23D-021 ACORD
M INSURANCE BINDER DATE(MM/DDYYY)
03/05/2012
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
AGENCY . COMPANY BINDER*
Webber & Grin ell Irma �.Inc. Peerless Insurance 812030516261
r �' DATE EFFECTIVE TIME X AM DATEXPIRAl10N
TIME
8 North King tre - � ,r �
_ ` 7
Northampton, A 060 03/01/2012 12:01 03/31/2012 X ME
PM NOON
PHONE f 13 58) 014.1 FEB atteN 4_3 5 _ 6 6481 „ . THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY
CODE: 6/20043. SUB CODE: PER EXPIRING POLICY #
_..........
AGENCY 00022784 ` DESCRIPTION OF OPERATIONSIVEHICLES/PROPERTY (Including Location)
C USTOMER D
00001 /00001
INSURED
36 Service Center Road
Stephen Ross Northampton, MA 01060
Attn: Kim Clairemont
36 Service Center Road
Northampton, MA 01060
COVERAGES LIMITS
TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS % AMOUNT
PRO CAUSES OF LOSS Business Personal Property 500 100 5,000
BASIC BROAD X SPEC ' BI w/ Extra Expense 72 Incl uded
;Equipment Breakdown 500 Included
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO $ 300
X COMMERCIAL GENERAL LIABILITY RFENTED_PREM(SES_.
CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
RETRO DATE FOR CLAIMS MADE: -. PRODUCTS - COMP /OP AGG $ 3,000,000
VEHICLE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO BODILY INJURY (Per person) $,_ _...... _...
ALL OWNED ALTOS BODILY INJURY (Per accident) $
SCHEDULED AUTOS ,. PROPERTY DAMAGE $
HIRED AUTOS MEDICAL PAYMENTS , $
NON -OWNED AUTOS PERSONAL INJURY PROT $
UNINSURED MOTORIST $
$
VEHICLE PHYSICAL DAMAGE DED ALL VEHICLES SCHEDULED VEHICLES . ACTUAL CASH VALUE
COLLISION. __
STATED AMOUNT $
()MERMAN COL
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO, OTHER IHANAUTO ONL Y . __, _.. ......
_._.. EACH ACCIDENT $ ....... _....
AGGREGATE I$
EXCESS LIABILITY
EACH OCCURRENCE $
UMBRELLA FORM A,REGATE_, . _ .. __.. $
OTHER THAN UMBRELLA FORM I RETRO DATE FOR CLAIMS MADE: SELF - INSURED RETENTION $
WC STATUTORY LIMITS _..
WORKER'S COMPENSATION _ EACH ACCIDENT $ .... _.. _...... .__
AND
EMPLOYER'S LIABILITY E L DISEASE - EA EMPLOYEE $
E . DISEASE - POLICY LIMIT $
SPECIAL
CONDITIONS / TAXES _...._ $ _....
OTHER
COVERAGES ESTIMATED TOTAL PREMIUM $
NAME & ADDRESS
MORTGAGEE __.. ADDITIONAL INSURED
LOSS PAYEE...._
LOAN*
AUTHORIZED REPRESENTATIVE )i _ n
Richard Webber, CIC/BARBG Y
Page 1 of 2 @ ACORD CORPORATION 1993 -2007. All rights reserved.
ACORD 75 (2007/01) The ACORD name and logo are registered marks of ACORD
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Suupe / : ^ Not Applicable ❑
Name of License Holder : �-�-L� {rJ � t>e✓ 71/6%)
License Number
36,. 5.-c r-v: c.. 6,...--/-,,,7 f -� y72.e / 3
Address Expirati n Date
, k1.. 4 1-71i . 1, 44-4_ U / U G,-° ,
ature Telephone
4'/r Sq -/ Zz'1
9. Registered Home Improvement Contractor Not Applicable ❑
C o any Name ✓ Registration Number
3G . s-e- ✓1 ect i. e 1 /PA.--- ., < s --/ q /2_e !I
Address Expira on D to
Telephone -CO '"-- / Z2_y
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 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing n
Or Doors (�
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [I=] Siding [O] Other [12( •
Brief Wok Description Pro�ose��Q � M 7 2 /344 ...s e; (
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 ho se and or addition to existin • housin • corn • lete the followin •:
a. Use of buildin e : One Family Two Fami ' Other
b. Number of roo s in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new cons ction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Ce plia 'ce. Masscheck Energy Compliance form attached?
h. Type of constructi •
i. Is constructio• within 100 ft. of wetla Ids? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of easement or cellar floor belo inished grade
k. Will building conform to the Building and .'ning regulations? Yes No .
I. Septic Tank City Sewer "vate well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ii./ 4 �{�G�f��P% , as Owner of the subject
pro erty
hereby authorize - 1 [2 0r5 -
to act on m behalf, in a matter relative,,to thorized by this building permit ap lication.
/ 3
Signature of Owner Date
I, S'-/I tt •A-� I)- �V 5 5 , as Owner /Authorized
Agent he by declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belie
Signed under the pains and penalties of perjury.
Print Nam
z
'gnat of Owner /Agent trite
4p IN 1 4 .... ..1 - 4 ,(0-te --- receia4
Al; /(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 fi ed in by
Building Depa nt
Lot Size
Frontage
Setbacks Fron
Side L: R: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footag-
(Lot area minus bid: : paved
parking)
# of ' . rking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding r been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regist of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 , 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 e t---- --
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exca tion, 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
PTV- Department use only
� __, ' Cit of Northampton StatusofPermit:
Bu Iding Department Curb Cut/Driveway Permit
1. FEB ' 12 Main Street Sewer/Septic Availability
2 � {3 Room 100 A/Vater/Well Availability
No hampton, 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: This section to be completed by office
5c C-r 5d(4._ Map Lot Unit
11 /Ylidt. G/'9 G, o Zone Overlay District
� EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
,mod Tv' - - * J- 7 2, I� .",.. k v7
Name (Print) Curr ailing Address: ,i (if
�° l Telephone •
Signature y 3 6 - 4 z z.
2.2 Authorized Agent: > �,�
S D. i e- cr-7 5-� ✓ ism_ ewe -/- --
Name rint) Current Mailing Addr ss:
.natu /� Telephone q §-sect -. /E I f
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed b permit applicant
1. Building Q 29 (a) Building Permit Fee
U `
2. Electrical I e - (b) Est imated Total Cost of
Vim( //' Co nstruction from (6)
3. Plumbing - 4/2 dr ' Building Permit Fee
4. Mechanical (HVAC) Q
5. Fire Protection .J �/
6. Total = (1 + 2 + 3 + 4 + 5) `mi qO'U . Check Number 3Y f 6,
This Section For Official Use Only
Building Permit Number: I s
g Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0753
APPLICANT /CONTACT PERSON STEPHEN D ROSS
ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413) 584 -1224 0
PROPERTY LOCATION 504 ELM ST
MAP 23D PARCEL 021 001 ZONE URB(100)/WP(17)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ``�
Fee Paid
Typeof Construction: REPAIR WATER DAMAGE TO 2 BATHROOMS & KITCHEN CEILING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 079160
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFy 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
Demolition Delay
621/S
Building Official Date
Signature g
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.
504 ELM ST BP- 2013 -0753
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 021 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0753
Project # JS- 2013- 001298
Est. Cost: $10900.00
Fee: $63.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq. ft.): 7013.16 Owner: TRAVERS DAVID J & KAREN ROY
Zoning: URB(100)/WP(17)/ Applicant: STEPHEN D ROSS
AT: 504 ELM ST
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584 -1224 () WC
NORTHAMPTONMA01060 ISSUED ON:2/15/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR WATER DAMAGE TO 2 BATHROOMS &
KITCHEN CEILING
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 2/15/2013 0:00:00 $63.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner