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25A-084 (5) 374 BRIDGE ST BP-2019-1106 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A-084 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category Bath reno BUILDING PERMIT Permit# BP-2019-1106 Project JS-2019-001793 Est.Cost $25000.00 Fee: $163.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License: Use GTOUP7 STEPHEN D ROSS 079160 Lot Sive(su, 8.): 12980.88 Owner. HACUNDA PETER 7&TERESA M Zoninp.: URB(100)/ Applicant- STEPHEN D ROSS AT. 374 BRIDGE ST AnaiicantAddress: Phone: Insurance: 36 SERVICE CENTER RD (413) 584-1224 p WC NORTHAMPTONMA01060 ISSUED ON:4/5/2019 0:00:00 TO PERFORM THE FOLLOWING WORKMEW BATHROOM AND GENERAL REPAIRS 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: 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 Signal FeeType: Date Paid: Amount: Building 4/5/20190:00:00 $163.00 212 Main Street,Phone(413)587.1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ,� 00p File#BP-2019-1106 �` �� ��� APPLICANT/CONTACT PERSON STEPHEN D ROSS ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224 Q PROPERTY LOCATION 374 BRIDGE ST MAP 25A PARCEL 084 001 ZONE URB000) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLEO OUT Fee Paid Building Permit Filled out Fee Paid Typo£Construction NEW BATHROOM AND GENERAL REPAIRS 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 INFQRMATION PRESENTED: Approved_Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Maj or 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 Demolition Delay �� 9- 5-2019 Sign eofBuildgOffoial Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply withal]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. µ;= ; Department use only City o1 D E I V E D �'rnit: Building Dep Val Tb+mft f/ 212 ain treet 1Selrtlo Availability i Rom 1P0 �pp j 2019 Wal r(Well Availability. Northamp on, IyIA 0'1060 Two Seta of Structural Plans phone 413-587-1 40 ax 413-587-1272 Plot Its Plans 1 nF�T '1-ruu nl*:c INAF=crloNDIM ISpeciy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 6p- /0/-( 10& 1.1 Property Add mss: This section to be completed by office 37 Y l3 ; 15„r- 54V-4- Map ab✓� Lot 62`{ Unit Zone Overlay District Et.SL District CS Distinct SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: I facuh Pa- 37 ( 13r'J�-cr---�-� Nam int Ct Mgess Telephone// 'N� /V � yo�e1 ✓lA 6 / 5 ¢O one Signature 22 Authorized A ent: �bS > �U-�'L1�✓Yf-t-Cte���/. ISL P Current Mailing Address' Telephone A4k. moti//? t,_ "i�f/•L- eZ ig ure /2 L y SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building 2 ( UdCI (a)Building Permit Fee 2. Electrical /�0O (b)Estimated Total Cost of D Construction from 8 3. Plumbing O(/6 W Building Permit Fee 4. Mechanical(HVAC) �pv, "1 r✓ �,l/ 5. Fire Protection 6. Total=(1 +2+3+4+5) ZS (/Ori. Check Number This Section For Official Use Only Building Permit Num r: Date Issued'. Signature: �-rJ- w)R Building CommissionertInspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction Summisor: Not Applicable 11Nems of License Noltler I r zP&4 .1/T. QOS S C.3 79/6 0 License Number J4 Strrizz GVtftr Atldress — IO/D(r0 apiration Dare yf yis•s8y-/AALJ Signature Telephone Not Applicable ❑ Samhrn D.R�sSCps/l�r»1 nfiru or lSOf3�9 Comrranv me Registretion .bel 6 &ro er- AIA 01040D 5--*1 'P0dZC' Address '� Expiration Date Telephone 7/3.58y-/22 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,§26C(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....... ❑ No...... ❑ The current exemption for"homeowners"was extended to include Owner,occuoicd Dwellings ofore(1) or two(2)families and to allow such homeowner in 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 farts structures.A person who comtrucfs 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 resoonsible for all such work nerformad under the buildine natal As acting C,unstrnetion Supervisor your presence on the job site will be required from time to time,during and upon completion ofthe 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 Employers for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you my be liable for persons) 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 end Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Tho column to be tilled in by Building Department Lot Size Frontage Setbacks Front ' Rear Bu ding Height BI .Square Footage % - - Open pace Footage % (Lot arw :nus bldg& rkin 4o Parking Spaces Fill: _.. . volume&Location A. Has a Special Permit/Variance/Finding e r been issued for/on the site? NO Q DON'T KNOW YES O IF YES, date issued:: IF YES: Was the permit recorded at the Regist of Deeds? NO © DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO @r DONT KNOW © YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , Date Issued: C. Do any signs exist on the property? YES Q 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 ©/ IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,exw on,or filling)over 1 acre or is it pan 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 applicablel New House ❑ Atltlition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [Di Decks [0 Siding[O] Other([:]] Brief Descrigtjcn 3J rS,r Workof Prop%�4"-� : !lllw Alteration of existing bedroom_Yes—No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll -Sheet ea. If NeW'hbuse and oT addition to exisi housing,comaletethe followina 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? I. Method eating? laces or Woodstoves Number of each g. En y Conservation Compliance. Masschec nergy Compliance form attached? h. Type o I. Is construction within 100 d.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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, P_.-e. � L.�w�h as Owner of the subject property hereby authorize to act m eh�alf, in Iia a relative to work authorized by this building permit application. Signa m of Ovine' r I' /v w.d�^'`� ��/'! , as Owner/Authorized Agent here y 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 NalheRUQ / S Lure of Owner/Agent Da e The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www ro ass.gov/dia ulkirke"'Coampereartion Insurance Affidavit:Builders/Contractors/Electricions/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / " p Please Print Levibly Name(Business/OManizatioWIndividual):_ Address:--.26 c /,alaN.4-�c+ City/State/Zip: *4••,i ,4-1O/ 'UO Phone#: ///j S f1`I—If Am you an employer?Check me appreprhte box: Type of project(required): L,�.,,as ye employer with employees(full and/or pan-time)` 7. ❑New construction 2.lrtiam a sole proprietor or partnership and have no employees working for me in g, ❑ Remodeling 'IY yeapacity.INoworkers'em, insurance required.] 3.❑l am a homeowner doing all work myself(No workers'compinsurance required.]' 9. El Demolition 4.❑I am a homeowner and will he hiring contractors to conduct all work on my property. I will 10❑ Building addition ensure that all convenors either have workerscompensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5 1 am a general tormentor and l have hired the sub-contractors listed on the'tached sheet I3,�Roof repairs These subcuntecturs have employees and have workers'comp.insurance 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 151,41(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. I Homeowners who submit this affidavit indicating they me doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this hos must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. Ifthe su -commuctors 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: Policy It or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy blithe workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152,ys25A 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 5250.00 a day against the violator.A copy ofthis statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby cert fy on the aims and penalties of perjury that the information provided a/bjve i/sfru�e�rand correct. Signature Date: �/ �/ �" 1 Phone#' Z//2 I-" /I 2M 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.Chy/fown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton lMassachusetts W x DEPARTMENT OF BpZLDING INSPECTIONS � 212 Nein Street eB`nicipal Building vy CS Northe,ton, M 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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: 37 y t3 d. (Please print hous umbera d street name) Is t��o//be disposed of at: v� (pleaa print name a d location o facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) i ure 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. City of Northampton j Massachusetts \ DEPAftTNENT OF BUILDING INSPECTIONS ` 212 Mein Street • Municipal Building y� �m Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR") regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction,alteration, renovation, repair, modernization, conversion, improvement,removal, demolition, or construction of an addition to any pro-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:!f the homeowner has contracted with arAlcorporation or LLC,that entity must be registered Type of Work: 5nia--w— �2..v..ci�C Est. Co t �Grw r✓ Address of Work: 474 ✓r �q-r-- ✓�"�r"`— ��- Date of Permit Application: 1 hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): —Job under$1,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: ���/�5����12.1r . fr /SVA7 V3 1;,7 Date Contractor Name HIC Registration o. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature 4��® CERTIFICATE OF LIABILITY INSURANCE °A'E'""I°°" " 4/13/201] 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 pollcy(las)must be endorsed. N SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may requlTe an endorsement A statement on this certificate does not confer rights to me Certificate holder in Ilau of such madorsement(s). PRODUCER Barbara GE okiesicr irsbber S Grinnell PxoxE (413)586-0111 FAX NRI:(413)586-6481 8 North King Street p'"pE06.bgryn —icz8"ebbersndgrirmsll.coot INSURENSS AFFORDING CWERAGE MAICI Northampton MA 01060 o.URERAZ..Ql.iOr/LUM&rtV 111045 INSURED INSURERBA.I.M. Mutual Stephen Rosa INSURERC: Attn: Rim ClairemOnt INSURER D' 36 Service Center Road INSURER E: Northampton MA 01060 1 IISURER F: COVERAGES CERTIFICATENUMBERBrp 3/1/18 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. ILTRI R TYPE OF INSURANCE POMC NUMBER M-KX EFF POINTY. I lame % COMMERCIHL GENERAL LIABILnY EPCH OCCURRENCE S 1,000,000 DAMAGE A '�.—I CW MSMADE OCCUR PR $ 2 100,000 CePB090098 13/1/2°ll 3/1/2018 MEO E%P fMyonepmn) 6 5,000 PERGgiAL'ACV INJURY :S 1,000,000 CIS L AGGREGATE LIMIT APFLIEISPEA: GEAERPLAG.FEZTE $ 2,000,000 �POLICY�JEGT JL6 PROOUCS-COMP/OPAGG $ 2,000 r000 OTHER: AUTOMOBILE LIABILITY E—annO51NGLE LIMIT $ ANY AUTO BODILY INJU RY Ea,Pawn) S ALL OWNEDSCHE°UIED 8:OjLY INJURY(Pxa,oEe S HIRED AUTOS N.N.E. PRCPEPT'DAM4GF $ AUTOS $ UMBRELIA LMB OCCUR EACH OCCURRENCE $ ( EXCESS U.. CLAI .. OE .AGGREGATE S ". DEO I I RETENTION$ S WORXENSCOMPE"SATON li X I STA ER ANOEITFIS1iT LNBIMTY YIH ANYPROPMETORNARTXER/EYECUTIVE IELEACH ACCIOEW ',S 500000 C£FIC3N BER EXCLUDED] CI NIA H IMmGabry In NH) Ia68°o8°°6E462O16A ]/1/2016 ]/1/2°1T EL.DISEASE-FA EMPLOY $ 500,000 X yes maalW 1 DEBLRNTON OF OPERATIONS IRA,- EL DISEASEPOLIMn S SOO OOO CESCRIPP0NOF OPERAHONS/LOCATONS I VEMCIFB IACOR IID 1o1,A66abnal RemM 3eMlule,maY Xa atlacN6 Mmanapau b rNULM1 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE **For Insurance Info Only.• THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDAROE WITH THE POLICY PROVISIONS. AUMORIZED REPRESENTATNE R Webber, CIC CRIS/BA ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(2omol)