36-100 (3) v
973 BURTS PIT RD BP-2020-1072
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36- 100 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-2020-1072
Project# JS-2020-001817
Est.Cost: $13400.00
Fee:$87.10 1PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group THEODORE TOWNE 000722
Lot Size(sg. ft.): 27834.84 Owner: POWERS SETH
zoning: Applicant: THEODORE TOWNE
AT. 973 BURTS PIT RD
Applicant Address Phone: Insw-ance:
PO BOX 1503 Workers Compensation
EASTHAMPTONMA01027 ISSUED ON:4/22/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD REAR DECK AND PATIO DOOR
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 =4;22,2020 0:00:00 $87.10
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
A',,u-l-t� v City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
- other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: dThis section to be completed by office
ra 'ti : ?w3 Map t Lot ( Unit
Zone Overlay District
Elm St.District_ CB District- i
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,1 Owner of Record:cz:p C -p^
��--77 >
Name(Print) Current Mailing Address:
Telephone
Signature ' .2,,
2.2 Authorized Agent:
z'
Name
Name ri t) Current Mailing Address: )
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION CO01 0
STS
Item Estimated Cost(Dollars)to be Official Use only
completed by permit applicant
9 Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3, Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4•+-5) Check Number 7/,
This Section For Official Use Only
Building Permit Number: Date , �G�C.0
Issued: -Z 0
n
Signature:
Building Cornmissioner/Inspector f Buildings Date
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 filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side I.: It.._ L: R:
.Rear
Buildin Hei6t
fildg.Square Footage
Open Space Footage
(Lot area minus bldg-d hnced
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO t 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? NO DONT KNOW C) YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained i Obtained 0 Date Issued;
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
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 pian
that will disturb over 1 acre? YES /-IN
NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
4
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3AIMP-
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apm
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SECTION 5-DESCRIPTION OF PROPOSED WORK(heck all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors M
Accessory Bldg. Q Demolition ❑ New Signs [IO] Decks f r�n' Siding[oi Other[rbi
Brief Description of Proposed ✓�
Work: -e-Arz- yJ J: F70 k:?
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
6a. if New house and or addition to existing housing, complete the following:
a, Use of building : One Family Two Family Cather
b. Number of rooms in each family unit: - Number of Bathrooms
c_ Is there a garage attached?Jie>
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 .
1, 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
t, as Owner of the subject
property
hereby authorize 4� ,>G Q_
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, �^-✓ ^ ✓ as Owner/Authorized
Agent heroy declare that the statem Wand information o he foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of per' ry.
Print Name
Signature of XnerAgent Date
va
y t T
'
/
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable D
Name of License Holder: 7
License Number
�
SignaturLU Telephone
� Address Y, Expiration Date
Registered Home Improvement Contractor: Not Company Name Registration Number
rx low,
..
�
Address Expiralion Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
I 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 Ye No.... 0
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City of Northampton
Massachusetts
DEPAR7MMT OF BUILDING INSPECTIONS 1
., 212 stain street *Municipal Building
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 aproperly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
�7-7-� cl-111'2: 4-4
(Please print house number and street name)
Is to be disposed of at:
��'T ,9?.-�d.=, ,,.?.,.�", , , ,.: e ... •�5��%, ",• � a- ,� < Baa/�.,,.� N, � ala�6y
(Prase print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Sign ure of Permit Applica or O her 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.
A,
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1
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x �
Boston,MA 02114-2017
www.mass.govldia
NNits-kers'Compensation insurance Affidavit-Builders/Cont-ractors/Electricians/Plu tubers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lezibl
Name(Busines,.;10rganizationAndividuui):Theodore Towne Jr
Address:17 Gunn Rd Ext
City/Stale/Zip:Southampton,MA 01073 Phone#.413 297-2916
Are you an ctuployer?Check the appropriate[pox: Type of project(required):
I.[]I am a employer with employees(full andlorpati-timc).* 7. New con,struction
2.nv, I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workcrs'coinp.insurance required.] z�
IM I am a homeowner doing all work myself.[No workers'comp.insurance required.] 9, E-1 Demolition
4,1-11 am a homeowner and will be hiring contractors to conduct all work on my property- I will 10[]Building addition
ensure that ali contractors either have workers'compensation insurance or are sole 1I.F-1 Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5 01 am a general contractor and I have hired the sub-contractors listed on the attached sheer.
Thome sub-contractors have employers and have workers'comp.insura"ce.71 13�n Roof repairs
6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,§1(4),and m c have no employees.[No workers"comp.insurance required.) I I
*Any applicant that checks box 9 1 must also fill out the section below showing their workers'compensation policy information.
t liomeow-ners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
tContractors that check this box must attached an additional sheet showing the name of the sub ,oritractors 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'evinpensation insurance for my employee--. Below is the policy and job site
information.
Insurance Company Name:Main St America I MSA
Policy 4 or Self-ins.Iic.#:#29939 Expiration Date:612912MI�
Job Site Address:—q -7 P LA-n 8=1T 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 STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby certify unde the pains and penalties of perjury that the information provided above is true and correct.
Si stare: e>-,;�O 2-
_gj—ure- Dale.
-291
Phone#..413 29 916
Official use only. Do not"Ifile in this area,to be completed by citJ,or 1mvr;official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2,Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone R.
AC40Rf> CERTIFICATE OF LIABILITY INSURANCE DATE(MWDONYYY)
F OW812019
1THIS 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
��EPRESENTAME OR PRODUCER,AND THE CERTIFICATE HOLDER.
.,iPORTANT- It the certificate holder is an ADDITIONAL INSURED,the policy(les)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 NOMEBrendaBrenda Klaus
:
Webber&Grinnell PHONE (413)58151-0111 FAX (413)586-6451
No Ext), (A/C No):
iAtC.
8 North King Street E-MADILRESS� bkfaus@webberandgr(nneI1.coni
AD
INSURER(S)AFFORDING COVERAGE MAIC 9
Northampton MA 01060 INSURER A: Main Street AmefimMSA 29939
INSURED INSURER B:
Theodore Towne,Jr. INSURER C:
PO Box 1503 INSURER D:
INSURER E:
Easthampton MA 01027 INSURER F:
COVERAGES CERTIFICATE NUMBER: Exp 06/20 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 CONOiTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR I ADDL SUBR POLICY EfF POLICY EXP
LTR TYPEOFINSURANCE INASPAV_VD POLICY NUMBER JMMIDDIYYYY) (MWDDNYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
F;;:;'1 DAMAGE 10 RENTE5
CLAIMS-MADE Lfj, OCCUR PREMISES(Ea occurrence) S S00,000
MED EXP{Any one Denson) S 10,000
A MP151046 06Y29/2019 06129/2020 PERSONAL&ADV INJURY $
1,000,000
GENIAGGREGATE LIMIT APPLIES PER: GENERALA GREGATE S 2,000,000
POLICY PRO-
T LOC PRODUCTS-COMPIOP AGG S 2.000,000
OTHER: EPLI $ 10,000
AUTOMOBILE LIABILITY COMBINEDSINGLE LIMIT
(Ea accident)
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per amden!) S
HIRED NON-OWNED PRflPERFY DAMAGE $
AUTOS ONLY AUTOS ONLY Per arciden;l
UMBRELLA LJAB OCCUR EACH OCCURRENCE S
EXCESS UAII HCLAIMS-MADE AGGREGATE $
DEO ON S _T PER WORKERS COMPENSATION
O
AND EMPLOYERS LIABILITY YIN I STATUTE ER
ANY PROPRIETOPtPARTNERIEXECUTIVE E,L EACH ACCIDENT S
OFFfCXFJMEM8ER EXCLUDED? NIA
(#".d..,y 1.N") E,L-DISEASE-EA EMPLOYEE S
If yes,d"cube under
DESCRIP11ON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddRional Remarks Schedule,may be attached amore 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
Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
8 1 988-201 5 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
Unrestricted-Buildings of any use group which contain
Commonwealth of Massachusetts less than 36,004 cubic feet(991 cubic meters)of enclosed
Division of Professional Licensure space.
4 Board of Building Regulations andStandards
000722 Expires:08/2012021
THEODORE D TOWNE JR
PO BOX 1503
EASTHAMPTON MA 01027 Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For information about this license
1
Call(617)7273200 or visit wwwmass.gov/dpl
Commissioner 111,4 K<4 �,,fj
ggistratics-y@lid for individual use only
1./� iva�r�rr»i•rrrfl n /tiri�i��r ri:r/fa -rare� : -;TPirelion date if it- eturn to-
office
o:
o fice of Consumer Affairs&Business Regulation �.:fice of onsumer Affai:r ar ' iness Regulation
HOME IMPROVEMENT CONTRACTOR ':9 Wa,hington Street
TYPE:Individual !.kion, A 02118
Rechtration Exairatian
132751 04/0112021
THEODORE.TOWNE JR. ---
—3
trot valid wit ut signatu
THEODORE TOWNE
21 LOt1DVILLE RD.
EASTHAMPTON,MA 01027 Undersecretary