23A-183 10 PINE ST BP-2017-1416
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 183 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2017-1416
Project# JS-2017-002349
Est.Cost:$98000.00
Fee: $198.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: WILLIAM LABOMBARD 060247
Lot Size(sq. ft.): 5880.60 Owner: CONTRADA FRED&AXELROD JOAN
Zoning: ORB(100)/ Applicant: WILLIAM LABOMBARD
AT: 10 PINE ST
Applicant Address: Phone: Insurance:
204 MAIN ST APT 1 (413) 687-7946 0 WC
NORTH F IELDMA01360 ISSUED ON:6/9/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:BEDROOM AND BATH ADDITION FOR
DISABLED CLIENT
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 Occu a anc Si!nature:
FeeType: Date Paid: Amount:
Building 6/9/2017 0:00:00 $198.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1416 �"'�
APPLICANT/CONTACT PERSON WILLIAM LABOMBARD
ADDRESS/PHONE 204 MAIN ST APT 1 NORTHFIELD (413)687-7946 0
PROPERTY LOCATION 10 PINE ST
MAP 23A PARCEL 183 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCL -D (WIRED DATE
ZONING FORM FILLED OUT /I
Fee Paid ll@
Building Permit Filled out [
Fee Paid t
Typeof Construction: BEDROOM AND BATH ADDITION F n )1SABLED CLIENT
New Construction
Non Structural interior renovations
Addition to Existing
_ Accessory Structure
Building Plans Included:
Owner/Statement or License 060247
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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 Nan
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
Demolition lay
,/ 1 � 7/'
Signa of Bulls ing 6 ficial 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.
Department use only
Nr� City of Northampton 3tatusofPattnt
Building Department Curb CutOrtveayPerme
r, .CJ 212 Main Street Sewer/SepbcAyallabdity
Room 100 WatermelfAy18mb*y
\ " Northampton, MA 01060 Two Sets of Sknrdura;Piens:
phone 413-587-1240 Fax 413-587-1272 PloYSite Plans
_ _ ONer'SeBFY
=1
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLIS/HA ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 0nnf" ) ,oi e g7#.7, "Dftliti I*
1.1 Property Address. Thos section to be Weted by office
(-\ Map ..)”71 Lot /✓P Unit
/J
[Ike 31. n'V C M. Zone Oyeday District
Elm St District CE District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Recor :
S1 { XNIro I'nl� Ea 1~ iki „/4 Jo by � , n(e A.
Name(Pont) i' 7 Current Malting Address:
// Telephone
Signature
2. ,uor' ed • gent: 1
//,"
(
Name(Print // Current Mailing Address:
az(C ,:eci Ni 3 -)SD - 49397 ___
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building %3 5 - 00 (a)Building Permit Fee
2. Electrical ?�/ �2') - CO (b)Estimated Total Cost of
f Construction from(6)
3. Plumbing LiI;OG co.) Building Permit Fee
4. Mechanical(HVAC) Api D 00, CC)
5.Fire Protection s 1
6. Total=(1 +2+3+4*5) y F Gt-c . cc Check Number /( ,�
! This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Budding Commissioner/Inspector at Buildings Date
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Budding Dgqutment
Lot Size
Frontage (9C
Setbacks Front
Side L: R: L:. R: .
Rear
Building Height l 4 1
Bldg.Square Footage - ,o JS(a�
Open Space Footage Ott
(Lei area minus bldg&paved
prolong)
#of Parking Spaces 3
Fill:
(volume&Location)
A. Has a Special Peermit/Variance/Finding ver been issued for/on the site?
NO 0 DONT KNOW YES O
IF YES,date issued:
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO 0 DONT KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained fl Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES O NO 12/
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 of
IF YES, describe size, type and Location:
E. WII the construction activity disturb(clearing, grading ex tion, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 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 0 Addition tY_i Replacement Windows Alteration(s) Q Roofing ID
Or Doors O
Accessory Blldd�g. 0 Demolition
p,�❑f,j New�/ Signs IDI Decks/jICI Siding ID] Other IC]
Brief ro os dj a h 4A,ii,on f .;/i. . nt ...—. .....
Alteration of existing bedroom Yes V No Adding new bedroom Y Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rol! -Sheet
sa. If New house and or addition to existing housing,complete the following:
a. Use of building One Family f Two Family Other_ ^h�
b. Number of rooms in each family 1unit': Number of Bathrooms rT
c. Is there a garage attached? J,1Q_ (�/ (, } f
d. Proposed Square footage of new construction. e96 Dimensions /O X dv)
/e. Number of stones?
