35-242 (7) 39 LADYSLIPPER LN BP-2017-1360
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-242 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-1360
Project JS-2017-002264
Est.Cost: $5000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BARRON & JACOBS 60475
Lot size(so. ft.): 60984.00 Owner: KITTREDGE ADAM&J1LLIAN
zoning: Applicant: BARRON & JACOBS
AT: 39 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
70 OLD SOUTH ST (413)586-8998 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:5/24/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR SHINGLES OVER GARAGE, DAMAGED
PORTION ONLY, REPAIR LEAK IN ROOF BACK OF HOUSE NEAR SKYLIGHT
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 It 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 5/24/2017 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
MAY 2 4 21.,
MF„- City of Northampton
°
Building Department
212 Main Street
• Room 100
1[ t •
Northampton, MA 01060
:C4 phone 413-587-1240 Fax 413-587-1272 _
-
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE ORDEMOLISH
yA ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION ut/P ( 7- /3"�V
1.1 Property Address: ThisThsection to be pl�completed by office
-3qr1 Le,A1,11 \ze- �. Map 3'7 Lot % Unit
lO,rC J nn,\ o\Ob L Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
tdcw Y W{Q 32 + Ld.\ S S S 'b°1 l Sly r I ar\- FL ev c
Name(Print) Current Mailing .mss:
[5D- Z^s14`Yt7
alq Telephone
Sire
2.2 Authorized Agent:
CAry '\Cv o\r\5 d O 'Ytrc1 i:.c_ch1S kg) QAd. ukL ' t1 f}Vb nAI'-‘
Name(Priinntt),r a //^(/� Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COST$
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (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 ��yy��
6. Total=(1 +2+3+4+5 Check Number 2O/03 c
7CJ
Thi: . on For Official Use Only
Building Permit Numbe ) Dateed:
P ed:
Signature: t � ,/ ire St. 'fly
Bulking 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
)� C �J lU QX 1S1 Building Department
Lot Size O- 'V h Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot 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 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES
IF YES: enter Book Page and/or Document ft
B. Does the site contain a brook, body of water or wetlands? NO cZU DONT KNOW O 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
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 Of
IF YES, describe size, type and location: w'
E. Will the construction activity disturb(clearing,grading,e cavation, or filling)over 1 acre oris 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House (D Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory Bldg. El Demolition ❑ New Signs [D] Decks ID Siding[D] Other(01
Brief Description of Proposed
Work: I&Q,QC.{ S\e"temk \ 0�1Ff <,c.Y�... ,Gttryvw.nc1 �i"'r—Q-a4-�- apc\, ‘4(`a`)L4,
J J ru. - sky Itt
Alteration of existing bedroom Yes No Adding new bedroom Yes )4" No
Attached Narrative ° Renovating unfinished basement Yes )( No
Plans Attached Roll -Sheet
aa.If New house and or addition to existing housing. complete the following:
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 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 CONTRACTORfAPPLIES FOR BUILDING PERMIT
I, . k f-MC' ,as Owner of the subject
prop§fllJAny
hereby authorize QC((o� jeCh5
to act on my behalf, in all mattes flative to work authorized by this building permit application.
5723/0-
Signat re of Owner Date
I, C xC(S '\(i.ivA1t ,as OwnertAuthodzed
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 OwnertAgent rate
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name ofJcense Hoidec: ( \A(tS�U'>�1'b< _.,y.L.:)l)S C/S
License Number
C)\C S*D-i\\cm , aurkV p r-. Vii 1TI\q , -
Address Expiration Date
ittn.`>ttz �'' ' `l8c
Signature ^ / Telephone
9.Re{�p�tetared Home I orovement Contractor Not Applicable
SJ ❑
CkYyW\ r Seas k5 QUO `'\
Company Name Registration Number
? O\Cl. cO11\'4\ '?"C 1 14o; 1\roc--\�'t'OVN 07.7.5! kg
Address Expiration Date
Telephone !13581•3'$1415
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.t..c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will resul'
in the denial of the Issuance of the building permit.
Signed Affidavit Attached Yes t- No 0
City of Northampton
Massachusetts '� '<
d A $ r <z
itC 41 g DEPARTMENT OF BUILDING INSPECTIONS
:�/ �' 212 Main Street *Municipal Building JA acs
Northampton, MA 01060
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.
The debris from construction work being performed at:
36"\ L � kf 1Svc aec L v , Y
(Please print hoV9�
use'number and street name)
Is to be disposed of at:
JO\, (J.wYbn DIA ,0.�"�'mavyJ'�Y��, :kA^%w,Q ^
(P se print me a location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
V/7
Signature of P-- it Applicant or Owner Dat
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
to wags. , Office of Investigations
is IA
1 Congress Street, Suite 100
t Boston,MA 02114-2017
y www nass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ;ry Please Print Legibly
•
Name (Business/Organization/Individual): ( yt A isi c.
Address: MD D\c\ Spv\ v 5t.
City/State/Zip: $4v'k\,xxgv,,o.tor, iN\ 0incn Phone#: 113' S 3E lc15S
Are you an employer?Check the appropriate box:
rCr Type of project(required):
I.5p 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
(fisted on the attached sheet. 7. ❑Remodeling
2.❑ i am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. ❑Demolition
workingfor me in anycapacity. employees and have workers'
p X 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.) 5. ❑ We are a corporation and its i00 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their (L❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 11fr Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. No workers' 13.0 Other
comp. insurance required.]
"Any applicant that cheeks box p 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.
[Contractors that check this box must auached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
emptoyees. If the subcontractors 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:_\A {yak
Policy#or Self-ins. Lie.#: -M no+ .'7 7.0\ Expiration Date: 1J M
Job Site Address:_,,,,,, C _as A .,11. City/State/Zip: �-\vr¢ne; , Mid tae 2-
Attach
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 e. 152 can lead to the imposition of criminal penalties of a
fine up to 31,500.00 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 providedaboveis tru
and
correct
Signature: - 4 Date: / 47vY/ /7
Phone#: ` %lb - 7 f er +g t
Official use only. Do not write in this area,to be completed by city or town official.
i 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#:
A`ORB CERTIFICATE OF LIABILITY INSURANCE DATE3/2r4MM.vOYyTI
7
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: If the certificate holder Is an ADDITIONAL INSURED,the polkylles) must be endorsed. If SUBROGATION IS WAIVED,silkiest to
the tents and conditions of the spiky,certain policies may require an endorsement A statement on this certificate does not COINS(rights to the
certlficat holder in lieu of such endorsement(s).
PRODUCER DOITAOT Adina Edgett
Webber 6 Grinnell flPHON
H
E,. (413)586-0111 Ws NoE 16131586-6ag1
B North King Street Esa_aedgett8>ebberandgrinnell.coal
•
NSIIRERISIAFFC D IG COVERAGE NqIC•
Northampton --_ MA 01060__. NauuPA Main Street Ameria/N8
cA 29939
INSURED _
ENSURERS/4124/MA
Barron S Jacobs Assoc. Inc. NNJREat A.LM. Mutual/A.S;M. .
Attn: Cecil R. Jacobs ENSURER D:
70 Old South Street INSURER E: _..._ _..
Northampton !A 01060-3833 I INSURER F:
COVERAGES CERTIFICATE NUMBERFXP 03/18 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.
J eVBR
I
LTR' TYPE OF INSURANCE Iraniµyp, PDLJCY NUMBER 'IYNgG'(YYp.11BeID.'YWYI Lon
X CgWERCPL GENERAL UABNTY ' ' EACH OCCURRENCE 'S 1,000,000
_ _._._... ' ENIFD
DAMAGE TO R '
CLAMS-MADE ' )[ — -'-
A __ OCCUR
PREMISES(Ea _ a 500,000
MPT0049D 3/9/2017 3/9/2018 MED EXP(MY ane Pxeonl S 10,000
PERSONAL&ADVIN _
pRY S 1,000,000
G
GENAGGREGATE AP
G9TE UMIPpES PER _GENERPI AGGREGATE Ti 3,000,000
C POLICY'__.Ta LCC PRODUCTS-COMP.CP AGG 1 S 3,000,000
OTHER . EPLI IS 10,000
AUTOMOBILE LABILITY COMBINED SINGLE UFA S
_ (Ea ILWeml
B • :µy AUTO _ I BODILY INJURY(Per person) :S 1,000,000
ALL
LLO ED X r SCHEDULED M1E804913 3/9/2017 13/9/2010 'BODILY INJURY(Per amdt) S
K HIRED AUTOS X NC4-OWNED •PROPERTY DAMAGE 'S
irk AUTOS LPgr acgen0 _..
r Mnaulpsymenis `S 5,000
•
' UNMANSGAB X .OCCUR EACH OCCURRENCE iS 1,000,000
r—
R , EXCESS LAa 'CWMSMADE L.AGGREGATE IS 1,000 000
DED 1 RETENTIONS 10,000 I .CUT8049D 3/9/2017 : 3/9/2010 IS
YORKERS COttENSATIOX Xf PEA
ETH _
ANDEMPLOYERS'LAeILITY _ S _
Y PROPRIETCPARTNERRXECUTVE Y7 E L EACH ACCIDENT I5 500,000
I DFFICERMEMOERWEXCLUDED'+
C NX NiA -_..
•Mandatory In Me 181E80063652017A 3/1/2017 . 3/1/2018 1 El DISEASE-EA EMPLOYEP,S 500,000
Iy Weab uOF OPERATIONS
DESCRIPTICN 4Mex MEL DISEASE-POLICY LIMIT:s 500,000
•
DESCRIPTION OF OPERATIONS I LOCATIONS 7 VEHICLES(ACORD 101,Additional RLmArb YMEW,may d MWG,sd If moo WIFE lL ngMeJl
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTORIZED REPRESENTATIVE
H Grinnell, CPCU, CIC 'ZG 1r-- '1('- --f0
I€)1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
IN8025I9111etHI
Massachusetts Department of Public Safety
ir Board of Building Regulations and Standards
License: CE-00005
Construction Supervisor
CHRISTOPHER
70 OW SOON St
NORTHAMPTON MA
(•1-%� CA— Expiration:
Commissioner 1V1snt*
l ,
d. a<
.. .I
- 3 �
r • o%%Cdo ni& utea/tA a/ wacAule/ t
.57,11,--,; Office of Consumer Affairs and Business Regulation
-nr' a 10 Park Plaza - Suite 5170
tlio-44'
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 100809
Type: Private Corporation
Expiration: 6/23/2018 Ire 419291
BARRON & JACOBS ASSOCIATES, ING.
Cecil Jacobs
70 OLD SOUTH STREET
-
NORTHAMPTON, MA 01060 -
Update Address and return card.Mark reason for change.
Address Renewal 7 Employment Lost Card
SCAT 0 2014-05/11
9 ^/7'flan,net ntaeaa ry/^irn.:udi',Ja
Office of Consumer Affairs&Business Regulation License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration data If found return to:
Registration: 100809 Type: Office of Consumer Affairs and Business Regulation
Expiration: 9P23/2018 Private Corporation 10 Park Plaza-Suite 5170
Boston.MA 02116
BARRON&JACOBS ASSOCIATES,INC.
Cecil Jacobs
70 OLD SOUTH STREET
NORTHAMPTON,MA 01060 Undersecretary Not valid without signature
Barron & Jacobs
DESIGN . BUILD . REMODEL
Established in 1986
Dear Code Official,
Enclosed please find an application and supporting documentation for a requested building
permit.
I have enclosed a self-addressed, stamped envelope for your convenience. Please mail the
building permit to our office. Thank you.
Sincerely,
Chris Jacobs
A Tradition of Building Satisfaction
70 Old South Street, Northampton, Massachusetts 01060 413.586.8998
barronandjacobs.com