44-123 (5) 1 123 FLORENCE RD BP-2017-1265
GIS a: COMMONWEALTH OF MASSACHUSETTS
Ma:44 - 123 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACT/NG WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath rend BUILDING PERMIT
Permit# BP-2017-1265
Project# JS-2017-002113
Est.Cost:$16800.00
Fee:$109.00 PERMISSION IS HEREBY GRANTED TO:
Const. Cla)s: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sg. ft.): 59677.20 Owner: SIRACO SANDRA J&DEBORAH A BLUME
Zoning: Applicant: STEPHEN D ROSS
AT: 1123 FLORENCE RD
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584-1224 0 WC
NORTHAMPTONMA01060 ISSUED ON:5I4f2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM
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 N 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 5/4/20170:00:00 $109.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
File N BP-2017-1265
APPLICANT/CONTACT PERSON STEPHEN D ROSS
ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224()
PROPERTY LOCATION 1123 FLORENCE RD
MAP 44 PARCEL 123 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Pemrii Filled out mt'V)
Fee PAW
TypedConstruction: REMODEL,BAT 'OOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 079160 //
3 sets of Plans!Plot Plan Yfc TPdfv/C. f+LS
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOfFIGIATION PRESENTED:
,/iiiApproved_ 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
r 'clay_
Si. ire of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with ail 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.
!,�
ti. iiii, Department us Stity int
.. 1UiA \ City of Northampton f �,
�'"tJ Building Department CvVtSM "- f=x * at�•r
<\ 1� 212 Main Street .
xi. Room 100 Water n Av:
'\ ,iii j Northampton, MA 01060 inivo Sets of Strilt rail hs cY ,e
c phone 413-587-1240 Fax 413-587-1272 Plot/Sate Plane.
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 •SITE INFORMATION uhf L`( /Y7//ic CCJ/25/
1.1 Property Address: tp CH
section to be completed by office
//S3 F •^'c"L t`o`j Map C( Lot /a3 Unit
firl-r..ri- /h' 47/4't#t Zone Overlay District
Elm St.District CB District
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ce..ti. d ySi✓•cO � --.
Na (PanP
i /� = 1/G (1',
SignatureCurte% ting
SU; /579
Telephone
....
2.2 Authorized Agent:
S-F- +ki---rn- ,D. taa 3c..c.A.rP4 144...-7,94.". .44".
Name(Ma) Current Mailing Address:
r../1 if rr,J 1 S65/— it ty
, ignal re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
hem Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 1/ "'"f (a)Building Permit Fee
/
ir
2. Electrical / ere !.i (b)Estimated Tota'Cost of
�i Construction from(8)
3. Plumbing i/ rex) Building Permit Fee
4. Mechanical(HVAC) ..-
5. Fire Protection /� �((
6. Total-ell +2+3+4+6) ii/6/// f'{� 'es Check
Check Number 3 +y
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Its
Section 4. ZZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
_®® Required by Zoning
This column to be filled in by
Building Department
®®®®
r
Setbacks Front
Sid=.
Rear
Open Space Footage ®®111.11._
(Lot area minus bidga paved
akin: _
--_-
A. Has a Sped err-nit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES C)
IF YES,date issued:.
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Book Page d/or Document It
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW ? YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained a , Date Iss d:
C. Do any signs exist on the property? YES O NO
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. WI!the construction activity disturb(clearing,grading,ex ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES a 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) ' Rooting ❑
Or Doors 0
Accessory Bldg. ❑ Demolition El New Signs [CM Decks (Cl Siding(CA Other[l71
Brief Desc' tion of Pr sjca
Work: �-c�'`" �'r� //
Alteration of existing bedroom YesV No Adding new bedroom Yes ✓ No /
Attached Narrative Renovating unfinished basement Yes t� No
Pians Attached Roll -Sheet
1i0.If New house and or addition to existing housing,complete thefollowing:
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 S•uare footage of ne . onstruction, Dimensions
e. N ber of stories?
f. ethod of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation ••mpliance. .#asscheck Energy Compliance form attached?
h. I ype of constructs.
I construction • thin 100 ft.of wetlands?^Yes No. Is construction within 100 yr. floodplain yYes No
j. Dep:.of :sement 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
I, se VJtt(v .as Owner of the subject
property ry
hereby authorize ,, '71.40/k .-C-1.4_1:).
' I<•-rf;
to aq on my behalf, in aattrelative to work authorized by this building permit application.
�' dh92
ignalum of O.me/ Date
I. s?'v,fJ(s*.-••+ !) r Ge S'7e^ as Owner/Authorized
Agent her$**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.
D. tla rS
Print Nave
+tri / f 6/1/77
.'�nat of Owner/Agent
SECTION 8-CONSTRUCTION SERVICES
1.1 Li :peed Cons ctio [.1u• son Not Applicable CI
Name of License Holder: c ) •�/. Rd$S l J / //6
License Number
. , See let Center . xir.<..r '/ 4/'.2,941o/7
Address O/D4 D.... Expiration Date
-iay
a
Signature Telephone
/ Or
r e• .,.•me . •ro eu Conk ton. Not Applicable 0
4 _at r bad QY
Company arae Registration t4umbee
4 _ r _ . tk..,n.. , 040 3-41 '020113
Address Expiration Date
Teiephonegl3`SBy'/2.2
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 building permit.
Signed Affidavit Attached Yes O No ❑
11. Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied DweSines of one(t) 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 108.33.1.
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
stmctures.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 buildinf 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,you 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
A s CERTIFICATE OF LIABILITY INSURANCE via/tea
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{ies)must be endorsed. M 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(,).
PRODUCER CONTACTIIOyBarbara Grynkiewicz
Webber & Grinnell IAm"Ma Fre {913)585-0131 I FAX
No:(4/3)506-6441
B North Xing StreetADDREs3,bgrynkiewiczewebberandgrinnell.corn
INSURERIS)AFFORDING COVERAGE NAICY
Northampton MA 01060 INSURER A:Excelsior/Liberty ''! 11045
INSURED INSURER BA.I.14. Mutual
.......... _
Stephen Ross INSURER a
Attn: Kim Clairemont INSURER D:
36 Service Center Road INSURER E:
ampW
Northampton MA 01060 INSURER F:
COVERAGES CERTIFICATENUMBER:Exp 3/1/la 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 REOUIREMENF,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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR. TYPE OFINSVIUNCE 1
',tttlsUSR, "" POLIO fFF POLSYEYD I
LTRBAR I vivo' POLICY NUMBER (MMENMYYYII(MM00M(YY1 Loon
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
F L€TO ,N1EO
A CLAIMS-MADE i X OCCUR PREMISESTM 9Cmc Rree} .S 100,000
CBYB840898 311/201' 3/1/2015 1 MEOEXP(Any Doe person) IS 4.000
i PERSONALS ADV INJURY 15 1,000,000
GENT AGGREGATE LIMIT APPLIES PER'. GENERAL AGGREGATE ''.5 2,000,000
I POLICY' X JEGaT _,,,,,,,,, LOC PRODUCTS�COMP/OPAGO I5 2,000,000
OTHER. I5
AUTOMOBILELIABILITY I COMBINED SINGE?GMT 15
_sEss' t
` ANY AUTO BODILY INJURY(Pe/person) 5
ALL OWNED SCHEDULED 1 BODILY INJURY(Pm accident) S
AUTOS
^ ONOWN ED 1 PROPERTY OALTA
HIRED AUTOS
AUTOS I,'Peracailm6
S
UMBRELLA LIAS OCCUR I EACH OCCURRENCE I5
EXCESS LAB CWMSMADE AGGREGATE I5
DED RETENTION IS
WN'6RS COMPENSATION 1 .X 61 1UTE i Eft •
AROEWLOYRRS'LW80.RY
ANY PROPftkTORPARTNERIEXECUTwE YtX EL,EACH ACCIDENT $ 500,000
8 NFICERMEMSER EXCLUDED? IXIA: - I
m6Mry in um I . II1a6SB00B0065462016A 7/1/2016 7/1/201'! E.L.DISEASE-EAEMPLOYE615 500,000
If yin.DESCRIPTOR
UMe, ' ,EL.DISEASE-POLICY LIMM '.S. 500,000
DESCRIPTOR OF OPERATIONS*Mum I '
•
•
DESCRIPTION OF OPEIATONS I LOCATIONS/VEHICLES IACORO 101,AddItbnel Remarks Sub&&Ue.may be attached Nmore space is rpuk d)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
*PROD Insurance In£O Only** THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
R Webber, CIC CRIS/BA iCY tL.AO LT aie
@11988-2014ACORD CORPORATION. All rights reserved.
ACORD 25(2014)01) The ACORD name and logo are registered marks of ACORD
INS02S(Dwml
City of Northampton 212 Main Street, Northampton, DVLA 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: // 23 ` /2-J /CZ
The debris will be transported by: /17errzs.e A
The debris will be received by: / ey I� c C -
Building permit number: /
Name of Permit Applicant Sc�-G)�' 2-0S/ �-'Q
Date Signature of Permit Applicant