17A-159 Jul - 12 - 2010 08:07 AM Remillard Insurance 1413 .itsoviv
16 . CERTIFICATE OF LIABILITY INSURANCE OP 03 1
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THIS CERTIRCATE IS ISStI3) AS AMATTER OF 1IFOR11AT1ON ONLYANO CONR5RS CO NO RIGHTS MON TffE CERTIFICATE HOLDER. THIS
CERTIRCA1E DOES NOT AFFMOMATNELY OR NEGATIVELY AMEND, EXT S) OR ALTER THE COVERAGE BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETYME3f THE ISSIMIG INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: Wths sarencese Inkier Is as ADisTIOTUCHNIBM the policyOes) must be endowed. IrMAIRIXATION IS WANED, subject to
the teems and oandlioas attic PAY, certain packs Nay require an endorsement Aunt on Via certificate does set confer rigida tothe
I , holder Is lien of each
PRODZR
MAIM
IRemfllard Insurance Arley, Inc ,F imt.
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`_ 79 Lyman Street
1 South Hadley MB 01075 mae DO 7--25
2hone:413 - 538 -7862 Fax:413- 538 -7179
ammo erell�nPFaRlonsoore+aGE MACS
A: Merchants rasurance Group
- Pelletier & Patricia mss: ACII TAIL
0 7 Nam St etc:
Holyoke MA 01040
INSURER 0:
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1 MINIM S:
COVERAGES ERA CERTIFICATE NUNBER REVISION MEM
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1 ■■ GAS a al= • MED19P (Am one pemore $ 5000 _
a II g lERSOWL&AWrICU 1RY $ 1000000 -
1 II GEMERALAGGREGATE s 2000000 -
GE AGGREGATE LeETAPPUESPEM PRODUCTS - LmiSmaPAOG : 20 0 0000
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i 018$82009 ACORD CORPORATION. All rights mewed.
1 ACORD 25 (21109/09) Thus ACORD mete and logo are registered matins ofACORD
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The Coaimonweakh emassathisem;
Department o.fIndustrialAcddents
. • — :-...—..,..--- ,,,,-: •
Office ofhwestigadons
--: 5 ) ---
- --,- MO Washington Street
Balton, MA 02111
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Workers' Compensalion Insurance Affidavit Boullen/Contractors/Elecirielans/Plumers
Anolicant laformadon Please Print Legibly
,
Name (Business/Organizsiegandividual): ' . - .IV krb au An 4 _, ' * ' , 0
Address: )J07 M,q, S1
cit ildobiokia- Na. olotio ph #: ( -1/3- 53 6 6DD----
Are , , an employer? Cinch? appropride bac Type ef project (required):.
1. Ki. I am a employer with 4. 0 lain a general contractor and 1
employees (full andlorpart-tirae).* have hired ihe sub-contract= 6- 0 New construction
2.01 am a sole proprietor or partner- Wed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contraenns have 8. 0 Demolition
working for me in any capacity.. employees and have swims'
0 BaarTmg a
[No workers' comp. insurance — comp. insurance.*
. ddition
, regalia] 5 iti Wenie a corporation and its 10.0 Electrical repairs or additions
3.1__iI am a homearmer doing all work- officers have exercis' ed their 11.0 Pkimbing repairs or additions
myself [No wodrers' comp. - right of exemption pa MGL 12.0 Roofrepairs
insurance required.] t . c. 152, §1(4), and we have no
130
Other , 1.-) 0 ;; SU le-A I
employees. [No workers'
comp. insurance lapin:di
*Any appliamt that decks box #1 met also Meet de section below allowing their workers' compensation policy information.
t Honnownerawboadnalt this affickvit iodating they an doing all work and than bins madder contractax must submit a aow affidavit iodating sock
tCoranactors doodad( ibis box east attached an additio' nal sheet showing the name of the sub-contract= and state minden- or not dame entities have
employees. Ifthe sub-cononoton; have employees, they most ;maids their madras' comp- policy number.
lam an employer that i s prositike workers' compensates imarrance for my emplo yee& Below i rase pug mail* she
information.
. Insurance Company Name: 0 ce tiSlq
Policy # or Self-ins. Lie' . #: e Expiration Date:
Job Site Address: L/ 3 46 Arz-ifY\ 4(.° atotaterrap:
Attach a copy of the workers' compensation polity declaration page (showing the policy amuhernrad expiration date)._ . .
Failure to secure coverage as required under Section 25A of MEL c. 152 can lead to the imposition of criminal penalfies 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 1250.00 a day against ihe violator. Be advised that a copy of this statement may be- forwarded to the Office of
Investigations of the DIA fir insurance coverage verifiadion.
I da hereby — t , wrier the paha; and parades ofpajary that the information povidedabirre is *me and coned
‘ I /
Signature: - # 1 ''' • P...611.,±44._ Data 1 0 /9a-1 i 0
Phone #: t113 - 63
Official use ally. Do not write in this arra,* be completed by cky art ofrsdal
1
City or Town: PITT PernfitiLicense #
Itanfing Authority: Baring Department
, -
Contact Pawn: Phone #: (413) 499-9440
•
8.1 Licensed Construction Supervisor. Not Applicable ❑
NUne of a. Holder : �av�l1� \ c c,� J , .\\ �' 1 j a
• License Number
l� CYO �� S� • . c� VS--1C)
—1)(4)Add Expiration Date
l !� • Nl 3 S 3' -
1 Signature Telephone
Not Applicable ❑
Company Name . Registration Number
Adds ( Expiration Date
4 14"rWi.tilt ) f �� - � Telepho
See `3oI8" REC lilPiENSATIM1NSV 1 Vit st #le 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 No ❑
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" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
. ? x oL, ; �, -,.-i.,:;.1.; ,E..,<. '. , +,fry A; S . . ..1,..' LK ._?i. .. s
New House 0 Addition Q Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks at Siding [0] Other
Work: 0 JAsed , ar X -. 3'' (, Lieu_ i�e�v /
Alteration of existing bedroom Yes No Adding.new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a. Use of building : One Family i 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?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masschedc 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 .
I. Septic Tank City Sewer Private well City water Supply
t 7a OWSER 'flON **04 0
i S A� # A � T �� P : ,
is
1, , as Owner of the subject
proPenY _
hereby authorize -� r � v� '- Pe-1/12 1_'
to act on my behalf,'" all matters relative to wo a orized by th' building permit applica n.
M - . /. A . 1 � -%l<
Date
I, 1 OOA)g /o/ I9f.I M as Owner /Authorized
'Agent hereby dedare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sig / n
under the pains and pe nalties of perjury.
j),i At)1'd'f (� Pe t / -e-� c e
Print Na
/ 1)n kit Re/i/bi /° f D
Signature of Owner /Agent Date
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 1
I
Frontage H
Setbacks Front l I
Side L: _ RLJ L:� R:� i] ._ 1
Rear
Building Height L] I 1 I
Bldg. Square Footage El] %
Open Space Footage
paved
((lot area minus bldg &
panting)
# of Parking Spaces I
SWIM Asaser
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ® YES
IF YES: enter Book Page _ and /or Document #L
B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ®
, Date Issued:
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1r
ci rct1� 1ca.41
•
City of Northampton
Building Department
212 Main Street
` ' Room 100
Northampton, MA 01060
1 1 phone 413 -587 -1240 Fax 413- 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION #{
1.1 Property Address: * w' n k Y ' II b �e
rAr 1-15 12c1
yr1 ♦
L s .
l I �. t ' ' � ,.} ' • Wx ' } ' ' w
StiOPl D
2.1 Owner of Record:
nre Gray-)
X13 �0A r
V (Print) / Current Mailing Address:
icje KC( C`e_. c=w4 r
Signature! FO
2.2 Authorized Ascent: •
rAi,1 �.eM `e-ru 11 0 1'U�,i aJ 1 / 01�e A
Name • rint) Current Mailing Address:
< 1 14.4,- !11 iede ,��.t� . 9l3 .5- to zy
Sig : re Telephone
Item Estimated Cost (Dollars) to be O
completed by permit applicant
,4 t
1. Building ' - SI7 0 p FP I O st
2. Electrical -o E' red Totat O o
nn'f� 4
3. Plumbing 1 Ne
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5)
4 011$401101V - -900604.10,c/40..
*lildil Nvr ,
is
.
File # BP- 2011 -0370
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION 43 FOX FARMS RD
MAP 17A PARCEL 159 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid C g , /
Typeof Construction: INSTALL WALL INSULATION C (� (GU{V
New Construction j ♦ �Jf 7
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 101876
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
Demotion Delay
/I() 9X - ��
Signature of Building 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.
V
•
•
1 ' BP- 2011 -0370
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- 2011 -0370
Project # JS- 2011- 000613
Est. Cost: $2221.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 27007.20 Owner: GRANT GERALD S & BERNICE B
Zoning: URA(100)/ Applicant: DONALD PELLETIER
AT: 43 FOX FARMS RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON:10/25/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WALL INSULATION - INSULATION
INSPECTION REQUIRED
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 10/25/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner