17C-079 (4) 37 HIGH ST BP-2017-1356
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-079 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2017-1356
Project# JS-2017-002253
Est.Cost: $6219.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
• Const.Class. Contractor: License:
Use Group: ANDREW STEVENS 81380
Lot Size(sq. ft.): 8232.84 Owner: PURSEGLOVE HAVELOCK J III&FRANCES M
Zoning: URB(100)/ Applicant: ANDREW STEVENS
AT: 37 HIGH ST
Applicant Address: Phone: Insurance:
815 WEST MAIN ST (413) 743-5394 WC
P LAI N F I E L D MA01070 ISSUED ON:5/22/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE OLD PT DECKING AND REPLACE
WITH TREX DECKING, NOT TOUCHING EXISTING FRAMING OF DECK
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 5/22/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
. '.-� DeFe:Mont use ady
City of Northampton Status o&Permit
�Vk Building Department CCuffsCutfOnvewuyPermit
�
212 Main Street Sewer/Septic Availability
\\ < 4 Room 100 WsbrANallA
` Northampton, MA 01060 Two Setsofatflict,el Plans
\\\\ phone 413-587-1240 Fax 413-587-1272 PMV&te Plana
Other Speedy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address' `/Thissection to be completed7by office
Si HICaw. Sr" Mao ( /e /
. Lot 9‘ Unit
-no,,,'4CL, Mpg. . Ol Ok+k Zone Overlay District
Elm St.District CE District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Haveloc J Purseglove III 37 High St. Florence,Ma.01062
Nac).(P Current Mailing Address: 413.584-840(1
----'-'` Telephone
nature
2.2 Authorized Agent:
413-743-5394 PftD u ST L/�-rxy 413-743-5394 SW 44. Moo/ 4r V\s{ni Irt,/t
Name(Pmt) Curtent Mailing Address: yyi p, crp~)a
f ee---'� ...... 413-743-5394
Signature - Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
(12215 . tk
2. Electncai (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5.Fire Protection
6. Total=(1 +2+3+4 +5) Check Number/ U � #(P6
ThiSection For Official Use Only
Building Permit Number: Data
/ Issued:
Signature: ._.. / ,,,Jtl� /<,f�/ ? n0" /7
Building Canmissionedtnspectorr of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors O
Accessory Bldg. ❑ Demolition El New Signs [O) Decks [p Siding[O] Other[0]
Brief Description of Proposed / � 1-070-00„0".;07��// /
Work:knm.e and Pd.
T. .k m„x erri> n r
.ma „.decking.N brag earwig framing ardeck. - r( 11) che'
J/"
Alteration of existing bedroom Yes no No Adding new bedroom Yes no No
Attached Narrative Renovating unfinished basement Yes no No
Plans Attached Roll -Sheet
sa.If New house and or addition to existing housing.complete the following:
a. Use of building: One Family X Two Family Other n>"'ra"d"k
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? No
d. Proposed Square footage of new construction. NA Dimensions NA
e. Number of stories? NA
f. Method of heating? NA Fireplaces or Woodstoves NA Number of each NA
g. Energy Conservation Compliance.NA Masscheck Energy Compliance form attached? NA
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes X 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 X
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING
�P'ERMIT
I, //avelOCf< s . Pus /O V'e- yT ,as Owner of the subject
property LJ
hereby auth ' eIA OP r ST-9..I YI/L4.
to act my alfa i .1 a ers relative to work authorized by this building permit applicatiiAon,y..
Si ature of Owner Date
I l
I, Q &. .--�7 C_CS ,as 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 perjury.
Print Name
2—._...17.o.1j- am C• 2z, C7
Signature of Owner/Agent Dale
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: 31 Ntc,ti- ST Co2Evrc vv10-
The debris will be transported by:
The debris will be received by: yl ,ir.a..,,frc,.&
Building permit number
Name of Permit Applicant 11--uiOcZt1/4 J Sj�3n'A
Date Signature of Permit Applicant
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage a/
Open Space Footage
(1n1 area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW O YES O
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 Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES O
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 O 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 O
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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152. §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future pemiits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax # 617-727-7749
www.mass.govldia
City of Northampton
S
• Massachusetts Fes ,y G
G
tt ,e�' ' DEPARTMENT OF BUILDING INSPECTIONS ~Air
;
212 Main Street • Municipal Building
Northampton, NA 01060 se iat O4
L=iT
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION 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 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 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/footinas (before backfill). sonotube holes (before Dour) a rough building inspection
(before work is concealed), insulation ins eD coon (if required) 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)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor c Not Applicableic20
Name of License Holder'. Hy7QL:fiJ
v
L:4-4 L. ) t+-ll�v�j Eft -aQ
License Number
Ste itik61v\ 57 TIJMvwcacr cm,A. CtVzc 7izlzz�J
Address Expiration Date
C -..\), —r 413- 743 ¶�4q
Signature / Telephone I
t owi/ £ Co„ , ('a,„,c4- 6) c3. A ik-v
9.Registered Home Improvement Contractor: L Not Applicable 0
aAo2r,:r t� � ��� 15-0c-a
Companyny Name r Registration Number
4
( h( � CoCU VI S�V"Ut�£'F()rl ., P/t Le) "ZC�t 1
-----
Address rn�f^1' rrII t, .I t(,I Excitation(rate
V 1 5 \Q1� �'s'ltA,l i < -k Q1n tvif Telephone413^7A3.-5'
M a nht 70
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.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 X No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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,oris 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 be considered a homeowner.
