22D-101 89 BLISS ST (wrong map block on card) (3) 89 BLISS ST BP-2017-1386
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:35 -040 CITY OF NORTHAMPTON
Lot: - PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2017-1386
Project# JS-2017-002311
Est.Cost: $53000.00
Fee:$344.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
SHAUN GIBERSON 149915
Lot Size(sq. ft.): 485415.00 Owner: COYLE DANIEL
Zoning: SR/WSPII Applicant: SHAUN GIBERSON
AT: 89 BLISS ST
Applicant Address: Phone: Insurance:
PO BOX 2178 (413) 237-4048 WC
WESTFIELDMA01086 ISSUED ON:6/1/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:FRAME NEW WALLS, DRYWALL, ADD STAIRS
TO ATTIC, NEW FLOORING, NEW KITCHEN CABINETS
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/I 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 6/1/2017 0:00:00 $344.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1386
APPLICANT/CONTACT PERSON SHAUN GIBERSON
ADDRESS/PHONE PO BOX 2178 WESTFIELD (413)237-4048
PROPERTY LOCATION 89 BLISS ST
MAP 35 PARCEL 040 ZONE SR/WSPII
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT AP• - CHECKLIST
EN LPSED REQUIRED DATE
ZONING Fri RM FI LED OUT
Fee Paid
Building Permit Filled out
Fee Paid
_Tvoeof Construction: FRAME NEW WALLS,D: ,ADD STAIRS TO A tIC,NEW FLOORING,NEW
KITCHEN CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 149915
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOOIATION PRESENTED:
//Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:$_
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 8c 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
Del olition D
—A/ yalleY
Sig and MI] • i'ci 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 St Development for more information.
3 Department use only
I i it City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
p>
oc212 Main Street Sewer/Septic Ava labMy
-
---'�" Room 100 WatoNWell AvadaWlity
Northampton, MA 01060 Two Sets of Structural Mans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plane!"_,,,,_
Other Specify_—
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be(co� mpleted by office
1.1 property Address:
89 $I ss S+reek Lot t V M� Ali 1
l Unit
Viorenee MA
Zone Overlay District_,
Elm St District„ CB Distdct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
"Dc I Co It 69 BIrSS 3-geek Florence MA
N., , 4 Ma '.
Current Merging Address
01. Telephone
2.2 Authorized Agent:
Sn (j ;berSGn _
FOSOx at-& Wts+;c¢a IY}r1 °"18(a°"18(aNamn(Print) Current Mailing Adtlres9'.
JjJSl n 9'12, 237 - tit y8
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building aqr 000 t,_ (a)Building Permit Fee
2. Electrical S 000k_ (b)Estimated Total Cost of
Construction from(6)
3. Plumbing $ Goo,— Building Permit Fee
4. Mechanical(HVAC) %ODD /�
5.Fire Protection
O _ �( (/a
6. Total=(1 +2+3+4+5) — 53, Coo Check Number LIPS ri`-/' !
This Section For Official Use Only
Date
Building Permit Number: — Issued: „_...
Signature:
Building Commissioner/Inspector of Buildings Date
�f13 _ d oy 2c 69 - Canl
Section 4. ZONING Alt 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 l e• 18' _ ...
Bldg.Square FootageOpen Space Footage
(lot area minus bldg&pour/
parking)
ti of Parking Spaces a oZ
Fill:
(volume&Location) ..
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW g YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
ND Q DONT KNOW e YES a
IF YES: enter Book Page and/or Document N
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained O , Date Issued:
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. 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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [J Addition [J Replacement Windows Alteration(s) b[� Roofing n
Or Doors 0
Accessory Bldg. 0 Demolition RI New Signs [O] Decks [O Siding(p) Other([7)
Brief Description�� of Proposed
Work: Frownp mew vglls . dry,.,all 404) 540.(r$ 41, `v44-:C r 111W ckgs the ntW tti 4cktn tala.eitt
Alteration of existing bedroom if Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet mat'"nq Ir earn ... ry krallsrwn .yt
W.If New house and or addition to existing housing.complete the following:
a. Use of building'. One Famly 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 _
e. Number of stories? ....
f, Method of heating? Fireplaces or Woodstoves Number of each
q. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
It Type of construction,
i. is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain._,,,_Yes No
I. 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 7a-OWNER AUTHORIZATION•TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Daniel Coyle _,.. ,as Owner of the subject
property 4,, Coyle
hereby authorize Shaun V Ib rson ..
::et on my be -If,in all matters relative to work authorized by this building permit application.
L 4.. - 5 - 31-1'7
.Signature . • Date
I, Shaun Gi bersov ,as Owner/Authorized
Agent hereby declare that the statements and infomtation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under he pains and penalties of perjury.
Shaun Gbecso�
Print Name /{��,� � �.
.�i.�.wAry .l••/•.1.S t so^rn 5 - 31 - 17
Signature of OwnerlAgent Date.. .—..._
SECTION 8-CONSTRUCTION SERVICES
8A Licensed Construction Supurvisor. Not Applicable ❑
Name or License Holder Shaun C4, .'j'.�r t/eOn t5 - Ob3ai0
License Number
'Do Bo< at-7E we514;a13 Mil aro% ta - 9 -(7
Address Expiration Date
gym �1Y9t dot
403-t3'7-90V9
Signature Telephone
9.Registered Home Improvement Contractor Not Applicable ❑
�ibersor, Con sf+'Qc-tloin Inc. ._.. ty49l5
Company Name Registration Number
90 sox ane we, c;eth ) t'114 arose a- at-16
Address
SessExpiration Date
L �I ��iU/ \ -1341.
Telephone `113-tri-40`10
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MAI.C.152,§25C(e)) 1
Workers Compensation insurance affidavit must be completed and submitted with this applicafion.Failure to provide this affidavit will result
in the denial of the issuance of the building permit. _
Signed Affidavit Attached Yes d No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwefines 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 act;
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-war 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 week 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
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 150k
Address of the work: 89 14S 51-res-1- Fiorenoe , MA
The debris will be transported by: Ca•npleft Asposm I ChzopM
The debris will be received by: MC Names , 5`2J
Building permit number
Name of Permit Applicant DoanW Coy
5 - 3 I- I"7 �.ktaur--
Date Signature of Permit Applicant
fi
City of Northampton
5 a,
Massachusetts
tAct
I { (Myr b DEPARTMENT OF BUILDING INSPECTIONS
*`
212 Hain Street a Hnnlcipal eailaing
Northampton, KA 01860 tPn En,C°
Fee Calculator for Residential Properties
Location : 89 $7l c53 5+ree4 Florence M 39
Square Footage Amount
Basement @ .20
1ST Floor @ .50 99Q si P. f 490, °O
2°4 Floor @ .50
Y Floors, Finish Attic, Garage @ .20
Deck ! Porches @ .20
Total : d `I`l0, --
' The Commonwealth of Massachusetts
amt.=
Department of Industrial Accidents
Office of Investigations
�fb 600 Washington Street
es
sum d
3." y Boston, MA 02111
kkt
.� www.mass.govfdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �^ may_ Please Print Legibly
Name(Business/Organization/individual): GI ber3Qr1 Con*QCI) on SAG
Address: 4)o b nX h?8 �..._.. _ _.._.. ...—
city/state/zip: WetA-Aela ,trig (AV, Phone #: yi3-a37-ypy8
Arejou an employer?Check the appropriate box: 1 Type of project(required):
L 14 I am a employer with Li 4. U (am a general contractor and 1
6. 0 New ew construction
employees(full and/or part-time).* have hired the sub-contractors
2[i I ship
asole proprietor
lo partners
listed on the attached sheet.t 7. , Remodeling
shipand have no employees These sub-contractors have S. 0 Demolition
workingfor me in anycapacity. workers' comp.insurance.
H. ❑Building addition
[No n
workers'comp.
.insurance 5. We are a corporation and its
required.]
.] officers have exercised their i4��Electrical repairs or additions
3.L] I am a homeowner doing all work right of exemption per MOL I' [1 Plumbing repairs or additions
myself.(No workers'comp. c. 152, *1(4),and we have no 12.0 Roof repairs
insurance required.]' employees. [No workers'
comp. insurance required.] 13.(3Other
"Any applicant hat checks box el must also fill out the section below showing their workers.compensation pOii q information.
`Homeowners who submit this alit it indicating they are doing all work and then hire outside contractors mus submit a ne\s artlda.it;Skating such.
