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Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association,corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall;
enter into any contract for.the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking.the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. Ifan LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed Iegibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
Le. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit ...
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone and fax number:
The Commonwealth of Massach---
Yart a€n rstal Aee
Office of Investigations NewEhJ) N 0 jE
600 Washington Street
Boston,MA 02111 C\IC K 1g. SO) FoCc
Tel. #617-727-4900 ext 406 or 1-877-1
Fax 617-727-7749 D W t.A--j!v iA tJ E R-
Revised 11-22-06
www.mass_govfdia
N ECD R€S cH t E 1 0 6
The Commonwealth ofMassachusetts
Department ofIn dustrialAccidents
0
f Office ofInvestigations
600 Washington Street
Boston,M4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):/4 i`/ 12;^, 1 f e v i c e f 1-. 4.d' ,
Address: 4/2 A,- }-[. A c."r 0-.-t i2
City/State/Zip:eh p ce .. I M 4 o to 36 Phone.#: 6/3) j C PJ
Are you an employer?Check the appropriate box: Type of project(required):
iJ
1 I am a employer with t/ 4. 111 I am a General contractor and I
have hired the sub-contractors 6. E New construction
employees (full and/or part-time).*
2. I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling-
ship and have.no employees
These sub-contractors have g. Demolition
working for me in any capacity.
employees and have workers'
9 Building addition
No workers' comp.insurance comp.insurance.$
required.]5. We are a corporation and its 10.0 Electrical repairs or additions
ffiocers ave exercisedh ' ised their 11. Plumbing repairs or additions3. I am a homeowner doing all work right of exemption per MGL
myself. [No workers'comp. 12.0 Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
Any applicant that checks box#1 must also fin 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 thisbox must amrached an additional sheet showing the name of the sub-contractors and state whether ornotthose 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 insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: 4 r 4 e. l 1(, I i ' 't`"' fy -,L. h r C p •
Policy#or Self-ins.Lic.#: I /0 Li 0`rse) Expiration Date:- 70 f/i3/ ocP
Job Site Address: SO 2-- 1y Get v+I I e- f c l City/State/Zip:. L e.N: f 1 M 4.
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK.ORDER and a fine
ofup to$250.00 a day againat the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investieations of the DLA for insurance coverage verification.
I do hereby ce
ma
Sranature:( „v
under the pains andpenalties of erjury that the information provided above is true and correct
j--LDate: / 1-4 0 7U
ifPhone'': 8P
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License t
Issuing Authority(circle one):
1.Board of Health 2.BuiIding Department 3. City/Town Clerk 4.Electrical Inspector 3.Plumbing Inspector
6. Other
Contact Person: Phone#:
he 6omirno uaea l' el.III acAwelts
Board of Building Regulations and Standards
Construction Supervisor License
ill
License: CS 96057
iF 4*.
Birthdate: 12/25!1972
Expiration: 12/25/2010 Tr# 96057
Restriction: 00
CHRIS LOMASCOLO
42 NORTH MONSON ROAD `'-'''4--" - ':
HAMPDEN,MA 01036 Commissioner
TM. CERTIFICATE OF LIABILITY INSURANCE 07/18/2007
PRODU Oiling: (413)781-2410 Fax: 413-731-9539 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INSURANCE CENTER OF NEW ENGLAND ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P 0 BOX 1175 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
WEST SPRINGFIELD MA 01090-1175 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELLOW.
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: ARBELLA INDEMNITY INS CO
ALL WASTE REMOVAL,INC & INSURER B:
ALL PROPERTY SERVICES,INC INSURER C:
POB 297
HAMPDEN MA 01036 INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR /NSRLTR /NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
DATE(MMIDDIYY) DATE(MMIDDIYY)
o
GENERAL LIABILITY 8500036961 05/21/07 05/21/08 EACH OCCURRENCE 1,000,000
X COMMERCIAL GENERAL LIABILITY PROEM
DAMAGE
ES occurence) 100,000
CLAIMS MADE X OCCUR MED.EXP(My one person) $ 5,000
A PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG. $ 2,000,000
1 POLICY —
PRO-
I LOCJECT
AUTOMOBILE LIABILITY 28294400003 05/24/07 05/24/08 COMBINED SINGLE LIMIT
ANY AUTO Ea accident)1,000,000
ALL OWNED AUTOS BODILY INJURY
Per person)
X SCHEDULED AUTOS
A X HIRED AUTOS BODILY INJURY
X NON-OWNED AUTOS Per accident)
PROPERTY DAMAGE
Per accident)
GARAGE LIABILITY AUTO ONLY-EAACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS 1 UMBRELLA LIABILITY EACH OCCURRENCE
OCCUR CLAIMS MADE AGGREGATE
DEDUCTIBLE
RETENTION$
WC
WORKERS COMPENSATION AND 9104870507 05/13/07 05/13/08 TORYY LIMITS OTHER BOTH CORPS
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT 100,000
A ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000
It yes,describe under
SPECIAL PROVISIONS below
E.L.DISEASE-POLICY LIMIT $ 100,000
OTHER:
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO
CITY OF SPRINGFIELD DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS
BUILDING PERMIT DEPT AGENTS OR REPRESENTATIVES.
CITY HALL COURT SQUARE AUTHORIZED REPRESENTATIVE
SPRINGFIELD MA 01103
e-
te7011e0Ar
Attention:liam O.Trull
ACORD 25(2001108) Certificate# 28770 ACORD CORPORATION 1988
Version1.7 Commercial Building Permit May 15,2000
SEC1ICSV10=S-11WS11.16dIkOriEftRE41#00-100-CAR•110t1) ... •
Independent Structural Engineering Structural Peer Review Required Yes Q tiii4„.._____I
SEATielftvffliER Arnie . .'.ItttAEPOINKEIralf4§.EN:
0**Rt':AGEW 011:04M.MtACTOitOIVES,ftleAROLDIN6poturr. ''•":.
r e,' -i- -1— 1,-/- •-•• g----
k
hereby authorize
0
act on my behalf,in all twitters relative to yjtrk authorized by this building permit application.
7
17iAi -1 f' /Z ( ;\
Signature of Oyster --
4--''t_...-L,— '---t- A-- t--,
7,—.-...."---—.1
7„
iLt,11 , 1 (--o• .A1 it-f c c>10 "PI /.,-trYLe,-6. fe,--v,sref.
t. ..,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
S'•hed _L•-r - •-'.I...,rid •-nalties ofpenua.
1.1 G0--,
Print Name , I
0,11,f' f to A j.%.1 cc 1 0 14 k, /6 )
t,
Signature of 0 YnerlAgent Date
SEPT16412'..,:cONStRULMONSERVICES ... •
10.1 Licensed Constipction Supervisor a I,.-:..r 1c Al a f c‘to Not Applicable 0
faC-77-.7 Tr----------------—7 CS os-61 6 ?Name of License Holder-I .. 'e At A C 0 1 cl_ i
License Number
fc-i.„ Akrt-ov i Ari.4- o ro.1 6 _ -75: SP-0/O___
Address Expiration Date
2keN.d-eelZ5"--
Signature Telephone
0.01#4.*****0010****00000004#9PAYA40 'c 4;4::.***...%:...,-- •- .',.
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 0 No 0
LOO/ L00'd 'LIST* lisswmlaudsay TOZGOSLEIII6 gt:ZT LOOZ/IZ/ZI
Version1.7 Commercial Building Permit May 15,2000
9=•P' JON! : if N`/WD• C1 : TORBUlti4MGS ANt)STRtUC CS-St1134.610 .:.
I4C L TO 790 Ciglil0•(£OIFAIMI G MO E:mil 35; QQ.0 F&EI ;L.OSEa 9PAAe
9.1 Registered Architect
T
i Not Applicable D
Name(Registrant)_
Registration Number
k......_.... J.1 ,---.
Address
Expiration DateDate
sigma Telephone
9.2 Registered Professional Engineer(s):
i
Name Area of Responsibility
t 1 .
Address Registration Number
Signature Telephone Expiration Date _.....-_- ,...... ...._.._
Name Area of Respon6ity
Address FOitgration Number - .,
Signature Telephone Expiration Date
r-
Name Area of Responsibility•
Address
Y..._ - Registration Nuitrber
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable 0
Company Name: --_ _.__— .. _.-..._
Responsible In ChargeofConstruction
Address
Signature Telephone
L00/ 900'd IISI# dadAfM93bId301d tOZSOSL£tu6 SI:Zt LOOZ/tZ/Zt
Version'.7 Commercial Building Permit May 15,2000
g:aIF.L"."Yr7.17.iM-.4:7:77.7 :::::::77--'14-. f':.(1.;..q
Existing Proposed Required by Zoning
This column to bc filled in by
Building Department
Lot Size
r....-....--.-__
Frontage i....
Setbacks Front 7–--7 r-------:
i....–..—:
7----7 r----7-------7 ,----,Side L R:!---....--:L i7
Building Height 7---3 r--)--,
Bldg.Square Footage r______,i ;,____...: oh 7-1
Open Space Footage 1 i----,
Lot area minus bldg&paved I ' i________
parking)
i r------:
of Parking Spaces 1 k....-..---
Fill:
R z
volume&Location) i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW V YES 0
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW *4.74 YES 0
IF YES: enter Book i Page I and/or Document if
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has'a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO osii)
IF YES, describe size,type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NOR
IF YES, describe size, type and Location: 1
E. Will the construction activity disturb(clearing,grading,ecvaton,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.
LOO/ 500'd IIGI# UIVM9Td1330V TOZSOSLETt6 GI:ZI LOOZ/TZ/ZI
Version1.7 Conuncrcial Building Permit May 15,2000
S1EC71ON 4-::COI11B 15ERYIP1r..... PRO: T;S LESS'_Tf i411:36;@00 •..
Interior Alterations Existing Watt Signs Demolitiorj Repairs Additions Accessory Building
Exterior Alteration Existing Ground Sign New Signs Roofing Change of Use Other 0
Brief Description :Enter a brief description here.—^ `----- 0 —
n
Of Proposed Work: J 2.+, C 1 ,t r v» c f et /fr.0I 8 a u ,,,„ J.-, , y..
sa ra oN:r ._
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly El
A-1 A-2 [] A-3 1A I
A-4 A-5 1B
B Business 2A
E Educational C3 26 I
F Factory F-1 F-2 [] 2C
H High Hazard 3A
I Institutional In 1-1 1-2 1-3 38
M Mercantile 4
R Residential R-1 R-2 R-3 5A
6 Storage S-1 S-2 56
1
U Utility Specify:
M Mixed use CI Specify: r
S Special Use Specify:
jCOMPLEtE THIS:SECTION.0 EXiSTING:BU)L-DIG UNDERGOING'RENOVATI..: '.'p''''......-9' 7.,.16 ND/OF CHMGE:IN USG•:•...:<,.:,.
Existing Use Group: T-, Proposed Use Group: l
Existing Hazard Index 780 CMR 34):L Proposed Hazard Index 780 CMR 34):? f
lR :':: :-S ,316 RiG G T DAEA '
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION ---=_ '`.c...Y Y -.°
Floor Area per Floor(sf)
1 r Z CtD I
ire' _ —__-=___-__.3ro
P xpi;'--_ — — ----
4 ,
Total Area(sf)I 'Z• ('O Total Proposed New Construction sf)
Total eight(ft) L2.() t=' __
c
Total Height ft _ _ F;'"
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Z.,Q,pg"Information: 7.3 Sewage Disposal System:
Public Private[J Zone __... ' Outside Flood Zone El Municipal On site disposal system
LOO/ b00'd LLSL# 83,LVM93 IId33d LOZSOSL£L66 6L ZL LOOZ/LZ/ZL
Versionl.7 Commercial Build-.:Permit May 15 2000
2....I.Irre54:4:J.,„„,,,,.,_,:.;:t.;.'.-4,47::-4-- -. l•-
z!F;;_--`,1 :*:.0
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Building Department t"4:"4... -, ''''• ''''''''''-'4"'" .'"'"-'74ZA4N,?." +.:: -,Y....f-44,•'* '.. .••• •''''
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t-,: 4.';',..-.;..„,-.
Northampton, MA 01060
4,..g;4,..±7.. '7...4a,-;-2.4 ..*,:-.--„,cgm .. ,,,,a- --7;„,-.4 •-- 1_7,--..- ,,phone 413-587-1240 Fax 413-587-1272
r'-',.,_=.1,7=",=--v:i',5"-11,
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ttil .z:4' ."..-.'.'C.51 ,.-4—.71&F,A.4 cr.-,----..-3,0==.,—.,....--.-..^- ..
CATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
kf•-•;,77g•s.'ll'a-:11E,R3q_.‘ ii:.-•-,"7:-.!,.,,,:.-‘74::::::-3•f t..L..2.-....:;!.:_.:'-''.::.;',.:.,--,•4t1tz-r7:::', •,:.(,...j.......--f-i.:1.1 Property Address: zza:-.;.:;:r.-_a:,,t.::::.:_•rf::.:.F.i.”.:s1:-:::•:•••:-. 2•7••••::.:• ••7••:-.--••••:::'::.:-•,F,J•r-,:'.t.-:::,:,,.-:et:L.:x:71..,..t-.4.:-: 7-.-;::•.: ••;:::::::,...f.f.::::•.:2,:••• . ..:.-::1:--• -;"-"-..,::,--•:-.:::17.•.:----'..--5:..T.E:-:.
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Name(Plat P Current MaNing Address:A
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Signature L''' Telephone
2.2 Authorized Agent
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Name(Print) 1Ait fc Ot Current Mailing_Address:
itt/i -rtt
Signature C (---ell
2 i4.4.k.4_,
25,- - g7/."1"""'"?' . Telephone
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File#BP-2008-0592
APPLICANT/CONTACT PERSON ALL PROPERTY SERVICES INC
ADDRESS/PHONE P 0 BOX 297 HAMPDEN (413) 566-8888
PROPERTY LOCATION 502 HAYDENVILLE RD
MAP 06 PARCEL 006 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid g`l!O
Typeof Construction: DEMOLISH BARN TO FOUNDATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 96057
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN,F, O)MATION 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 ofHealth
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Peanut DPW Storm Water Management
Demolition Delay
Z-7 CS
Signature ofBuilding 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.
BP-2008-0592
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0592
Project# JS-2008-000920
Est. Cost: $6000.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class:Contractor: License:
Use Group: ALL PROPERTY SERVICES INC 96057
Lot Size(sq. ft.): 162914.40 Owner: FLINKER PETER A&STEPHANIE J
Zoning: SR Applicant: ALL PROPERTY SERVICES INC
AT: 502 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
P 0 BOX 297 413) 566-8888 WC
HAMPDENMA01036 ISSUED ON:12/27/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMOLISH BARN TO FOUNDATION
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 12/27/2007 0:00:00 $20.001296
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or twofamily
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a
home owner."
The building department for the City of Northampton wants person(s)who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical, plumbing&gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
understand the above.
Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date ci( l 05
Address of work
location 420 2 14-4---yo` °`' /1 c„
o 21 O
A,
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office OfInvestigations
600 Washington StreetXJa
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
0Name (Business/Organization/Individual): 1 L- R_ F L- 1 a L, A'
Address: 6j U G l..1-'A- 0 7`1 Jt Ll E )2-0 -
City/State/Zip: X-L DS I 2'0L t
Are you an employer?Check the appropriate box:Type of project(required):
1. I am a employer with 4. I am a general contractor and I
6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers'9. 1 Building addition
No workers' comp. insurance comp.insurance.t
required.]
5. We are a corporation and its 10.0 Electrical repairs or additions
3)21 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL 12. Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13. Other
comp. insurance required.]
Any applicant that checks box#1 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.
tContractors 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 andjob 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 Section 25A ofMGL 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'un er the pain penalties ofperjury that the information provided above is true and correct.
Sisnature: 1- z' —_ Date:
Phone#: (f 22) ,5 3 2 - 57
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable
Company Name Registration Number
Address Expiration Date
Telephone
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 building permit.
Signed Affidavit Attached Yes
6l
11. - Home Owner.Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to 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 farm
structures.A person who constructs 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
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the 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
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifi assumes re •insibility for compliance with the State Building Code,City of
Northampton Ordinances, State andLoc oning La A. .nd tate of Massachusetts General Laws Annotated.
Homeowner Signature
l/ - 't.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bldg. S- Demolition New Signs [D]Decks [i] Siding[D] Other[D]
i
Brief Description of Proposed
Work: I° L -t NCN l OF A 1rike-ti--E`t9 gi-- -\
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 Other
b. Number of rooms in each family unit:Number of Bathrooms (
I`Z-
r
c. Is there a garage attached? ND VIT Ft c'dz 1 16 i. •
f111-+%0r,041)'
7d. Proposed Square footage of new construction. 6 Dimensions C.-
e. Number of stories?1Vz— Cm 0T 1Na-1,-001drj e02-c-,{rr7)
f. Method of heating? /'0A-1 Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction Zx6 v"t'V' F -A cC
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 LoOAt && o3'+ C') 4-- i '(y
k. Will building conform to the Building and Zoning regulations? X Yes No.
I. Septic Tank Y. City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I PE Tie. F L I ,i iz-EX-- as Owner/Authorized
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.
Print Name
l
Signature wrr f g?rit~," Date 111
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 4'... G?
Setbacks Front fig. :
Side L:IL,4. ... R:.,2,5._„„L:wi.L)_. R •1,1 5-
Rear
Building Height
Bldg. Square Footage 0 a/o f
Open Space Footage 3-oc'r.`°'z It-1 `7.,._ % L Ft)or ec'r Ai 7)"_
Lot area minus bldg&paved
parking)
of Parking Spaces w”
W
Fill:V t)oi: f2 14a-ko
volume&Location) 1 !
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO
41:0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book ' Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 0
4tttA-Lit. eC>N 3
IF YES, has a permit been or need to be obtained from the Conservation Commissio ?
Needs to be obtained 0 Obtained 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 0 NO
JO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,ex avatiorr, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
c
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability '.
Room 100 Water/VVell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
iI , r Jth rSiecify
APPLICATION TO CONSTRUCT,ALTER,REPAIR;RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION i SEP - 3 2008
1.1 Property Address: j This section to be completed by office
tj r7 R-sib IN `r i i l f` iI' r. Mapf} Lot Unit
L C v; ilk A-Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
P sT> i 6 r L J k E r c7 2 ki ti t+t I 7 .EE P5
Name(Print)I Current Mailing Address:
c• ti Telephone
Signature
2.2 Authorized Agent:
Name(Print)Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building i Cr-er_y 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) 12 L"ZrU Check Number 56g014 049 (2,
This Section For Official Use Only
Date
Building Permit Number:Issued:
Signature:
Building Commissioner/Inspector ofBuildings Date
r
File ti BP-2009-0230
APPLICANT/CONTACT PERSON FLINKER PETER A&STEPHANIE J
ADDRESS/PHONE LEEDS (413)585-5724 0
PROPERTY LOCATION 502 HAYDENVILLE RD
MAP 06 PARCEL 006 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled uto 5 h- 5,Fee Paid
Typeof Construction: CONSTRUCT 2 STORY ATT BARN/PORCH(36 X 35)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
0
THE FOLLOWING ACT N HAS BEEN TAKEN ON THIS APPLICATION BASED ON
4
NFO ATION P NTED:
Approved _ dditional 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
Z-Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Del.
C'
Signa re of Bu' i ing Off• a Date
6/1 ! !p 0
Note:Issuance of a oning permit does not relieve a applicant's burden to comply with a 1 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.
4& ,BP-2009-0230
GIS#: COMMONWEALTH OF MASSACHUSETTS
maxioodc 46 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0230
Project# JS-2009-000299
Est. Cost: $65000.00
Fee: $252.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class:Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 162914.40 Owner: FLINKER PETER A&STEPHANIE J
Zoning: SR(100)/ Applicant: FLINKER PETER A & STEPHANIE J
AT: 502 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
502 HAYDENVILLE RD 413) 585-5724 0
LEEDSMA01053 ISSUED ON:11/3/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 2 STORY ATT BARN/PORCH (36
X 35)
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 11/3/2008 0:00:00 $252.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
502 HAYDENVILLE RD BP-2009-0230
GIS #: COMMONWEALTH OF MASSACHUSETTS
ek!' . 006/ CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2009-0230
Project# JS-2009-000299
Est. Cost: $65000.00
Fee: $252.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class:Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 162914.40 Owner: FLINKER PETER A& STEPHANIE J
Zoning: SR(100)/ Applicant: FLINKER PETER A & STEPHANIE J
AT: 502 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
502 HAYDENVILLE RD 413) 585-5724 ()
LEEDSMA01053 ISSUED ON:11/3/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 2 STORY ATT BARN/PORCH (36
X 35); e, hetypersiing-updatectxonstroction.plans
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 Sinnature:
FeeType: Date Paid: Amount:
Building 11/3/2008 0:00:00 $252.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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a n- The Massachusetts State Building Code - One 4 Two Family Dwellings- lth Edtlon
O TABLE 5501.2(4) MASSACHUSETTS BASIC. HIND SPEEDS Leeds, MAi V <40uA-+ mph
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4 X 5501.2.11 Design Criteria Minimum Design Loads for Buildings and Other Structures (ASGE -1-02)
O Wind Loads- Method I(Slrcplifled Procedure)
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o a 5501.2.14 Exposure Category B
u OO 540816 Foundation Anchor The wood sill viola slid be anchored to tho foundation with le
tl, O 3 mhhwm diameter A507 steoi-anchor bolts with nuts and plate washers spaced a maxim" of d
3 3 n o center. Bolts shall be located not more than 12"nor less than seven bolt arneters fromOshalld
each end of the plate section. Anchor bolts shd extend a minimum of seven inches Into concrete.
For shear wd design,provide 46"diameter anchor bolts for each end of each shearwd.
560210.5 Braced NW Panel Construction
Braced wall panels In the 2nd story slid follow 560210.5
Braced wd panels h the 1st story shag be Shear Walls as shown.
All panel points (vertical and horizontal) to be backed by studs or solid blocking
Where nil spacings are 5" or less, studs shall be doubled s panel Joints.
560210.8 Gornectlorm.Studs at ends of shear wills shall be doubled and shall be fastened to the
foundation with Simpson Strong-Tie Holdowns(or equal)to be provided as shown at let floor.
56041 WOOD STRUCTURAL PANELS-Identification and erode. Wood structural panels shall conform
to DOG P5 I or DOC PS 2.
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Louis Hasbrouck
From: Louis Hasbrouck
Sent: Tuesday, October 28, 2008 2:11 PM
To: Peter Flinker'
Subject:Barn at 502 Haydenville Road
Peter,
I've gone over the plans for the barn, and there are several things I'd like to discuss. In no particular order:
The barn must meet setbacks for a principal structure (20', not 15'; too tall and too close to the house to be considered an
accessory structure). It is shown on the plan as meeting the setback, but we will need to verify that dimension once the
foundation is in place.
We'll need point load calculations for the cupola.
The barn will need a structural ridge; the plans don't show one.
There aren't enough braced wall panels on the ground and first floor levels to meet the prescriptive requirements of the
code.
We'll need the load calculations for the LVL beams.
We'll need the floor plans labeled for use(fire separation and floor loading).
We'll need better framing details (dimensioned and labeled section drawings).
I'm in the office from 8:30 to 9:30 and from 1:00 to 1:30; call me and we can set a time to go over my concerns.
Louis Hasbrouck
Local Inspector and Zoning Enforcement
City of Northampton Building Department
212 Main Street
Northampton, MA 01060
413) 587-1240
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DEPARTMENT OF BUILDING INSPECTIONS
sd 212 Main Street • Municipal Building
Northampton, MA 01060
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Peter Flinker
502 Haydenville Road
Leeds, MA 01053
April 3, 2008
Dear Peter,
I visited your property on December 26, 2007. Your barn had collapsed under the weight of
snow from a recent storm. I documented the damage and approved a demolition permit at that time.
The barn's rubble foundation (see attached photo) does not meet the requirements of the
Massachusetts State Building Code. It is not of sufficient strength to support any sort of a structure. It
must be replaced if the barn is to be rebuilt.
If you have any questions, please call. Our telephone number is 587-1240 and our office hours
are Monday through Friday, 8:30 am to 4:30 pm, excepting that we close at 12:00 noon on
Wednesdays. My email address is: lhasbrouck(a city.northampton.ma.us.
Louis Hasbrouck
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City of Northampton
Local Inspector and Zoning Enforcement
lhasbrouck(a city.northampton.ma.us