1. Method of heating?Otl holts.Al(P } yyf.rtrD'0b f Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction &lp!/!•44I
is construction within 140 ft. of wetlands? Yes /' No. Is construction within 100 yr. floodplain Yes Y No
Depth of basement or cellar floor below finished grade =f r /_
k. Will building conform to the Building and Zoning regulations? 4? Yes .. No.//
I. Septic Tank_ City Sewer kt Private well City water Supply !cam
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTORJAPPLIES FOR
,[BUILDING
PERMIT
I, -2;lM /T Oro/-6hIc A -t Y/z'G( 6iir474 , as Owner of the subject
property /,� 1 J lid hereby authorize h✓.�/r4m 44. 11f/9AP4-f
to act on my behalf,in all matters rp,Jative t auth.,tzed by thi . tiding permit application.
wisiameasmisSignature oDate
f owner 1 /t,
I, /rr W/4Ha (...i M LJec/Jrt
�,{��q 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 pen es of jury.di
Paz! ocgni,
\n' ..-/7
Signature � 0 en! Date
SECTION 8-CONSTRUCTION SERVICES
8,1 Licensed Construction Supervisor: //p f/t, Not Applicable 0
Named License Holder,.___a),14&t 4 4L5e ( s"Cr,r
License Number
-Ta �t Aid ffi Ge rt? 13�l CS- 6(20_ )4*7
AddressExpiration Date
4:401f.
:4 `eat / 1( 43 -6,c.2 -l7' / 1
SLq ture Telephone , 6/ ` / da/�
4.Rewhtered Nome lmmo Not Applicable 0
sirMoia f a - ic ./14.5-13 _
tat.- Registration Number
_►., i )o3 a;ntW f z ecll� �^/dt a aa'
Address 1 1 Expiration Date
Telephone /13 +.1 yy7
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*II result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes j@" No 0
11. —Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-wonted 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 10$,3.5.1
Definition of Homeowner: Person(s)who own a parcel of and 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
stnx:hpes.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 Ifabl§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 150A.
Address of the work: /U 12:11 ( fri aCntc2 //(41
The debris will be transported by: �� - / C 1 U r e P
The debris will be received by:
Building permit number:
Name of Permit Applicant A07 1.4" )vih �2
111 I414
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
.-- t
`kh,� Office of Investigations
= `- 600 Washington Street
=_ i_.te
: y Boston,MA 02111
`0r,r; www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information p /, Please Print Legibly
Name (Business/Organization/Individual): 4 ..fit f lkce 18il r/' rtrr nnc.
Address; )03 e; ^"'t.. fj
city/State/Zip: ''4 ;e Li f Cifie Phone#: `61322 S-- JoY,;
Are y an employer? Check the appropriate box: Type of project(required):
L I am a employer with 2 4. ❑ 1 am a general contractor and t 6. 0 New construction
employees(Full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. EBuilding addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
10.0 Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MOL 11,0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑Roof repairs
insurance required.] ' employees. [No workers' 17.0 Other
comp, insurance required.] �
'Any applicant that checks box WI must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such.
',Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and their workers'comp.policy information.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. /
Insurance Company Name: '-r-u7vciccc' �coffgd'ir /.{tin$un//rY 6. d,1 ;es !_ / /__
Policy#or Self-ins, Lie.f #: / PrJ^^L"b l it//.7 36 4Y/b Expiration Date: 10 r�//dnr f7
Job Site Address: !o ?"!t dt ReiretLt City!StateiZip:_ C /O
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 pwirry and rallies of perjury that the information provided above is true and correct
Signature: U %4 . t✓t:'a.> r =CG' Date: — /`- L'S//
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):
I.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Ra CERTIFICATE OF LIABILITY INSURANCE OATEINMIWMYt
06/05/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THI
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZEI
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(1es)must be endorsed. If SUBROGATION IS WAIVED,subject n
the tents and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to th
certificate holder In lieu of such endoraement(s).
PRODUCER CONTACT
atom Dakota Klin
ii
A H RIST INSURANCE AGENCY INC PHONE . 0113) AX
I 1u moo ), ___
ppm'MAI'IAc:Lo w.dakota hastcom
P 0 BOX 391INSURERf81 AFFORDING COVERAGE i AMCA
_._—__________
TURNER FALLS MA 01376 INSURERn TRAVELERS PROPERTY CAS CO OF AM 25674
INSURED INSURER -
R
AGING IN PLACE BUILDERS INC msuwrRC: _1
INSURER O: —.—---_—i—
203 BIRNAM ROAD INSURERS:
NORTHFIELD MA 01360 iesuREa F I 1
COVERAGES CERTIFICATE NUMBER: 160967 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 OP 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.
DI$Rr —`naat—stleR- -T POuCYE£C POLICY ESP I -..
oral TYPE OF INSURANCE EINeD YAM POLICY NUMBER (MMDEAYS,+l (MMNOCKYY1 OATS
_I COMEERCIALGENERAL LU61ttry I EACH OCCURRENCE $ _ _
_ j CLAIMSMAOE L��OCCUR PPREMISEEu'J uccur_r �E
I
�.I ..._ MEiE%P(Pay IP±P..eBEE E
„_ _,___) N/A iPERSONAL& ADAINJURY I£ _.____
GEN'L AGGREGATE LIMIT APPLIES PER. I GENERAL AGGREGATE E
POLICY r IFERO- �J LOC L RODUCrs- A3G I _—_—
_ COMMA AOC £
OTHER: S
1AUTOMOBRELUAWUT OMEN SINGLEI,IMIT $
—1 IOODdde 9 __—
ANY AUTO r
AURA
NJURY(PN reMn) E
I ALL OWNED t SCHEDULE _.
_ AUTO AUTOS N/A �i1GD(LYINNRY(Per E E.
I NON-OWNED blI FI�1�Gfi—s
HIRED AUTOS I AUTOSa�a�__ _
1_1 £
I
1 H UMBRELLAUAB I OCCUR j I �I EACHOCCURRENck__ £ ___
L_ CLAIMS-MADE,' tI
WORKERS EXCESS oNs N/A I AGGREGATE s
O- I RETENTIONS 18
RS COMPENSATION iX PEA 'OhL
'AND EMPLOYERS LIAMITY I ,TATIRE L fR_
A OFPICEERMEMSEREANYPROPRIETORRXGINIJDEatri VE WAIN/A WA 7PJUB7H75366A16 10/28/2016110/28/2017 -EL_EAcn ACCIDENTmss 100,000
I(MaMMory in NH) 1 1EL.DSEASE-EA EMPLOYEES 100,000
rt dmlm Ander —'--
[DESCRIPTION OFOPERATIONS below ELOISEASE-IIOLICYOMIT IS 500,000
1 1 I
II N/A I 1
1 I
DESCRIPT ON OF OPERATIONS/LOCATIONS I VEHICLES(ACORB 101.Aeytiata Remarks 5ChSuk.now be attached Moore space in required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage'Coverage Verification
Search tool at www.mass.gov/Iwd/workers-compensationl'Nwesigationsl.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Northampton Building Dept ACCORDANCE WRHTHE POLICY PROVISIONS,
212 Main St Room 100
AUTHORIZED REPRESENTATIVE
Northampton MA 01060 "k c
I Daniel M.G y,CPCU,Vice President-Residual Market-WCRIBMA
CD 1088-2014 ACORD CORPORATION. Alt rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of Acorn)
® hlassacluser's
Boara or fia 4e0w3l s marnaos
e=se CS-06O247
n s'zllcU9 S,, er?sCr
WILLIAM W LABOMBARD
2 SOUTH STREET
PO BOX 406
MONTAGUE MA 01361
Ss e)^.2- 06/062018
:..Office of Consumer Affairs&Busmen Reg of Iion
`1r NOME IMPROVEMENT CONTRACTOR
Registration: 114593 Type:
Expiration: 10J612017 IndvIduaI
WILLIAM W.LaBOMBARD
WILLIAM LaSOMBARD
37 Pine Street •
Northfield.MA 01360 I nJcnrcrei .'
5 . s >s•43'Sr w sa.00• sC`rta
wooden
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pvr FRED CONTRADA & JOAN AXELROD
BOOK 3479. PAGE 97
Oink
d PICng
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w/o
.3 porch /
80.05' 90.88'
N 720747" E ..
PINE STREET
FOUND IRON PIN NORTHAMPTON, MASSACHUSETTS
UNMARKED POINT
FRED CONTRADA & JOAN AXELROD
RANO: y
ER
IZE
135032
0' 20' 40' b0'
____
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