:contractors that check this box must attached an additional sheet shots Mg the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
insurance Company P Y Name: ] f1`1 ryl,h,q1 fin_$; ..._.._... _._
Policy#or Self-ins.Lie.#: rC1wQ lot a. 733 Oi a01e Expiration Date: 5- Ib - 16
Job Silo Address: 89 BiCss 64teel- Florence , MA _._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
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
ceerttffyunder the pains,,,,a,,�nddnpenalties of perjury that the information provided above is true and correct.
Signature:a'.0 r I LNttG Jalikkosses _...-_ Dates 5- 3i-tr./
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.CitytTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other _.._._.__.._..�..�._
Contact Person: Phone ho
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
AIM. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800)876-2765 NCO NO 26158
POLICY NO. AWC-40077012953-2017A
PRIOR NO. AWC-400-7012953-2016A
The Insured: Giberson Construction Inc
DBA:
Mailing address: P 0 Box 2178 FEIN:"'"'3640
Westfield, MA 01086
i.egal Entity Type: Corporation
kplaces not shown above: See Location
The policy period is from 05/16/2017 to 05/16/2018 12:01 a.m.standard time at the insureds mailing address.
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liability insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ _ 100,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
The premium for this policy will be determined by our Manuals of Rules, Classifications,Rates and Rating Plans.
AU information required below is subject to verification and change by audit.
ossifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
•
TRA 264086
ITER SEE CLASS CODE SCHEDULE
Premium $500 Total Estimated Annual Premium $6,022
--- Deposit Premium $6295
GOL/
CLASS
5645_ State Assessments/Surcharges
____ $6.603.00 x 5.6000! $370
L Lk C e�,_()
;y, including all entlorsements, is hereby countersigned by Date
-'- 04/19/2017Da
Authorized Signature e
)ffice: Roger Butler Ins Agency Inc
Avenue P 0 Box 816
n MA 01803 Westfield, MA 01086
001 A{7-11)
spyrigbted material of the National Council on Compensation Insurance,
is permission.
//�� r-I1?, «li//tw it/, 0/ C /ir,. .,{f(/U;(J77
tie= Office of Consumer Affairs and Business Regulation
*Wm- 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 149915
Type'. Public Corporation
Explratlan_ 2/21/2018 Trk 27401
GIBERSON CONTRUCTION INC
SHAUN GIBERSON
POBOX 2178
WESTFIELD, MA 01086 - - - - " - -- - - - -
Update Address and return ea/ft Mark reason for el
Address " Renewal Employment La
_Office of Consumer Affairs&Rosiness Regulation License or registration valid for individut use only
^- 1OME IMPROVEMENT CONTRACTOR before the expiration date if found return to:
_ _C:*egistration: 149915 Type: Office of Consumer Affairs and Business Regulation
Expiration: 2121/2018 Public Corporatior 10 Park Plaza-Suite 5170
Boston,DMA 02116
31BERSON CONTRUCTION INC
IHAUN GIBERSON
21 FOWLER RD- ,yl . • 4.X.Ci lawn
VESTPIELD,MA 01085 I.ndemeeretmrs Not valid without signature
Uttassacnusetts ,eraR: = q
�W.t 30a,11of9 r) g . quFat -+s i JSia :vis
_
cr.-.4e, CS-063210
SHAUN C GIBERSON
PO BOX 2178 11�!
WESTFIELD MA 01086
12/09/2017
�II
;I
�-Y�� I
�ScM@ttlThI III
C>
( — Ir
p -M �.�.-� — _ L IL._ 1 4 _k
,,_ � 1 � 1 �t
; 1 I .� .
I v 1 I : 1 )1 i'- � - —�
Se%Epntp 1 , v 1H
c(iC� 1I n . -II 5- T *I
�1 .�� I. 1 . . ..4:cti: xs i- \—�_1 i I I1 �
I
III Ct - �11 1. / r 1 1
I II S ul � ,� i !
IIS zi 0.1. A � :-:04,-..:<•:-.*:-��1 I� i t
x NA 1
i ,
III
1LI r
[ f04lM1fi t I I I '
11 I �
1 I �I I I , I 1 I
III I _7 h
1 1 i `I - 41 , :� 1 I �� i 1 I 11 �'
11 I .1 L 1 ; �_ r Y I1
II
II 1
II 1
A ✓ I I — I .I
/'� is
Lu=. ,r,x,- . r
S �rY/ ,11')--> City of Northampton
graz � i7