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38B-282 (3) 16 WINTHROP ST BP-2017-1391 GIS a: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-282 CITY OF NORTHAMPTON • Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: $iding BUILDING PERMIT Permit# BP-2017-1391 Project# JS-2017-002319 Est. Cost: $2175.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WILLIAM CORBETT 100136 Lot Size(su. ft.): 10410.84 Owner: GERSTLE KATHERINE&JENNIFER WERNER Zoning:URB(100)/ Applicant: WILLIAM CORBETT AT: 16 WINTHROP ST Applicant Address: Phone: Insurance: 16 UPPER HAMPDEN RD (413)267-4211 WC MONSONMA01057 ISSUED ON:6/1/2017 0:00:00 TO PERFORM THE FOLLOWING WORIL STRI P LEFT SIDE OF HOUSE 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: O1: 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 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner r .- City of Northampton Building Department rWI 3 1 1 212 Main Street Room 100 -- .� Northampton, MA 01060 0,7 -ghorte-413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 6 P—i7- /3 Z 1.1 Property Address: \ >•`s ssbtlon to Uetdnt office 1 kJ- WAV \\'N. 0‘t S\- -`""--,--- , , 1 b ' Lr7t ' t�2ik 'g.. SR (strict..''... - t4siigtricii- - SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: -Z.e.--, �7 1p2.—rte ce-....-- Name(Print) Current Mailing Address: Telephone /. `\` Signature .Grrypa 1V one 2.2 Authorized Agent: `` 1�.J.t \`i 0..._V--^.._ Co N1-�P\l l. LA , o•--V.4vr,9 )cy v Name(Print) Current Mailing A�dr s6 1 ass' VLA C.��� ( 3 a-101 — •(zt l Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building1 ci (a)Building Permit Fee 2. Electrical (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 /j V? 0 This.Section For Official Use Only Building Permit Number: hate Issued Signature: � �( / J 7 /-/ Building !�y Commissioner/Inspector of Buildings - -Date 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 % Open Space Footage % (Lot area minus bldg&raved 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 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW ® YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O 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)aver 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO 0 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 12 Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Eq Siding[O] Other[0] Brief Description of Proposed ` Work: �.. L.* ��`e O C['� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet a. Use of building:One Family )L 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 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 7a-.OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date n •¢ k. /J(R,- to e ,' ,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 Signature of Owner/Agent Date SECTION 8.-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: � Not Applicable 0 Name of License Holder'. �/ \ `\k GI.V�. C06-'(n�" `{. (e —t License Number y,x�aapS L s 64,cf - n L7 Address Expiration Date — L( ttL Signature Telephone &ma;/: M p w` to ale 1 ({ Z c l 3 j Li.t - =_itLs .. 'Let= Not Applicable 0 Company Name Registration Number 2S1 15 Com , � I (.P O 2°L3 Address ` '!� / Expiration Date {�� ■ 4 p CJ r `^r�Vh f��tot, �r,f-6-elephone 'Ltd] — \ �1 c G LD SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,:§25C(6)) I, 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 No 0 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 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 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 de State Building Code,City of Northampton Ordinances, State and Local Zoning Laws andState 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 150A. Address of the work: \ The debris will be transported by: 7vik The debris will be received by: Cyato Building permit number: Name of Permit Applicant C---t-Th GZ-v\.-- CO \J"- (44 Date Signature of Permit Applicant 1/4 The Commonwealth of Massachusetts w-== Department of Industrial Accidents ty Office of Investigations 1 Congress Street, Suite 100 w Boston,MA 02114-2017 %;; www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,, CC-4- 'j Please Print Legibly ' Name (Business/Organization/lndividual): v``K ` C-4 Address: lit c..��Qo..�r�c�.w .et-� 'al \ \'l.04NA.c % City/State/Zip: Phone#: Areyoou an employer?Check the appropriate box: Type of project(required): I.LWI am a employer with 4. ❑ lam 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 g, ❑ Demolition workingfor me in anycapacity. employees and have workers' P ty t 9. El Building addition [No workers' comp. insurance comp.insurance. 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 11.5 Plumbing repairs or additions myself [No workers' coin right of exemption per MGL Y R 12.5 Roof repairs insurance required.]f 152,§l(4),and we have no employees. [No workers' 13.H Other h comp.insurance required.] *Any applicant that checks box#I 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. 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'comppolicy 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: N-11t C ^4�rr Co`e Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: ` t-k t..1)t V _ccrt p 5\ City/State/Zip: '1' o Ov-s•-\^u....R kp(.- 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 under the pains and penalties of perjury that the information provided above is true and correct Signature: .-.� / C ir_ < Date: 5 Phone g: Z-(e,�1 Lt-L. t L 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 Massachusetts ¶1 tt.4. „waiH v c 2 { c ' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building �` 1g�' qC Northampton, MA 01060 4. 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/footings (before backfill). sonotube holes (before pour). a rough building inspection (before work is concealed), insulation inspection (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 \ Lz uD r � ^ or t3 0L.-- t-N e._v.,.�AOv ‘f," S • 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 ajoint 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 perfomrance 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 permitflicense 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 permits 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 Fax# 617-727-7749 Revised 7-2013 www.mass.gov/dia Massachusetts Department of Public Safety Board of Building Regulations and Standards License. CSSL-100136 ConstructiononSupervisor Specialty WILLIAM F CORBETT 16 UPPER HAMPDEN RD MONSON MA 01067 /n c' '1zz C_& L.. Expiration: Commissioner OT/23/2018 I. -11,15 . .j r „ 1. Office of Consumer Affairs&Business Regulation HINGE IMPROVEMENT CONTRACTOR I..; i; ROBIstsdonl 160293 Type: Expiration: 71972018 DBA Bin's Carpentry William Corbett 18 Upper Hampton Rd. Monson,MA 01057 Undersecretary ii 05/25/2017 00:26Richard Green Insurance trml.e.. .,wTaw.. Aconct CERTIFICATE OF LIABILITY INSURANCE 06PLEz 7 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS MO RIGHTS UPON THE CIR71PICATE HOLDER.TMS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TMS CERTIFICATE OF INSURANCE ODES NOT CONSTITUTE A CONTRACT SEMTEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: II the eertNlwd holder Is en ADDFDONAL INSURED,Vi.polkygM)must have ADOITIONAL INSURED provtelons or be Nldonad. U SUBROGATION 18 WAIVED,*Ant to the ISmu and tondhbns of the policy,seam polios*may»quire an endorsement A statement on this cenMoete does not tenter right*to the certificate holder in lieu a1such sndmaemtrODO. PacoVOEa Demeanor! Mallard R.Green Instant*Agency,Inc, (413)558402SI*ma(4141&M$-000 WE COM O*Ref Hampden,MA 01036 e, rnawnporerkhentgreeninaurenceMam PRIMING mellewO OIfVWMOE Mee mom,*E COMMERCE INS CO 34154 wauuo WIIIiem F Embett dba Bulb CarpMtly IN1p lMglal ASSOCIATED INDUSTRIES OF MA MUT INS 33188 tet/peer Hampden Rd weMMa: ' Monson,MA 010870747 , SIMM o: mummy er eean COVERAGES CERTIFICATE/UMBER: RECISION NUMBER: TIS 1S TO CERTIFY THAT THE POLICIES OP INMURAaTE LOTTED NUMONDcTI HAVE inn TO THE Munn NAMEN ABOVE PDR THE POLICY PERIOD INDICATED, NOT M4STAUE NC ANY REO T,TERM OR CONINTION OF ANY CONTRACT OR OMER DOCUMtOII PATH RESPECT TO t4 T THS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,TME INSURANCE AFFORDED BY THE POLICIES GESCRIEEO HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POUCIEL LIMITS SNOW!MAY HAVE BEEN REDUCED BY PAID CLAIMS nreprawrµvae AVOLIStIlw J PgtaYMmMA (OM A ✓COMMCRCIALs0S"AL wale( DOKTRW 10/10/201S 10/1012017 mssoccuNNEFece 1,000,000 }Cw ®acs roatMaret 100,000 — Woes,We one soma 2.000 PEWDNALsAwmnn 1,000,0001 9GIM1MMI� {RB uMITAPPPik OEWpAL.iDMeBMe 2,1100.-000 2 SOUCY 2LOT• I�I�LOC PMO.M-COMNOP MO 1,000,000 0114t A AUTMMOY%A LSMWn .11BMJ72 '06007/2018 OSIOTIZOD ;aAMfl®aMnper -s uttAWO �COOCKY INJURY IMrp*IMO I 100,000 J 'OCILT MAY IPVd9Va4M I 300,000 PHAND IXILY Pw°srea MP i 250.000 i IMAMS 4M CG:4N WE OSCMNMC1 i I I2U UUM CLAIM 4...D1 AZDgcAT5 I B an Pe 2411 `,M Ye VW C40OI020D02.2017A 04105/2017 w/051 216 A nn [RI' Apif' Ina watiermirsow Hearn, T© NiA ELEACNACC1pENt S 100,000 McMANryN Lt , eLOawAsa•M mROrEE I 100,000 ,Ihnanreatienrouea ese e.4 mew-Polio,ukirr E 500.000 aMaNMiMN RM INTMS I NMAMMMIWSW*Reese IM.MdMPWnorms NMtie.mar seeeeUUMISMMMMMUMe* Subject to pulley terra and oondtIoa, Sole Pnepdeter N euludsd from coverage under the Workers Compensation poky. CERTIFICATE HOLDER CANCELLATION Fax 0:(413)$S7-1272 SHOULD AMY OF THE MOVE OESCMSSD rotator MM D EELLED MSPORE THE ExPTRATION PATE TEAM NOTRAI Wm sE D*LIVE*E0 M City of Northampton ACCORDANCE W MENE POLICY PROVISIONS. 212 Main St NortMmpton.MA MOOD, AVmapasea eKEMnAnre 02, p, G 1/01.20016 ACORO CORPORATION. AR rights reserved. ACORD2$(2011143) The ACORO name and logo am regletsad marks otACCRb Sill's Carpentry S 3 % 9 59 Residential Roofn/Siding ,. ..• ir-.7a CVk 45°c The Boss 16 Upper Hampden Road Monson,MA 01057 Office: (413)267-4211 Cell: (413)668-4410 Far (413)2674211 Fully Inured MA License#CSSL100136 Reg#160293 CONTRACT Fully Insured MA License #CSSLI00136 Reg# 160293 Name: Jen Werner Address: 16 Winthrop Street City: Northampton State: MA Zip: Finail: jenwemer®usa.net Cell Phone: Cost Strip roof on left side of main Install 6 feet icc and water barrier Install underlayment Install white drip and rake edge Install vent on peak Re-cut vent on peak Install 30 year shingle Remove all debris from job site Total $2,175.00 I/2 don $1,100.00/remainder 51,075.06 on eamrpktion or job. \10, gg����1rree I�Il--a/��� 5/2 7�/ 7 r 1 rte'" Date Signature Date