisumR(SI AFFORDING COVERAGE MAICk
Amherst MA 01004-0048 INSURER A:Western World
INSURED INSURER B:
B24UrO6IDa Builders INSURER C:
57 South Valley Road INSURER 0::
INSURER E: _.
Pelham NA 01002 RNSURER F:... ."... -�-.
COVERAGES CERTIFICATE NUMBEfCL1662002041 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED eELOW 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 MCH THIS
CERTIFICATE MAY BE 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.
1NS -ADDCMISIL POLICY EFF Pdl1LY EXP
LIN TYPE OF INSURANCE INS WW1 PIRACY NUMBER IMWOONtYYI IMMDDNYYYI UNITS
X COMMERCIAL GENERAL UAEKIY EACH OCCURRENCE $ 300,000
-.. - - MdAR TO RENTED 108.000
A CUUNSMADE X OCCUR AR£MISEM0y591BmIwj $ _
NPPB315044 5/4/2016 5/4/2017 MED EXP(Any me person) $ 5,000
PERSONAL%ADV INJURY $ 300,000
GEN'L AGGREGATE UNIT APPLIES PER'. . GENERAL AGGREGATE $ 600,000
X POLICY rig IOC PRODUCTS.CONDOR AGC $ ...._. 600,000
OTHER-. . .. . ___. EmpkypBewfla $
COMBINED SINGLE LIMIT
AUTOMOBILE UPNUT' accident) $
ANY AUTO BODILY INJURY(Per parson) $ .�
ALL OWNED - SCHEDULED BODILY INJURY(Per sA.AN) $ _.
HIREDSAUTOS AUTOS
OOWNED y sccgemPROPERTY pAMAGE $S -
5
UNSRELLA LMB OCCUR EACH OCCURRENCE S
EXCESS UAO CLAIMS-MADE AGGREGATE $
DEB R4SATIODHE - $
WORKERS COMPFNSMIOX PER OTH-
AND EMPLOYERS'LABILITY YIN .. STATUTE :ER _ . ..
ANY PROPRIETOR PARTNER/EXEGUTVE E.L.EACH ACCIDENT $
GFFICERMEMDEI EXCLUDED? NIA
(Mandatory In NH) • E L DISEASE.EA EMPLOYEE $
If
N yes,
itr
DESCRIPTION
i O OF''OPERATIONS wow EL DISEASE-POLICY OMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(AGGRO 101,Additional'east..ScMONF,may G attached M mare pace Ia emirs)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Marga S. Eager THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
D. Eric Davis ACCORDANCE WITH THE POLICY PROVLSIONS.
351 Pleasant Steet
Northampton, MA 01060 Au DME/P/IRE.ssE AIME
He We &loran HEIDI �_•
W1988-2014 ACORD CORPORATION. Ail rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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