11-015 (6) 34 RUSTLEWOOD RIDGE BP-2019-1495
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: It -015 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Deck BUILDING PERMIT
Permit# BP-2019-1495
Project# JS-2019-002419
Est.Cost:$22000.00
Fee:$143.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use Group: STEPHEN D ROSS 079160
Lot Size(sa.ft.): 56018.16 Owner: WHITE MATTHEW W&CHRISTINA K
Zoning: Applicant. STEPHEN D ROSS
AT. 34 RUSTLEWOOD RIDGE
ApplicantAddress: Phone: insurance:
36 SERVICE CENTER RD (413) 584-1224 O WC
NORTHAMPTONMA01060 ISSUED ON:&¢7/1079 0:00:00
TO PERFORM THE FOLLOWING WORMALTERATION TO EXISTING 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 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 Sienature:
FeeType: Date Paid: Amount:
Building 6/2720190:00:00 $143.00
212 Main Street,Phone(413)587-1240,Fax:(413)587.1272
Louis Hasbrouck—Building Commissioner
File k BP-2019-1495
APPLICANT/CONTACT PERSON STEPHEN D ROSS
ADDRESStPHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224 Q
PROPERTY LOCATION 34 RUSTLEWOOD RIDGE
MAP I1 PARCEL 015 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED T
Fee Paid
Building Permit Filled
Fee Paid �Cc PLANS
Tyaeof Construction: ALTERATION TOE DECK SEE NOTnap
New Construction
Non Structural interior renovations
Addition to Existinu
Accessory Structure
Building Plans Included:
Owner/Statement or License 079160
3 sets of Plans/Plot Plan
THE FLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
_Approved_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
Demolition Delay
I "el-•../ 6 27 1
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all Wring
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.
CAS www K.ea�t � (�y�u
Department use only
"--'� City of Northampton status of Permit:
.�� Building Dep C UDriveway Permit
� -
212 Main tre 1ECEIVE wed epllcAvallability
Room 00 w ter en Availability
Northampton, 06� 2019 r set of Structural Plans
phone 413-567-1240 ax 13- -1 PI unite Plans
c er s ci y
APPLICATION TO CONSTRUCT,ALTER RE6l6�BR A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
54- Map I ( Lot t Unit
Fw¢eNoE Nth o 0(02
Zone Overlay District
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
I'AA-MNtw A-A7A Tt"AA W44t-rE �' Tl wvo0 �1D4E
Name(Print CurteM Meiling Atltlress:
�/pL/J 413 - LSi�041'i
^"�V"�^'�r.�/ Telephone
Signature
2.2 Authorized Aaent:
gVirya ) D. 110yS 3fe bT�12LJt[ �A7TE2 ROrEb
Name(Pont) Current Mailing Address:
4a - f7b4 -(2z.k
Ig re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Building 2 4 .
� (a)Building Permit Fee
� Qu
2. Electrical _ Q (b)Estimated Total Coat of
Construction from B
3. Plumbing G Building Permit Fee
4. Mechanical(HVAC) _ 4 X43
5.Fire Protection
6. Total=(1 t 2+3•4 i • Check Number
This Section For Official Use Only
Building Permit Number: Data
Issued:
Signature:
Building CommissionaAlnspeetor of Buildings Dale
S-�ep'1,ross @ �'9h60 . GOM
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
�iC.i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑p
Name of U..Helper: � � �. QGS S G liry
S / MO D
License NurW.
36 SCrriet *28 -,MAI
Aaaess T O/OG a Expiraaon Date
yis•ssy-/aa�
Sp.twe Telephone
Not Applicable ❑
.em hen D.Ret Cztp�� C'en�racz<or ISORy9
me
ReOiR�umbe7
I& &ro&_ t�enar./C/ the /RA 401O6D 15-1 -.21%20
Address Expiration.Date
TelePhone_13• - 21
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavtt must be completed and submitted with this application. Failure to provide Mb affidev8 will reau8
in the denial of the issuance of the building peril.
Signed Affidavit Attached Ves_._.. C No...... ❑
AlibmwOwnerExMIt a
The current exemption for"homeowners"was extended to include Owner-pce DW Dwellhay of one(1) or mo(2)families
and to allow such homeowner to engage an individual fm hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 1083.5.1.
Definition of Homawmr.Person(s)who own a parcel of land on which he/she sides 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 faun
structures.A person who constructs more then one home in a two-var 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
responsible for all such work performed order the buildine permit.
As acting Construction Supervisor you presence on thejob 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 ofPmployers to
Employees for injuries not resulting in Death)ofthe Massachusetts General Laws Ammteted,you 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,Stine and 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
This column to be filled in by
Building Department
Lot Size 531959 S3 a(
Frontage 21Z • C3a t2 . L'3'
Setbacks Front to`' "� tow
Side L: G,O' R: 1251 L (e0' R: IZg'
Rear L-7' 2-61
Building Height N/A ctkA.A�'E.
Bldg.Square Footage 3o t % {{{7
Open Space Footage %
(Lot am minus Wit&paved 48ra ''. :89 %,C,2 89
N ofParking Spaces
Fill:umNONH NONE
vole&location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO @ DON'T KNOW O YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® 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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is 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 applicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
01 Doom O
Accessory Bldg. ❑ Demolition ❑ New Signs j0) Decks lip Siding g7) Other(OJ
Brief Description of Proposed
Work: ALTes2AT\m.] 'CO EX\5Tw4 DELK
Alteration of existing bedroom_Yes C No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
So.If New house and or addition to existing houslna, coma lets the following:
a. Use of building. One Family X— Two Family Other
b. Number of rooms in each family unit: l,rIyt, Number of Bathrooms
c. Is there a garage attached? YE,i
d. Proposed Square footage of new construction. 144 DECK Dimensions
e. Number of stories? ti/A
I. Method of heating? W 46 Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 fl.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? X—Yes No.
I. Septic Tank X City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, MA-M"Ew W 41\TE as Owner of the subject
property
hereby authorize STePHLN
BOS �VheA't
toactonmybealf.iinnalllark Sth �dby tCbuilding
/permit
ua"pCpl'Kicaktiocn-.
N � �wT
bR
W 7 t�?�9
Signature of Owner
NONN-
I, �7f61�Et✓ RO G- miA"t do L. Co""T"STOR ,as Owner/Authorized
Agent hereby declare that the statemen and iMoation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
ST¢PIAia;V b - RLnS
Print Name
GAf�,If
e�gnalu f OvmedAgem Dale
Q
City of Northampton
Massachusetts
W i
OBPARTM OF BUZLOZNG ZNSPECTZONS
212 Mein Street • Municipal Building '• rL+ qCy�
aortha ton, M 01060 w
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, con"mion,
improvement, removal, demolition, or construction of an addition to any pre-existing ownsroccupied building containing
at least one but not mom than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must a registered
TypeofWork: ADDITIol7 To k-XvST1&i4 DECK. Fst.Cost ZZ •�
Address of Work: 34 RVSTL�Wona 21DSE FL02E.r?GE
Date of Permit Application:
I 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 INFORMATTON.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
S reP ASkN Ross rr=�' C. coArm. -fib 1ro084-7
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 Signature
The Commonwealth ofMassaehusem
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 021.14-2017
www.massgov/dfa
Wil.rkers'Compensation Insurance Affidavit:Builderg/Contmetorx/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leaibly
Name (Business/OrganintioMndividml): STtPttEN ll:>. 9061. CESPS LL GgNTRJcCTU�j
Address: -S4 `GE2vkC-Q CAw-te,2 Wof-C
Ci /State/Zi 01060
City/State/Zip:p: Alp�Tb4I MPTON E& Phone#: Aolj • Sb 4- M2 d—
Am you an employer?Check the appropriate box: Type of project(required):
L[3 I em a employer wild employm(full"or part-tinct• 7. ❑New construction
2.�Iama ale pmpneror or penncnhip and have no employees working formein g. ❑Remodeling
any capacity.[No worker'comp.insurance required]
3.❑1 am a homrowner doing all work myulf.(No worked comp.insurance required.)1 9. ❑Demolition
4.❑1 am n homeowner and will be hiring connectors to conduct all work on my property. 1 will 10❑Building addition
mum that all contractors either have workers'compensation insurance or am sole 11.E]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5C]1 am a general commctorand 1 have hired the subconmean listed on are'ttsched shed. 13.❑ROOf repairs
These sub-contmctws have employees and have workeri immm
comp. ue.
6.[]W is sm a co.rait. it is omcers have exercised their right of exemption per MGL c. 14.[:]Other Abo 70 i1. 1
152,§I(4),and we have an employees.[No worker'comp.ineumnce required] �EGK
•Any applicant that checks box NI must also fill out the section below showing their workeri compensation policy information.
?Bummer.who submit this affidavit indicating they ere doing all work said then him outside contractors must submit a new affidavit indicating such.
:Comruton that check this box moat attached an additional shwt showing the nam.of the aub-conuaetor and sat.whether or not thou entities have
employm. If the suhconnactors have employees,they most provide their workers'comp.policy number.
Jam an employer that is providing worAere'compensation insurance for my employees. Belmr is the policyand job.site
information.
Insurance Company Name:
Policy#or Self-ins.Lia#: 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 S 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 pains
�and penaaies of perjury that the information provided ab ve is tru and correct.
)e:::!=
Signature, � // — D t 47 �j 4
Phone#: y/3 -S dy—f-0Z-
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#:
City of Northampton
Massachusetts
A � L
'J DEPARDONT OE BU211DZNC INSPECTIONS
212 Iain 8""t •Wnicipal Building
ft.th p ' M8M 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:
34 (LV6Tl. V-gC)UDRIDAS f�AjOE
(Please print house number and street name)
Is to be disposed of at:
VIA TZOGIL TO VhLLE;`( Z�G tCLWC 1-10 RTFWAAP'it>u
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
7L 7� L SA7
SSi nature of Permit Applicant or Ownet 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.
AC RO H CERTIFICATE OF LIABILITY INSURANCE DATEIMLI1D-
08121/2019
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATNELY 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),AUTHORIMO
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT. It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
It SUBROGATION IS WANED,subject to the terms and Conditions of the Policy,certain policies may require an endorsement. A sMfemerd on
this certificate does not confer rights to the cerfificate holder in lieu of such endorsements).
PRooucER CON"CT Sam..Grynki.
Webber B Grinnell u�NrIE 1013)588-0111 NP: (413)W-81
8 North Kin,Street E-NAIL b,rynkiewl¢ pbererM dmlell.com
ADORES
A ,
INSVR INPIN WGCMFaAW X,SICa
NoMampte, MA 01060 INSURERA: Wast AmedcelVLlbady 44393
INSURED INSURER a: AIM 337M
Stephen Rose INEOPERC:
AM:Kan Clalnmom INBVRBr D:
38$YVk4 Lamer ROW WeVRERE:
Northempe, MA 01080 WSbREII F:
COVERAGES CERTMATE NUMBER: Exp 3120 REVISION NUMBER:
THIS IS TO CERNFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN MUM TO THE INSURED NAMED MOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDINGANV REQUIREMENT,TERM OR CONDITION OF ANYCONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED SYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS.
LIT, TYPE DPa1MY0 PDYLY NVMaB! IMMCCI M lMra
COWFMJALOBIMIK IINWrY FIOrDCKIMAPJKE S 1.DDO,0W
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
"For Insurance Into Only" ACCORDANCE WITH THE POLICY PROVISIONS
AUTNORDEO REPRESEMARYE / 77
m 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2011V03) The ACORD name and logo are registered marks of ACORD
-NOTE-
THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED.
BUILDING LOCATION ACCURACY IS NOT GUARANTEED
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BOOK 5060, PAGE 275 rjl2zi U'/.�
PLAN BOOK 171, PAGE 35 � �
LOT #2
63 969 5866 47 cmc•/\
212.63'
RUSTLEWOOD RIDGE
TO: NORTHAMPTON COOPERATIVE BANK &
CONNECTICUT ATTORNEYS TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES,
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY #250167
_ —NOTE—
SURVEYOR: 'Q m ". "� THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
zN —MORTGAGE LOAN INSPECTION PLAT—
NORTHAMPTON, MASSACHUSETTS
RAN .ALL �, PREPARED FOR
IZER y MATTHEW AND TINA WHITE
#35032 SCALE: 1"=50' MAY 25, 2010
(q� SuRVE�� HAROLD L. EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET — HADLEY — MASSACHUSETTS