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31B-003 (3) • -620—eam ' t7;1 = =V - -� =i =_ = Office • of Consumer Affa and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 160105 Type: DBA Expiration: 6/25/2012 Tr# 298839 D & D MASONRY & CHIMNEY NICHOLAS DOUP ----- ___ - -- 12 KATI LANE PALMER, MA 01069 Update Address and return card. Mark reason for char (l Address Renewal F Employment Li Lost DPS -CAI 0 SOM 04104- G101216 6ontwron 1 a&4 a 770;:::adrr.uae!!s License or registration valid for individul use only Office of Consumer Affairs & Buness Regulation g HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to . Registration. 160105 Type: Office of Consumer Affairs and Business Regulation Expiration: 6/25/2012 DBA 10 Park Plaza - Suite `ii70 Boston, MA 02116 D CD & CHIMNEY NICHOLAS DOUP 12 KATI LANE PALMER, MA 01069 _ _ _ _ _ _ _ _ _ _ _ Undersecretary Not valid without signature i 5 i;♦.i tl`l'�S 4 S;t 3k1 �te .tilf• nt tittttt lti , Efti trit s ^�.•S ,;, 10213 • • DOUP • fi GEORGE IT UCA AVM .,�. .: PENS ACO A FL 325 Exp 411120 13 102134 )m:Rosemary DiNatale FaxID: Date:3 /6/2012 03:33 PM Page: 2 of 2 D &DMASO -01 DIRO ..44CG7RL7- I DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 3/6/2012 THIS 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 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must 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 (413) 733 - 3131 REACT Rosemary DiNatale FieldEddy Insurance PHONE , Ex t(: 413 - 3131 123 FAX 96 Shaker Road + (Arc, No): 413 - ?33 -3191 P.O. Box 709 ADDRESS: RDinataletfieldeddy.com East Longmeadow, MA 01028 -0709 INSURER(S) AFFORDING COVERAGE NAIC A INSURER A : Western World INSURED Nichols Doup DBA D &D Masonry and Chimney INSURER B: 299 Columba Street INSURERC: Chicopee, MA 01 020 INSURER D : INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 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 CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH(S 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILLTTRR TYPE OF INSURANCE INSR WVD POLICY NUMBER IMMIDDAYIM POLICY LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY NPP8085344 1/4/2012 1/4/2013 DAMAGE TO RENT PREMISES (Ea occurrence) $ 50,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLES PER PRODUCTS - COMP /OP AGG $ 1,000,000 X POLICY O- LOC $ u AUTOMOBILE COMBINED SINGLE LIMIT UTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED - SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS -- HIRED AUTOS NON- OWNED PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED I REILNTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E L DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIME $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Building Inspector AUTHORIZED REPRESENTATIVE i O 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : G eU t e . ° / v 2 / 3 L/ License umber C l 04_ /( >✓ / Yu Pet kV 1 , Ql Address Expira ion Date Signature Telephone 9 Re • Istered Home Improvement Contractor Not Applicable ❑ ►�1�J N c.( CLwvtet ` ( f 6 C5l 0 S Company Name l Registration Number ) 2 IC (it it C vfi/ -- Va5 �I Z Address Expirati n Date er Telephone ql E'`t Y `f `l 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 ❑ No ❑ 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" 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 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 L:, R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved 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 C IF YES, date issued: YES: Was the permit recorded at the Registry of Deeds? NO 0 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 0 DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 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 0 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 0 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 Alteration(s) ❑ Roofing ❑ Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0] Brief Description of Pr osed Work: new c`e. ? ,S r. c. C- C `..,,,v i p ,.-..r,_ rtLA_ 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 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. 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 . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN WNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, /4c/711, 6 CC e, , as Owner of the subject property hereby authorize b "/' _--- c" h to act on my behalf, in all matters relati - . ,,., k authorized by this building permit application. , 2,, , i -.. / ..2_ 1 , n a S i ture of O Date i 44 I, , 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 Signature of Owner /Agent Date D epartmentuse'oniy F RECEIVED City of Northampton Status of Permit ° . � , Building Department Cur•b:Cut/Driveway Permit VAR — 7 2012 212 Main Street Sewer /SepticAvailablity ' Room 100 Water/Well Availability .oF BUILDING INSPECTIONS Northampton, MA 01060 Two Sets of Structural Plan! ' - T NORTM■'"pTON MA 01 413- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify -, r k Ce APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office (O .ki- Map Lot Unit N l ' " 1-t" 140-194u-N- Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: i�'L " - / /' y� � /cr lc� 7 /' (-01 �5 ''' /�' 5crsr T Ste' + k __/47," Name (Print) Current Mailing Address: x/13 �4S ,5 O r 7 2-- -' 7 Telephone 1. ,, Signat ,,,,, w 1 2.2 A o rizedd Agent: j J fil'1u' _ ' r1J ,,(1 - I f9L "t t\ C ') / Z. lc Pt if L.,vTLC i1 e-icr ' v oi�- >(,`j 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 ('ow ( 9L j & c o (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 4,053 t5.5 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date A File # BP- 2012 -0774 APPLICANT /CONTACT PERSON D & D MASONRY & CHIMNEY ADDRESS/PHONE 12 KATI LANE PALMER (413) 348 -9839 PROPERTY LOCATION 66 BANCROFT RD MAP 31B PARCEL 003 001 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 6655 4 Fee Paid '�✓✓��// Typeof Construction: CONSTRUCT FIREPLACE,CHIMNEY & FLUE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 102134 3 sets of Plans / Plot Plan THE FOLL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION PRESENTED: pproved 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 Demob' 'o • lay / 7- 1/ 21'' ‘ • is ...1 e . e nil. ing O fi 'al 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. 66 BANCROFT RD BP-2012-0774 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 003 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit # BP- 2012 -0774 Project # JS- 2012 - 001155 Est. Cost: $8000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: D & D MASONRY & CHIMNEY 102134 Lot Size(sq. ft.): 8886.24 Owner: GRANDONICO KATHRYN Zoning: Applicant: D & D MASONRY & CHIMNEY AT: 66 BANCROFT RD Applicant Address: Phone: Insurance: 12 KATI LANE (413) 348 -9839 PALM ERMA01069 ISSUED ON:3/12/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT FIREPLACE,CHIMNEY & FLUE 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 3/12/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner