12C-045 (4) 28 LEENO TER BP-2017-1408
Gsa: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C -045 CITY OF NORTHAMPTON
i.at:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ADDITION BUILDING PERMIT
Permit a BP-2017-1408
Project a JS-2017-002345
Est.Cost:$588$0.00
Fee:$193.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group DAVID FORTIER 008026
Lot Size(sq.It): 21126.60 Owner: MATTISON LAWRENCE C&PAULA
Zoning:RI(100)/URA(100)YWSP(IOO)/ Applicant: DAVID FORTIER
AT: 28 LEENO TER
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965 WC.
NORTHAMPTONMA01 O60 ISSUED ON:6/412017 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 16X16 FAMILY ROOM OFF BACK OF
HOUSE WITH A 6X11 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 ft 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 TTS RULES AND REGULATIONS.
• Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 6/9/2017 0:00:00 $193.00
212 Main Street.Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck --Building Commissioner
File#BP-2017-1408
APPLICANT/CONTACT PERSON DAVID FORTIER
ADDRESS/PHONE 32 Laurel St NORTHAMPTON (413)586-8965
PROPERTY LOCATION 28 LEENO TER
MAP 1W PARCEL 045 001 ZONE RIO 00)/URA(1001/WSP(100)/
TICS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid jr
Building Permit Filled out TrJ}
Fee Paid
Typeof Construction: ADD 16X16 FAMILY ROOM OFF BACK OF HOUSE WITH A 6X 1I DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 008026 T'.'."/ J
3 sets of Plans/Plot Plan o e.'-' C"1eC7,Cbt e
acktia-r kb
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED: yzT1'hC J
Approved Additional permits required(see below) Q- sG,
PLANNING BOARD PERMIT REQUIRED UNDER:§ ( tilk S 1 !
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan t (re
Major Project: Site Plan AND/OR _ Special Permit With Site Plan c
ZONING BOARD PERMIT REQUIRED UNDER: § `-C 1.(,t'�Lt)
Finding Special Permit _ Variance* F 9✓" l
Received& Recorded at Registry of Deeds Proof Enclosed 741:71-
Received
Other Permits Required:
Si'i • 3�^rO
Curb Cut from DPW Water Availability Sewer Availability 4 u 1e..f
r
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
� . 'Ion Delay +
.71V
Signature pf Building ' cial 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.
City of Northampton �1}f^�-----iit ti— - ; vc��.,
-- Building Department ei '' =tt�r w( ,g+i j' tri,,
( - 212 Main Street ", 5.-4;.�TAax , „atx�
.. ' Room 100 „1i „ .,i; „ �..
OM - 5 Northampton, MA 01060 ih' :Ka7 aVtt - -a.'":
phone 413-587-1240 Fax 413-587-1272 i. r >E n u - -
N TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OROTW0 FAMILY DWELLING
SECTION 1 -SITE INFORMATION V-" <.CW �,a hS
1.1 Property Address: This section tocompletetl by office
013 L E WO (t€,f 6 Map MC Lot Unit
G
Zone - Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/44gEt €1 /Mason/
Name(P nt) Current MailingAdder'
//�/p/
001/€6416 ierT v /f/-7, '4c
al.-- % . Telephone 1 /',�.,q pr
2.2 Authorized Agent: -
Da ? Foter)c✓L 'o LA(Rec Sr. Akv.totifirom, M.
Name(Pr' ) (...-- , Current Mailing Address'.
C-aqti 0 3399
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Buildings S (a) Building Permit Fee
2. Electrical n� (nt (b) Estimated Total Cost of
a Q u D Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection GI Zr? S
6. Total= (1 +2+3+4+5) ,+j Zg.c Check Number /46$? #/93
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
4 4
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 try
Building Department
s. _
Lot Size PTO-Cif/ - - I -..- f-._._ _w-
Frontage . 1.171g-r- I ___ .- _ __ - •
Setbacks Front 1.14; "--1
Side L,[ z"..1 R:L117_. 4I.lu R:L. +' I I........ I I.......__J
Rear gi=1 "?3J
Building Height I IV I UM E l
Bldg.Square Footage Zn I i(.5J % )'7&5 94 __ 1
Open Space Footage %
(Lit area mums bldg&rayed rfUg 71,1 rI13 „Lai,
_..._ ...A
,
jyking)
#of Parking Spaces ._ _-.._I _-.....,
J
Fill: __-___... -_ ___ n .__--.... _ _-. _
Datiume&Location) �. - —__ _� __._.
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES enter Book Pagel and/or Document#j_
B, Does the site contain a brook, body of water or wetlands? NO @ DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained @ Obtained O , Date Issued: iA
C. Do any signs exist on the property? YES O NO Q
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:
_I
E.
E. WII the construction activity disturb (clearing, grading, x avation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES @ 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 ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [® Siding[D] Other[D]
Brief Description of Proposed p W '
Work: NO0 R ILx(Ij I MILY Rri OFF PAOF $,Os& lu9H L,ff xii nkakaD -F
Alteration of existing bedroom Yes X No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roil -Sheet
5a If New house"ariwor additiodto existing I otisina:complete thefollowing:
a. Use of building:One Family Sit_ 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. SI, SP Dimensions I 10 XRv W/ (I xq OR, k
e. Number of stories?
f. Method of heating? µIN1 SPtI I Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction (-jl C f;
i. Is construction within 100 ft.of wetlands? Yes Q No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade t41
k. Will building conform to the Building and Zoning regulations? 4 Yes No .
I. Septic Tank City Sewer $/ Private well City water Supply ,>C.
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, !" , as Owner of the subject
pro rty
hereby authorize
to act my behalf, in all att rs relative to work authorized by this building permit application.
AMOK—t �
nature of Owner Date s-Ia U II
I, OA`-1(1 r0 k T tkit_ a'Flawg f/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.
Ono to TUrc'C 'kr--
Print
Y.A'iPrint Name
vjoo 110
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8,1 Licensed Construction Supervisor: Not Applicable ❑
Name oft.icense Holder: O 17 j0ee' S i ... CS 06101u
license Number
3 Lf4Ut2Ftt �l. Dco4fr d7 N, 9. O!O400 311.0 1 ad(a
Addre s\ r,_. Expiratio Date
` 6r7-33q
Telephone
Telephone
�YYJRr �'
0,Registered NSmelmoroyeentCeintractor: ^, -I Not Applicable ❑
OA,)In t7%eile (
� uL,10 ,ec 1039/1 _
Company Name` �// Registration Number
L, u r .tet , Al°047RrYAiON ) . of Q a t 71/0 (0o! a
Address Expiraf n Dote
Telephone Hi'3l7J,. 4e1
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT mai... §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 r2ScNo_.... ❑
11. ;Promo' 0 nor-Exemption
The current exemption for"homeavners"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.(MR 780, Sixth Edition Section 108,$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 sayable 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 he 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,vou 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 150A.
Address of the work: az- l-rutiv d j F.2R/f-C/21
The debris will be transported by: DAA 9 Fd/Ci/i/Iz/ .
The debris will be received by: tit,ou_r y IQRCrcL/ n, s
Building permit number: n/� d
Name of Permit Applicant U/04ui I�rptrr I tin
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
l Department oflndustrialAccidents
9rnr= Office of Investigations
Ga 'IS - 1 Congress Street,Suite 100
mi irk
Boston,dlA 02114-2017
Nor p,
• www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizatioMndividduual). ;//.y 11a 0p fig/2 ()Ii%Il/,nS
Address: ' Qp/L ku L'Kt „c-1City/State/Zip:1Y1_i - • it V - . O(O&20 Phone#: 1/3- A , 3'39
Areyou an employer?Check the appropriate box: Type of project(required):
I.e i am a employer with 4, ❑ I am a general contractor and I
employees(full and/or part-Moe).* have hired the sub-contractors Cr. 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 S. ❑ Demolition
working for me in any capacity. employees and have workers'
rworkers' comp.insurance comp. insurance.=
9. (� Building addition
required.]] 5, 0 We area corporation and its 10-0 Electrical repairs or additions
3.❑ [am a homeowner doing all work officers have exercised their MD Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152,§:114),and we have no
employees, [No workers' 13.❑Other
comp.insurance required]
*my applicant that cheeks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors mutt submit a new affidavit indicating such.
teorttactors that cluck this box must attached an additwnal sheet showing the name of the sub-contractors and stale whether or not thoseentities have
employees. If the sub-contractors have employees,they must provide their workers'comp.pokey number.
I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site
information. Oil Company Name: Oa t o s (! (r..
Policy#or Self-ins.Lie.#: ,k'j,(1 t.,cg- 9 a a$ '3 4,-- Expiration Date: 114 /17
Job Site Address: 3^1 I /teat ' a
P� �Q�'s/I Cc _ City/StatelZip;{'[�v,hK.',R/�TI , OIQb'�
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.
Ido hereby ce n under 14c pains and penalties of perjury that the information provided above k true and correct.
Signature: / Date: (Q,.1
Phone#; Lt 15-1160 -.13W' 1
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#:
DATE
AW CERTIFICATE OF LIABILITY INSURANCE 5/22/2017
THIS CERTIRCATE 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 holler is an ADDMGNAL INSURED,the po&SyOes)must be endorsed. D SUSROGAtION IS WANED,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).
PROOUCFA CONTACT OY6a
Ring i Cushman Inc. o N 33)584-5610 FM
we Mot l433M99-9322
P.O. Box 447 RPORESe:
176 Ring Street W s30UREP4S)AFFORDING COVERAGE RAC 9
Northampton NA 01061 INSURER AOBIO Security Insurance Co, 29082
INSURED INSURER e:
David Fortier Builders ROMER c:
32 Laurel St INSURER D:
INSURER E:
Northampton NA 01060 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL1752202052 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 WTH 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.
INSRIAPDL SUV I WILICY epc POLICY P
LIE TYPE OF INSURANCE IMOD WM POLICY NUMBER uwooHYYYI LIEA
IMWDYYYVV) DINT
I COWFRCIALGENERAL WwLRY ( EACH acaRNENCE I5 3,OOOr000
A jCwn6MN1E Z occuR ) yFDOa } 8 300,000
J 9E555]]xe3S j 12/2/2016 13/3/]01] PER ESP OVAL& one INJURY , $ 15,000
_ PERSCN4LaAER INJURY IS 1,000,000
OWL AGOREG1rE 11MT AWUES PER: :GENERAL ACERPOATE 5 2,000,000
EX POLICY�l ZT , LOC PRODUCTS-COMThOPAG' 3 2.000.000
'_ OTHER. I Expense mod Fabrt $
COMBINED SNOTE LAST
AUTOMOenF LUNLIIY M is
C„ 71ANY AUTO BODILY INJURY(Per person) 5
ALLTOOMEO I SCHEDULED BWILY PRIORY PIR aadnnt 1
IOREOAVTOS NIXLIXMFD I ( PROPERTY ElAiF
MM15
AUTOS
I 5
UMBRELLA LIAR , OCClR1 I EACH OCCURRENCE $
--
CESS AR CLPIs%SHOE ,ACOREGATE S
i I
LEU } t COMPENSATION
5
Wy0RXp5CgrS UANLJR PER I OTH-
AMOEMPLOYEESNABILITY _.. SCHAC 1 R
ANY PROMPIETORMARTNER,FXECUTIVE ION
j EL EACH ACCIDENT 3 100,000
OWE:E MEMBER FEOLUDEV+ N/A
A AAndsmontim W555722835 9/4/2030 9/4/2017 EL DISEASE-EA EMNLOYE/11 100,000
Hy+» mldt
Jebe Y
DESCRIPTION OF OPERATIONS below I El.DISEASE-PCIUCY LINT I 500,000
i
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACOR0101.Ackktiasal RemNs Schedule,may be attached N mac space N regsred)
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
210 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
Northampton, MA 01060
AUTHORIZED REPRESENTATIVE
S Fleury, CIC, CISR/S r-S..L xX/..s... S. ./ -IL:-1-.•c(
A 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/07) The ACORD name and logo are registered marks M ACORD
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