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24D-290 Oct, 22. 2012 3.36PM No. 1214 D P. 1 V oD , Y ,, Y , ACORD„, CERTIFICATE OF LIABILITY INSURANCE 1 0/22/2012 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SULLIVAN,KEATING & MORAN INS , AGY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. BOX 2619 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. SPRINGFIELD MA 01101 - 2619 1 - 413781 - 5750 INSURERS AFFORDING COVERAGE NAIC# INSURED FITZGERALD ROOFING INSURER A: PILGRIM INS CO MICHAEL FITZGERALD DBA INSURER B: GRANITE STATE INS CC) 33 CATAUMET LANE INSURER C: WEST SPRINGFIELD MA 01089 INSURER D: _ 1 1- 413 - 734-8438 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, Irv8R�o D'L POLICYEFFECTIVE P OLI CY E�)(pI I QTR Igano TYP , , , POLICY NUMBER • E „I,ppD DATE MMIOO RAT •N LIMITS GENERAL LIABILITY EACH OCCURRENCE 3 - MIA - GE TO RENTED COMMERCIAL. GENERAL LIABILITY PREM18ES (Ea acaXerboa) 3 CLAIMSMADE I I OCCUR MED EXP /Any one parson) 8 NONE PERSONAL & ADV INJURY 3 GENERAL AGGREGATE $ OEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY (� T , LOC , AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYA TT° (Ea acddenl) ALL OWNED AUTOS BODILYINJURY $ 250,000 X SCHEDULED AUTOS (Per person) A X HIRED AUTOS PGC00001007213 12/06/11 12/06/12 BODILY INJURY X NON- OWNEOAUTOS (PeraocIdenl) $ 500,000 PROP ERTY OAMAGE $ 100 (PetBcefde,Y) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT 3 ANYAUTO NONE OTHER THAN EA ACC $ AUTO ONLY: AGO 3 EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE 3 OCCUR I - i CLAIM9MADE AGGREGATE _$ DEDUCTIBLE S _ RETENTION 4 $ WORKERS COMPENSATION AND X I TQRYI IM I ER EMPLOYERS LIABILITY WC009944027 10/11/12 10/11/13 E.L. EACH ACCIDENT $ 100,000 ANY PROPRIETWPARTNER/EXECUYIbE oPFICeAJMEMBER EXCLUDED Y E.L. DISEASE - EA EMPLOYEE $ 500,000 eyes doccribeunder SPE C IAL PROVISIONS Wow E.L.018EASE- POLICY LIMIT $ 100,000 OTHER NONE DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT ( SPECIAL PROVISIONS MICHAEL FITZGERALD IS A SOLE PROPRIETOR AND HAS ELECTED NOT TO BE COVERED UNDER THE ABOVE WORKERS COMPENSATION POLICY. YOU WILL RECEIVE A SEPARATE CERTIFICATE FROM THE WORKERS COMPENSATION COMPANY. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO■ BUILDING INSPECTOR DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL_1O w DAYS WRITTEN 212 MAIN STREET NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL NORTHAMPTON MA 01060 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, 1T8 AGENTS OR FAX 1 -413 -587 -1272 REPRESENTATIVES, AUTOO REPRESS THE (— _CORD 26 (2001108) 0 ACORD CORPORATION 1998 City of Northampton Massachusetts �.. .; LI: ft, DEPAR OF BUILDING INSPECTIONS � i 212 Main Street • Municipal Building -� Northampton, MA 01060 6r.1,760 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 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 home owner." The building department for the City of Northampton wants any 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 Address of work location The Commonwealth of Massachusetts "....-` Department of Industrial Accidents 41. - Office of Investigations I:: �- 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information r Please Print Legibly Name (Business /Organization/Individual): T 9 ) 29 e -A b l) R _ Address: i l-' IN-a4 c)i AV all117 t 1 City /State / . : ,Jek .P.61 I iiiitNI Phone #: 2��fr` , Are you employer? heck the appropriate box: Type of project (required): 1. am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. El New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub - contractors have 8. E] Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plum • g repairs or additions myself. [No workers' comp. right of exemption per MGL 12. oof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. U Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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 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 and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: b i Job Site Address: ) 5C eSGp-�' City/State /Zip: d�`�T �T r ! (.U\ 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 of MGL 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 and the pains d penalti of perjury that the information provided bove i true d correct. Signature: 11,41 -' ��J�✓ Date: /0 1 - I' /-- , Phone #: 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 #: , ECTION 8 - CONSTRUCTION SERVICES J8 w .1 Licensed Construction Not Applicable 1:1 Name of License Holder : / y m d- T F ,' 1 tip _ License Number -- H ylz.o e ....." Al address Ex�ira ition Date 7 00 73V r1 z_oji Signature Telephone `�° "'°' K Not A 9.�Re9istered.klome;Impcovemeit Contractor ,,., �- .�,� � ,,,��,,,� ��_...,.- Applicable ❑ Company Name Registration Number , 1 z/4 Address , Expiration Date j Q / 2 j 474/ AV Telephone 16 76 / i - icl nv-cl 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 mit. Signed Affidavit Attached Yes No ❑ lkl4nO ne .Owner Xe ptio 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 • J SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) e. . New House n Addition ❑ Replacement Windows Alteration(s) 1 1 Roofing -� Or Doors 0 r Accessory Bldg. I .I Demolition ( 1 New Signs [E] Decks [[]. Siding IDI Other [0] Brief Work Description of Proposed R 2— 001.Z F nc y k , ��,p Alteration of existing bedroom Yes No Adding n >f k i edroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If,Nevii house and or addition existing ho complete the following: ` a. Use of building : One Family L Two Family Other b. Number of rooms in each family unit Number of Bathrooms c. Is there a garage attached? i,,C,S _ 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 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, ! j _k ; <?. L.- • , as Owner of the subject property hereby autho ize to act on y half, 1 - I matters re it to work authorized by this building permit application. �yln4 OA. -.ir i. Signature of Owner ,r Date 1, , 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. V 1 i AIMS t me 1 . natur of er/ , . - t N.‘ Date I c 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 E s Building Department . Lot Size --...� ° i Frontage ----- - -- -- __ Setbacks Front tl _ .. Side L:' R:_._.. L: R:_.... Rear t -- Building Height 1 t Bldg. Square Footage - % - Open Space Footage (Lot area minus bldg & paved _____ , parking) # of Parking Spaces , 1 Fill: __ . �� _ .___. _.w__ . .. .. (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:` IF 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 # 9 A , B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 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 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 plan that will disturb over 1 acre? YES 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t 1 - Departme� #u on REG� �/ °t- City o Northampton Status of Perrin i , rz , , Building Department C b C u P, l P enn -t � t - : r OCT 212 Main Fax Street S ewe r /Sep al ' ti �. . `k < - S W , -* � " ts *', 'a.:.. 23 Room 100 W Availability . * A vtsz� a ma " " , " o- 1 1 t t x i Northampton, MA 010413 60 Tww S is of ? Struc t u 11? a � - Pr. of BUILDING INSPECT o ne 13- 587 -1240 587-1272 Plo Stt = � ` '' � ' 1 NORTHAMPTON MA 010 Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION Thi section to be" c ompleted by office 1.1 Property Address: ,, 1—... c- 0- Map Lot Unit ..jor�'d' �� i b x , k.. �,� T one �= r ..., , ., OverlayD,i N° Elm St. District" " GB District" SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT '- ' ,. e..s1.;,..j. (44.. 2.1 Owner of Record: ,f 'r® '. a Si CAS f 5 C-gL Na : (Print) Current M ailing Address: / _ y; i� i l.� Telephon :ig ur ) 5 34 /'-t 05 2.2 Aut �• ed Name (Print) Current Mailing Address: Signature Telephone SECTION 3 .. ESTIMATED C N CO NSTRUCTIO ' . Item Estimated Cost (Dollars) to be O fficial Use Only' completed by permit applicant 1. Building c.),0-(:.'")t/ (a) Building`PermitFee m ( 6) 2. Electrical (b) E T otal Co of " Construction fro 3. Plumbing Buildin Permit Fee 4. Mechanical (HVAC) 5. Fire Protection _ 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 0 This Section For Official Use Only Permit Number: . Building Date 9 Issued: Signature: Building Commissioner /Inspector of Bu Date • 156 CRESCENT ST BP- 2013 -0472 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 290 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2013 -0472 Project # JS- 2013- 000756 Est. Cost: $8600.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MICHAEL FITZGERALD 100297 Lot Size(sq. ft.): 4835.16 Owner: GEORGANTAS MARGO C Zoning: URB(100)/ Applicant: MICHAEL FITZGERALD AT: 156 CRESCENT ST Applicant Address: Phone: Insurance: 129 WESTMORELAND AVE (413) 234 -8438 WC LONGMEADOW MA01106 ISSUED ON ::10/22/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE ROOF 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 10/22/2012 0:00:00 $70.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner