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18C-119 (3) 30 ALLISON ST BP-2019-0886 GIs#: COMMONWEALTH OF MASSACHUSETTS MV-.Block: 18C- 119 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category:Bath reno BUILDING PERMIT Permit# BP-2019-0886 Project# JS-2019-001476 Est. Cost: $22400.00 Fee: $146.00 PERMISSION IS HEREB Y GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN D ROSS 079160 Lot Size(sg. ft.): 7492.32 Owner: MEUNIER LAURIE A Zoning_URB(100)/ Applicant: STEPHEN D ROSS AT. 30 ALLISON ST Applicant Address: Phone: Insurance: 36 SERVICE CENTER RD (413)584-1224 0 WC NORTHAMPTONMA01060 ISSUED ON:2/13/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENO BATH AND LAUNDRY ROOM 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: 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 2/13/2019 0:00:00 $146.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0886 APPLICANT/CONTACT PERSON STEPHEN D ROSS ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224 O PROPERTY LOCATION 30 ALLISON ST MAP 18C PARCEL 119 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building-Permit Filled out Fee Paid Typeof Construction: RENO BATH AND LAUNDRY ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 079160 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION PRESENTED: pproved 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&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 y—Demolition Delay Si re of Building Official 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. dep�rt-0ntFuse City of Northampton 5tatus.of Permit: Building Department 'Curb'Cutoriv*dyPermit" 212 Main Street 8evurleptiirAvilability Room 100 000lllveilty 4 Northampton, MA 01060 i 'Sets+ *'U" P phone 413-587-1240 Fax 413-587-1272 � tlanss !or. fiy APPLICATION TO CONSTRUCT, LTE DE OLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION F E B 1 2 2019 1.1 Property Address: This section to be/c/ompleted`by office// I(�Soti. ' f�,.-�� DEPT OF PUILDINC INSPMP6II NS " (-pt t r q Unit NORTHATON.MA Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Laurie Meunier 30 Allison Street Northampton ma Name(Print) Current Mailing Address: l Telephone Signature 2.2 Authorized A-gent: Name(Pri Current Mailing Address: Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building as (a) Building Permit Fee /v vdv, 2. Electrical (b) Estimated Total Cost of /200, Construction from 6 3. Plumbing 3 24o7. cX` Building Permit Fee 4. Mechanical (HVAC) _ Ij 5. Fire Protection G 6. Total=(1 +2+3+4+5) 2 Z d U • Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date /Py /�' '-1/V '44cl-`0 v--- 4--ij0,r 1, 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:� U = R: Re Building fight Bldg. S are Footage Open S ace Footage (Lot area inus bldg&paved parking) #of Parkt &SCaces Fill: volume&Location A. Has a Special Permit/Variance/Fin din ever been issued for/on the site? NO Q DON'T KNOW YES Q IF YES, date issued:l IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW 0 YES 0 IF YES: enter Book ', Page' and/or Document# B. Does the site contain a brook, body of water or wetlands? NOC( DON'T KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: . C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, expdvZation, 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition New Signs [O] Decks [M Siding[O] Other[0] Brief Description of P nosed / Work: R •» e -(2 L'711' ro d," Z-4 J n2 Alteration of existing bedroo Yes i No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes i/ No Plans Attached Roll -Sheet ea,if New house aind 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 CONTRACTOR APPLIES FOR BUILDING PERMIT I, L44 ..e.. r l.w„�,'ct as Owner of the subject property hereby authorize _ �1�"[� (^— Vy VeoS to act on my behalf, m all ma ers relative to work authorized by this building permit application. Signature of 0 n Date �tz / �� I I, �7 ��✓s- h. as Owner/Authorized Agent her6by declare that Me 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. 5� �-�- �• IZ ors Print a& t--1 2 f ZA� Si to o caner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Stephen D. ROSS License Number 36 Service Center road 79160 4/28/19 Address Expiration Date Northampton Ma 01060 Signature Telephone tj?g� V-L-- 413-584-1224 9.Realstered. ome Imaroyemlent Contractor: Not Applicable ❑ Cornifany Name f Registration Number 7 4 $,✓✓ � ic-�- � -�ri' �� t � /l/1 150847 Address Expiration Date Telephone r-ser—lez 5/3/20 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 will result in the denial of the issuance of the buildi g permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton ji, .. Massachusetts � � '�� W g DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Cb4 ,. Northampton, MA 01060 Debris 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. The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: ( ease print me and I atioh of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit Applicant or Owner Date 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. DATE(MMIDD/YYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE 06/22/2018 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 policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,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). PRODUCER CT NAW Barbara Grynkiewicz Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481 AIC No Ext): AIC,No): 8 North King Street ADDRESS: bgrynkiewMcz@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC p Northampton MA 01060 INSURERA: West American/Liberty 44393 INSURED INSURER B: A.I.M.Mutual Stephen ROSS INSURER C: Attn:Kim Clairemont INSURER D: 36 Service Center Road INSURER E: Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 7/1/19 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. INSR - -POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 7 OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 15,000 A BKW58371793 03/01/2018 03/01/2019 PERSONAL a ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑X PRI ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SIN LE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPER DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HEXCESS LIAB CLAIMS-MADE AGGREGATE $ OED RETENTION$ $ WORKERS COMPENSATION X STATUTE ER 500,000 AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE WE.L.EACH ACCIDENT $ 500,000 B OFFICERWEMBEREXCLUDED? NIA MZ80080065462018A 07/01/2018 07/01/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN "For Insurance Info Only" ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rightsYeserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Stephen D Ross Address:36 Service Center road City/State/Zip:ma 01060 Phone#:413-584-1224 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10E] Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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. $Contractors 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'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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 MGL c. 152, §25A is a criminal violation punishable by 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.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 pain and penalties of perjury that the information provided abo is true nd correct. Si Date: ZZ l Phone#:41 -584 24 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#: