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17A-281 (3) 4133398321 P• 1 JEFF PECK y $Vincent Rd.-Heath i , Phone:413-339-8321 home harlemont,MA 01339 sitgrot(c faatmail,fm _ 91 413-834-0034 Cell Licensed&Insured Contractor ! CS 074031/HIC 147757 � a 423939$322 P. 2 the Commonwealth of Ma rsarchrrseft Department oflnd=trWAt.et&v& p,fJ'"of1"erd9atxous 660 Washington Street Boston,MA 02111 - ;: www massgov/aria Workers' Compensation Insurance Affidavit:BuMers/Coubadors/Electrki slPlnmbers Applicant 1 n_ Print Look Name(BusinesA)rgwizedonllndividuat): Address: Jr— �` CjtEL City fStatdZi : A�2 t i4' 13� Phone#: 1 -33 7 —�o z t Are you an employer?Check the appropriate box: Type ofprqJect(re4uhvd). 1.❑ I am a employer with 4. 0 I am a general contractor and[ employees{full and/oj�Z� have hued the sub-cont actors 6. ❑New cos�stxuction 2. I�am a sole pumprietor tied oar time attached sheet. ❑hi and have no eml These sub-+000tractors have g. ❑Demolition w for me in e1pbY�and have workers' $ �'�hY- 4. []Building addition [No workers'comp.insurance coatp.insurance.* thud-] 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 1 l.[]Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12-Aptoof repairs inmmince requhred.]t c. 1 S2,§1(4),and we have no emplvYM.[No wcnicers' 13.;g Other ftOV- 70C -r comp.insurance un—V&I il tZ.i:Z►'z(�i2+G EM t. j ' Y apPl that obecks box Of aust alto 01 out the section below showing their workers'eompemation policy iefmrnatim roers t Hotneaa wbo submit this a FAivit irtdicatiag they are doing all wank and then hire outside contractors must suburb s new affidavit indicating such. :Contractors that chock this box must anadhed an addskmal sheet showing the im ne of the subcontractors and state whetbw or not:home entitu s bows employees. If the svb•conuno n have employees,they dust provide their worlan'cony.policy nundw tan an emgdvyw Oka(b prong worUrs1congmaudan ban ante for X►Byars Bedew Is Z -po-zw andjob see infiwonaminaL Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: CitylStawZip: Attach a copy of the workers'compensation policy declaration page(sbowmg the policy number and expiration date). Failure to secure covearage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-Year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to WO.00 a day agate the violator. Be advised that a copy(of this statietmnt may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. f do kere6y cer*:(elder the sh9u of p erjtarry teat the ftt:f rasedm pr�vt�&d above sr Mw acrd caonam Si Envy, DM: /Z Z`j bg 37 Offkial aw only. Do nW wrMe in Mrs area,to be cong*%Od by chq or:fewer oB'irlat City or Town: Permif/i4ceuse# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Ckrk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Plome#: IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) Page 2 of 2 INS025 pio8p8a ACORD-. CERTIFICATE OF LIABILITY INSURANCE 3DATE/13/2008 ' PRODUCER (413)773-9913 FAX: (413)774-3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MassOne Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P. 0. Box 638 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 117 Main St. Greenfield MA 01302-0638 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:NGM Insurance Company, 14788 Jeffrey Peck INSURERB: 5 Vincent Road INSURERC: INSURER D: Charlemont MA, 01339 INSURER E: OVERAGES 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. INSR ADD-1-1 POLICY EFFECTIVE POLiCY EXPIRATION' -- TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 300,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence) $ 500,000 A CLAIMS MADE X OCCUR MPT3592A 3/12/2008 3/12/2009 MEDEXP(Any one erson $ 10,000 PERSONAL&ADV INJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AG $ 600,000 POLICY X 0 OT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OT1-ICO Tt.l[,N EA ACC 2 AUTO ONLY: - AGG S EXCESS/UMBRELLA LIABILITY OCCURRENCE $ OCCUR FI CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION _ ~� $ WORKERS COMPENSATION AND WC STATT- 1 1171 EMPLOYERS'LIABILITY ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE$ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION (413) 863-9643 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Franklin County Regional Housing Authorit EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Attn: Brian McHugh 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT 80 Canal Street FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE P 0 Box 30 Turners Falls, MA = 01376 INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Peg Saulnier/MESS ACORD 25(2001/08) ©ACORD CORPORATION 1988 I NS025(0108).08a 5 Vincent Rd.-Heath Phone: 413-3 39-8321 home Charlemornt,MAL 01339 sitgrot(d7fastmail,fm 413-834-0034 cell Licensed&Insured Contractor CS 074031/HIC 147757 fie -Vo�nvnuiY °�✓�ta�aacfzr�an.Cly -- _ Board of Building Regulations and Standards _ - HOME IMPROVEMENT CONTRACTOR Registration: 147757 Expiration: 8/4/2009 Tr# 259990 Type: Individual JEFFREY S.PECK JEFFREY PECK 5 VINCENT RD.HEATH CHARLEMONT,MA 01339 _ Administrator i beva rill)er.t ut t'utrlic tiatci� Buxrd of Buitdin Rc„ulatio»s and Stand<u'd, Construction Su7ervisor License License: cS 74031 Restricted to: 00 JEFFREY S PECK 5 VINCENT RD-HEATH T~ CHARLEMONT, MA 01339 Expiration: 6/25/201C Tr- 29563 JEFF PECK lj Vincent d-Heath � Phone:413-339•-8321 home Charlemmit,MA 01339 , 5itgrot @fastmail.fm _ 413-834-0034 cell Licensed&Insured Contractor ^^ CS 074031 JIIIC 147757 December 28, 2008 The following is an attachment to the building permit application prepared by Jeffrey S. Peck, contractor, to perform work for homeowner Fraser Stables of 129 Oak St. Florence, MA. The contractor shall -Interrupt a 16' span of 2x6 (2nd floor) floor joists 24" on center with a carrying beam approx 12'6" to span 12' with floor joists flush mounted with joist hangers. The proposed carrying beam shall be constructed of 4 2x8x12'6" fir with alternating layers of 1/2" plywood. The resulting dimensions for the beam would be 71/2" x 71/2". Construction adhesive shall be applied between each layer. 2", 4" coated screws shall be fastened at each layer every 12". 10" carriage bolts shall be installed 2 every 24" for a total of 10. Add $800 to estimated building costs labeled "reinforcement work" SECTION 5-DESCRIPTION OF PROPOSED WORK(check all apolicabie) New House ❑ Addition ❑ Replacement windows Afteration(s) Rooting Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[Q Brief Description of Proposed E w Work: P-,MC>�Le j 7cx �� t) s 1..Ari"g T1� 1'AI � `'. 'r,+ .fir i-r fftL.G ` ft Alteration of existin m Yes No Adding new bedroom Yes No Attached Narrative 7� Renovating unfinished basement Yes No Plans Attached Rol �- et 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 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ' as Owner of the subject property hereby authorize F ��.�� S i��Z L' to act on my behalf, in all. atter relative to work authorized by this building permit application. Signature of Owner Date 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 j I L&L 0S Signature of Owner/Age Date L SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: f - Q L4 V 11 License Pumber q Expiration Date t) . Signs ure Telephone 9. Renistered °Ho m Im rovee d Contractor: Not Applicable ❑j} Company Name Registrat' n Number P Address Expira n Dat" Telephone,)cI " 1 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 i 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 Frontagae 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 O DONT KNOW 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON`T KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O NO Ar IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, excav ion, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. a Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability, Room 100 WaterANell Availability Northampton, 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 Map Lot Unit Zone Overlay District Elm 31L District C8 District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C /L� Name(Print) Current Mailing Address: Telephone Signature I `z- u 1 2.2 Authorized Agent: WA- CH(k 01131 Nam int) Current Mailing Address: f / �11 c 9 fir- A Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant 1. Buildings (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) ,l o Check Number'A'ZC� This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2009-0616 APPLICANT/CONTACT PERSON JEFFREY PECK ADDRESS/PHONE 167 E.BUCKLAND RD SHELBURNE FALLS (413)625-8438 PROPERTY LOCATION 129 OAK ST MAP 17A PARCEL 281 001 ZONE URB(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 Typeof Construction: Strip,ply and reshingle roof and interior support beams New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF( 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 of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay 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. BP-2009-0616 GIs#: COMMONWEALTH OF MASSACHUSETTS It tom, etx 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-2009-0616 Project# JS-2009-000896 Est.Cost: $10200.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin: JEFFREY PECK Lot Size(sq. ft.): 12283.92 Owner: Fraser Stables Zoning:URB(100)/ Applicant: JEFFREY PECK AT. 129 OAK ST Applicant Address: Phone: Insurance: 167 E. BUCKLAND RD (413) 625-8438 SHELBURNE FALLSMA01370ISSUED ON:1212912008 0:00:00 TO PERFORM THE FOLLOWING WORK.-Strip, ply and reshingle roof and interior support beams 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 12/29/2008 0:00:00 $55.00250 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo