22D-101 (2) 89 BLISS ST BP-2019-1100
GIs#' COMMONWEALTH OF MASSACHUSETTS
Mao:Block:22D- 101 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2019-1100
Proiea# JS-2019-001785
Ea.Cost:$38000.00
Fee:$247.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: SHAUN GIBERSON 083210
Lot siae(sa.ft.): 273121.20 Owner., COYLE DANIEL
Zoning:URA(100)/WSP(100V Applicant. SHAUN GIBERSON
AT. 89 BLISS ST
ApplicantAddress: Phone., Insurance:
PO BOX 2178 (413)237-4048 WC
WESTFIELDMA01086 ISSUED OM4y"019 0.00.00
TOPERFORM THE FOLLOWING WORX.•FINISH ATTIC SPACE, DRYWALL, PLYWOOD
FLOOR, REBUILD KNEEWALLS
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 Occuoancv signature:
FeeTvve: Date Paid: Amount:
Building 4/920190:00:00 $247.00
212 Main Street,Phone(413)587.1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File N BP-2019.1100
APPLICANT/CONTACT PERSON SHAUN GIBERSON
ADDRESS/PHONE PO BOX 2178 WESTFIELD (413)2374048
PROPERTY LOCATION 89 BLISS ST
MAP22DPARCEL101 001 ZONE URA(100)/WSP(100)1
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
ZONING FORM FILLED OUT a
Fee Paid �r
Building Permit Filled out
Fee Paid
Tvoeof Construction: FINISH ATTIC SPACE,DRYWALL,PLYWOOD FLOOR REBUILD KNEEWALLS
New Construction
_— Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 063210
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
___Approved_Additional permits required(sce 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
Demolition Delay
U lz 4-9•ZDp
SiBuilding Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain ail required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
Variances me granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
6P-- fj-f/ad
Department use only
City of Northampto'
a us o
' .w.^•� Building Departmen curb cuVD ea Permit
�. 212 Main Street APR gOQ' ept ave ability
'( Room 100 WaternNell valla illy
"
Northampton, MA 01 60 $lm ral Plans
P oral OF null nl'rl "I i„P c I ry$
phone 413-587-1240 Fax 41 -987- nmri Vit1AB'lle Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Prooerty Address: This section to be completed by office
FFto 61iss SrlA Map D Lot to / unit
trenCe , �A
Zone Overlay District
Elm St.Dishid CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AOENT
24 Owner of Record:
Daniel Co le eq 31 ;55 Stree+ Florehce Mil
Na (P Cunenl Melling Address:
vfJ_ aov_ 8sdi
Telephone
uthorized Agent:
51%ur Giberson PO Box a11S Wes�T;eld Mw 01086
Name(Prim) _ Cunmt Malting Address:
- Q. -, 4)3- a3r7 - 4oL/
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by pemilt applicant
1. Building 3 a 1 (a)Building Permit Fee
2. Electrical (b)Estimated Total Coat of
3 Cb0 Construction from 6
3. Plumbing Building Pemlt Fee ��/
4. Mechanical(HVAC) 3Weo O /
5. Fire Protection
6. Tagil=(1 +2+3+4+5) 3Y3 DUO.p° Check Number 1731
This Semon For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissionelflnspector of Buildings Date
9iber5oncon5tr,&%-Oy1 inc @ 9 " Oat • Cutty
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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 oIIM in by
Building D,anmmt
Lot Sin
Frontage
Setbacks Front
Side L: R�
Rear .___
Building Height _^
Bldg.Square Footage ---_
i_
Open Space Footage
(rot area minus bldg a Paved
r__ I
q of Puking Spaces — �'----'
Fill:
vohme ffi lactim
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book l Pagei ...j and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO O 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 O Obtained 0 , Date Issued
C. Do any signs exist on the property? YES O NO O
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 acdvity,disturb(deadng,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
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 Altiraeon(s) Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks (O Siding[E3] Other[[:a
Brief Description of P'�Pa�ed
work: Fnpfion attic .5�ace , dry mall �Iywood rlovrf re b��bl4lUpuG�
Alteration of existing bedroom_Yes No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement _.._Yes VNo
Plans Attached Roll -Sheet
ea.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?
L Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Complience. Masscheck Energy Compliance form attached?
h. Type of construction
1. 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. SepticTank CitySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, LGnl(,l Co�k .as Owner of the subject
property (l
hereby authorize S'1_ o utA GI ber$Or)
to act on my behalf in all matters relative to work authorized by this building permit application.
Signature of Owner^ /1 I_ Date
S1 OLUy� G;bk,fSOrh as Owru,r/Authonzed
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
SV)O,on G bersok
Prim Name
.:� kir y- a-i9
Signe um,of OwnerfAgenl Daft
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Superrvlsw: Not Applicable O
Namaof Lflcanse Holds: Sout/�1 C Giber5m C6 — cx,��lo
License Number
Po [30� a1�8 we5t�; ek➢ M A of og6 i a _9_ aolq
Address Expiration Date
S a,amC, -dditfy '113- x3'7 -4o`I$
Signature Telephone
111,Rsalstsrsd Home Improvement Contractor: Not Applicable ❑
Gibef--w) cor)5P,>C�-t on TnC. 149915
Compamr Name Registration Number
Pb 30,E a(�8 west r2�d1 MA o1D86 oa - ab - spas
Address Expiration Date
AA'�a.l trvi C. Telephone 413- a'3'7-4W8
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L,c.152,§25C(8))
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....... d No...... ❑
City of Northampton
a
Massachusetts
DRABSTN6'NT OF BUILDING INSPECTIONS of
212 Main atr..t • Municipal BvildinglpCu
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, modemization,et nversion,
improvement,removal, demolition, x construction of an addition to any pre-axisb'ng ownsroccupied building containing
at least one but not more than/our dwelling units....or to structures which ere adjacent to such residence or building"be
done by registered contractors.
Note:If Ike homeowner has contracted with a corporation or LLC,thm entity must be registered.
Type of Work: Fini% G0.4iC Est.Cost: 3, 000' –
Address of Work: 89 N -s5 5+ree,4 F�ore�ce N1W
Date of Permit Application: y – S – 19
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 owneroccupied
—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:
4- 5- 19 Giber�Dr. Cons+roc,4ion T�) C, 14`i9)5
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signal=
City of Northampton
•�'� Massachusetts 'k
G
Df@ARTlRNT OF BUILDING ZNSP£CTLONa � {"
212 Main Street •Mmicipal aulltl g •Ol
Northampton, M1 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
Ol 61i55 6+v-ee+ FJorev ee , MW
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Ca5ellq \')Q* ,y161-e...s $roe, Nolyo�e ��w
n1- �(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.
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigatrans
600 Washington Street
Boston,MA 02111
www.massgovIdfar
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
Name(Bminess/Orgmdrationlindividua0: Gibersorn Con*ueli bn STICr
Address: VO box N-76
City/State/Zip: We.5+C,ala rMR DIV. Phone#: 413-3,37-y0y8
Arc °u w employer?Check the appropriate box: Type of project(required):
l.F l am a employer with 1,A 4. ❑ I am a general contractor and 1
employees(full and/or part-time).*# have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or paruwr- listed on the attached sheet= 7. ❑Remodeling
ship and have its employees These sub-contractors have 11. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised thew 10.0 Electrical repairs or additions
3.❑ 1 an a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,¢1(4),and we have in 12.❑Roof repairs
insurance required.] employees.[No workers' 13.❑Other
comp. insurance required.]
•Mywplieem Net cheeks box#I muu also all out Neseaion behn slowing Neir uarkels'.,Mdm police information.
t Hanmwneetwho subrnitthis afidavit indicting they are doing all wvrk vhd Ihen hire abide roMamon muse submit a new eTasit ind oteing such.
:Conn mthatchwkthisboxmustattachedmadhgtmo shat showing Imname of thesub-coueetartand lhcirworkeW comp.Wliq information.
I am an employer that is providing workers'compensation insurance jos my employees. Below is the policy and jab site
information.
Insuance Company Name: A 1 M M-A na t Sr1.9.
Policy#or self-ins.Lia#: A W C—7019,957-3 of aoje Expiration Date: 5— 11. ' 19
lob Site Address: 89 all 55 St. City/stete/Zip: Flo'enc.Lr Mll
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dam).
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 three point,aln td�p-enalties of perjuy that the information provided above is true and correct.
Simmture'�f.V`CllYY� l,. .l�a�Clb�� Dare, y' �4
Phone#'
OIf¢lal use only. Do not write in this area,to be completed by ciN or town ofciat
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#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NOCI NO 28158
POLICYNO. AWC-400-7012953-201eA
PRIOR NO. IAWG400.7012953.2017A
ITEM
1. The Insured: Giberson Construction Inc
DBA:
Mailing address: P 0 Box 2178 FEIN: "3840
Westfield,MA 01088
Legal Entity Type; Corporation
Other workplaces not shown above; See Location
2. The policy period is from 05118201 B to 0W&2019 12:01 a.m.standard time at the Insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Llability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100_000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 Oe B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Cleasiticationa,Rates and Rating Plans.
All information required below is subject to verl8catlon and change by audit.
Claesi8cadona _ Premium Basis Raise
Code Eetimetad Par$1DD Estimated
No. Total Annual Of Annual
Remuneration nenwrereDon Premium
INTRA 260088 -
INTER BEE CLASS CODE SCHEDUE
Minimum Premium $500 Total Estimated Annual Premium
GOV GOV Deposit Premium
STATE CLASS
MA 5845
This policy,including all endorsements, is hereby countersigned by ��—�` 7"–'�� 04/19!2018
re mem
Service Dittos: Roger Butler Ins Agency Inc
64 Third Avenue P O Box 816
Burlington MA 01803 Westfield MA 01086
WC 00 00 01 A(7-11)
Incluaaa copyrighted materiel of the National Council on Compensation Insurance,
uses with IU pennlselon.
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvements oortractor Registration
Type: Corporation
GISERSON CONTRUCTION INCRegistration: 148915
PO BOX 2178 _ Expiration: 02/20/2020
WESTFIELD.MA 01086
Update Address and Return Card.
scn r o 20M- 17
,�.e �ivnnw�nuv./n`o�✓�i¢d✓aaSrael4
OMua W Cansumsrxisess 6 Susln.rispuhusan
NOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE-CaroaeWi, before the expiration date. 8 found return to:
Registry, Expiration Ofaes of Consumer Affairs end Business Regulation
0220/2020 10Park Plaza-Suite6170
GIBERSON COO _ Boston,MA 02116
r —
Il
SHAUN C.
7 LLOOO STFlE�ETWT'FLOOR (�ff "'"
WESTFIELD,MA 01085' Undersecretary Not valid without signature
Commonwealth of Massachusens
7 Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-063210 Expires: 12/09/2019
SHAUN C GIBERSON
PO BOX 2178 '
WESTFIELD MA DIMS
�/"—
Commissioner -
City of Northampton w Massachusetts212 11�in rtc • MuM 01l buildingeocNbmpGon, Mn 01060
Fee Calculator for Residential Properties
Location : 80l iD k 55 /+reef R o rence MR
Square Footage Amount
Basement @ .20
1ST Floor @ .50
2nd Floor @ .50
/2 Floors, Finish Attic, Garage @ .20 y60 qa• 00
Deck / Porches @ .20
Total
Cro55 5ec4;Dri
tc pad a' Fof prop
Lf' a-i5 R-i5
3A NVRN�'LC�
Ears+,�5 I sr FI
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az�a.
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