Stich"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,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
STEAN-1 OP ID:JN
saCfaJRO CERTIFICATE OF LIABILITY INSURANCE DATE
YVYfl
05/22/2017
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: N the certificate holder is an ADDITIONAL INSURED, the policy(les)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 CONTACT
GREYLOCK-NORTH COUNTY xANe Julie Nichols
GREYLOCK INSURANCE AGENCYINC rio Em:413-663 576 FAX 413-664-7558
Nep 413464.7558
66 MAIN ST. EWAL
NORTH ADAMS,MA 01247 ADDRESS:
Julie Nichols INSURER(S)AFFORDING COVERAGE NAC
INSURER A:Atlantic Casualty Insurance Co
INSURED Andrew Stevens INSURER a:Liberty Mutual
dba 4County Const
815 West Main Street INSURER C:
Plainfield,MA 01070 INSURERD:
INSURER E: ---INSURER F
COVERAGES CERTIFICATE NUMBER: 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 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY EXP
MTTRR TYPE Of INSURANCE /ASDp MVP POLICY NUMBER PMIODYFSF MWODI'YYY
IMMUCYEYT] IPOLICYYEYl1 LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 300,000
CLAIMS-MADE X OCCUR M276000038 09/09/2018 09/09/2017 DA^'V`6ETONLNIEU 100,000
PREMISES IEa arunenul
MED Err(My one Person) 5,000
j PERSONAL B ADV INJURY 300,000
GENT AGGREGATE LIMIT APPLIES PER- GENERAL AGGREGATE 600,000
POLICY iJECT LOC PRODUCTS-COMP/OP AGG 600,000
OTHER:
AUTOMOBILE LLAMLRY COMBINED SINGLE LIMIT
(Ea aWLeU
AAV AUTO BODILY INJURY(Pe,Person)
ALL OWNED SCHEDULED
AUTOS BODILY INJURY(Per accident)NON-O
HIRED AUTOS
NON-OWNED PROPERTY DAMAGE
AUTOS
AUTOS (Per aulden0
UMBRELLA LIAR _ OCCUR EACH OCCURRENCE
EXCESS UM CLAIMS-MADE
AGGREGATE
DEC RETENTIONS
WORKERS COMPENSATOR PER 0TH-
ANDEMPLOYERS'LIABILITY STATUTE ER
B �IPROPRIIETR/PAER RTNEEEo�CUTIVE YI I�IN(A WC2315613251016 07/09/2016 07/09/2017 E.L,EACH ACCIDENT 500,000
(Mendabrm NH) I I EL.DISEASE.FA EMPLOYEE 500,000
N yea.deamoe under
DESCRIPTION CF OPERATIONS below E.L.DISEASE-POLICY LIMIT 500,000
DESCRIPTOROF OPEFLATONS FS M AdditionalSchedule, hENspace NnpulMl
ANDREW STEVENS IS EXCLUDED FROM WORKERS COMPENSATION BENEFITS.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF NORTHAMPTON THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
NORTHAMPTON, MA 0100 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
AO tits.)
lb 1968-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
art .
_'— h Department of Industrial Accidents
.
'_
MINIM
Office of Investigations
{ NI0 I Congress Street, Suite 100
1413441Boston, MA 02114-2017
� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Rosiness/Organiration/lndividual): Andy Stevens DBA 4 County Construction
Address:815 West Main St.
City/State/Zip:Plainfield, Ma. 01070 Phone #:413-743-5394
Are you an employer? Check the appropriate box:
Type of project(required):
I.❑ 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
listed on the attached sheet. 7. ❑Remodeling
2.® I am a sole proprietor or partner-
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. insurances 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions
myself [No workers' right of exemption per MGL
Y comp. 12.0 Roof repairs
insurance required.] I c. 152, §1(4),and we have no re-surface deck
employees. [No workers'
13.11 other
comp. insurance required.]
*Any applicant hat checks box 41 must also fill out the section below showing their workers'compensation policy information.
r Homeowners 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.
Insurance Company Name:
Policy#or Self-ins. Lie. #: 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 5250.00 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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature: ( - �—J� Date: C. ` �2' 11
Phone#: 4U3, - -14-4 , 4Th 9 4
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#: