15B-037 236 CHESTERFIELD RD BP-2017-0132
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 15B-037 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2017-0132
Project# JS-2017-000214
Est.Cost: $5125.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID OUIMETTE 059132
Lot Size(sq. ft.): 90604.80 Owner: THEROUX GARY R&EILEEN M
Zoning: RR(72)/URA(28)/ Applicant: DAVID OUIMETTE
AT: 236 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
P O Box 1038 (413) 527-5469
EASTHAMPTONMA01027 ISSUED ON:8/4/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 14 X 16 DECK
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 8/4/2016 0:00:00 $65.00
212 Math Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0132
, y t5
APPLICANT/CONTACT PERSON DAVID OUIMETTE fo , J
ic
ADDRESS/PHONE P O Box 1038 EASTHAMPTON01027(413)527-5469
PROPERTY LOCATION 236 CHESTERFIELD RD
MAP 15B PARCEL 037 001 ZONE RR(72)/URA(28)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ,
Fee Paid 74i6 7/7'Fo dS #47e
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 14 X 16 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 059132
3 sets of Plans/Plot Plan
THE�LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN
FORMATION 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
It"Delay
' i
t f l< a7
Si ar :+r .mg O icial 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 40k Contact Office of
Planning&Development for more information.
I
al
Departmentusaopl
City f Northampton Stat➢ of petme -
JUL 2 8 2016 Building D partrneni Curs Cut/Driveway PermR
Ltd Man SLreet Sewer'SepticAvailabty
arr.CFgA{DPg 11 -
aw m Poon 100 "Yate/Well Avoi abiliry
North2"7pbn PJIP-, G"Gb0 Two Sets cfotruci38-I Plans
phone 413-587-1210 Fax 4 '3-587-1272 Plot/Sr.e Plass
Other Spemiy _
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section tube completed by once
a3w ChESi6/ Pr5Gn ,L�.. 'n4ap Lot - Unit
epVNERS _Zane s do b ay oistnct
01"S°
V -Elm St District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
CA My -776g6 .j 023 . P ESTFrGG7 7PD
✓ Name(grim) C lepra!Mailing AdEress'
mature '(✓/Y Te= none
Sgnawre Y/3 --SSs"ten 96
2.2 Authorized Anent: .
SMD ir c1 O::,MEITE re l3t c /039 6hn.« /Iia- 0,01'7
Name(Print) Current Mailing Address'. -
/i��+•u,�.r� °a- /' 9/3-SG s- VEP-C3 Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item timafed Cost(Dollars)to be I Official Use Only
cnmpletod by permit applicant -
1. Building 3.5'i.zS.0 0 I (a)Building Permit Fee
2 Electrical 1 (b)Estimated Total Cost of r "
Construction from/6)
3 Plumping I I Building Permit Fee 4b-7, r%'-�
4. Mechanical (HVAC) { ,Q�it)0"��
5. Fre Protection l
6. Total=(1 +2+3 +2+5) 1-$7dr0° I, Check Number
This Section For Official Use Only ��
Building Permit Number: Date
Issued
Signature:
Building Commissioner/Inspector of5ulldings Date
Etnai/ •
Section 4, ZONNIPIG All k.rormaluon Must Be Completed. Pernit Cao Be Denied Due 7o Incomplete information ' d
o;astine Proposed Requiredho Lon ee•
1
Thu
onerroo
me Etm ..._ v
Blinding Dv nn n;
Loi Size . .._ —.. _ -... ._ _.....,.I.. .�
Frooage --._ _ _
S_tbackn Front I"
Side Li_. _ ?? I ` _ R _- _ ...„.,—�
Rear ___- e.�.>...
Building weight _.� .�.� ........
Slog.SquareFootage
Yl
OpenSpace &p — I Tit„Ii;z nu56ldg&pavrr�
c t- lm
n of Parking,Spaces ...._ _,___
Fill: II
•
il
(vDmt&i. tation) "' _�_ _,., .i
A. Has a Specie! Permit/Variance/Find n, ever been issued Forton the site?
NO 0 DONT KNOW YES ''0
IF YES, date issued::
IF YES: Was the permit recorded at the XiStry ci Deeds? i
NO 0 DONT KNOW YES 0
IF YES: enter Book Page I and/or Document 6
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 I
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained C.) , Date Issued:
C. Do any signs exist on the property? YES 0 NO d
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 6
IF YES, describe size, type and location:
E. Wit the construction activity disturb totting,grade excavation, or rlms;over la rr it pal of common plan
tat will disturb over 1 acre? YES 0 NO CS
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
e
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable}
New House n Addition ❑ Replaoement Windows Alteration's) ❑ Roofing n
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks I Siding [ID] Other[0]
Brief Description of Proposed _
Work: erc.iLD/.+•1.. to i$° X/4. �'SS5GRG 7X4M7 D
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes if No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
GaffheeW'hoiase arid or addition fo'ezissna 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 constructio\ / Dimensions
e. Number of stories? N
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. A 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 fi - had grade
k. Will building conform to the Buildin and Zoning regulations? Yes No .
Septic Tank City Sewer Private well Cit water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. itry 111 ft,v{ , as Owner of the subject
property /
hereby authorize ..DA,.//37
to act my behalf,in all utters relative to work authorized by this building permit application.
✓ w,./ i�/JJltr�
Signature of Date r/^a 7^at.
4 yR T ft'in DrE as-Griner/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.
.,7flv:2P 0— Out w7F77;5"
Print Name
nSignature of Owner/Agan; Date
SECTION 8-CONSTRUCTION SERYVCES
8.1 Licensed Construction Supervisor: - Not Applicable E
iNomeof Llcrose Hoiden 2.1.9✓in r/ Odnn6TT6
I License Number
Ic ?lx /c1S a17/4"4 /79 e.:tna'7 .SGA- aC3/3
Address / Expiration Date
Asa en.5.,Y1 O,..0 /- Y/4- SGS- 4'9S3 3 -'o -do/9
Signature Telephone
9. ReaisteretlHome'linorovement Contreotor - - Not Applicable £
,cru➢c-EY '�E no DEb irs _ _ .
Company Name Registration Number
70 3., • /o29' Ehn..-.,, ?A/' 0/0.4'7 /07989
Address Expiration Date
/-5'/3-SG 3-9gm3
A 2%44,..AvQ el2-cy,.. Telephone .9 -//-92 (,
47%
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§250(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 bbyilding permit.
Signed Affidavit Attached Yes.t�.. f No E
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occunied Dwellings of one(L) 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 1083.5.1.
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 twc 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 maybe 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
CCINE wonwee ela ofMassae✓'nsed`s
,-„ Depantme. a 12,2a➢y,sfrialAccidents
i---.4 .,=:" Office rfInvestigafons
^} 600 Washagag3®n ghee?
ps m
-,' Boston, MA 02111
``''4 -'--'A'A www.nsc ss.gov/dia
Workers' Comrpensation Lnsnnee felME:At: PIlInters/Contractors/LlectriciEns/Pluaebers
Apry&ant Information Please Print iLeelnly
•
Name (Business/Organza..^.om1ndividual): jwgc,;D ,j Ou/HbfrE ,v3E 734.iD6gr gr,ctwoELi.4-
Address: PO L3oxi /o38
City/State/Zip: ,Flan .ae env: n Phone#: /-Y(s --C4'3 V8-C 3 Geol._
Are you an employer? Check the appropriate box:
4. I am a general contractor and I Type of Newprconstructionct(required):
1.❑ I am a employer with —
employees (full and/or part-time).*
have hired the sub-contractors 6. ❑
2.X I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insnrance.t
re 4 aired. 5. ❑ We are a corporation and its l0.0 Electrical repairs or additions
]
3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.n Roof repairs
insurance required.] r c. 152. §1(4), and we have no
employees. [No workers' 13.E Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicans they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors 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. lithe subcontractor 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: 7h, TRgu64eit,^ ZND$/tNiy P.c np yyay- c ,»F.P_e c..A-
Policy or Self-ins. Lie. #: (n//4i/3-o322M72 - 4 "/C Expiration Date: 9-
Job Site Address: a3h &n .sr .pFinL; fir). City/State/Zip: 4.8.6 p$ Ma o,o63
.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 5250.00 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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature: /0o.4.4,e-( at.42-448rC _ Date:
70
Phone#: /- Si/7 — SG 3 V PS-3
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#:
City of NCrtharcton
Massachusetts
< ... s
( I Et
Zr
S -z -m^ oF SUSWIvc ZWECTXORTS
:k1.7‘1. - - 212 Main StreetMunicipal a ydirs
Northampton, Mn0.060
INSPECTOR
Louis Hasbrouck Chuck Fuller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGE_VENT
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 dwelllna, 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/footinos (before backfill), sonotube holes (before pour), a much buiidina inspection
(before work is concealed), insulation inspection (if required) and a final buildina 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 sig ature req esting exemption)
I will call to schedule all required b Nine in- ections necessary for the building permit issued to me.
Date
Address of work location
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: o23c &hEST-Ere PtFun i?,?
The debris will be transported by: J aur Er1&
The debris will be received by: //4th1 tEpy-cLe gan.rcz
Building permit number:
Name of Permit Applicant IJAo ,j 0WiflE-r75
Date Signature of Permit Applicant
300
I 1211
756-049 1 158-088
65>2 3M)3
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--__.`.-_-------_— 156073.9 ne-r.,1-
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TRAVELERer WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6HU6-0322M72-6-15)
RENEWAL OF (6HUB-0322M72-6-14)
INSURER: ME TRAVELERS INDEMNITY COMPANY OF AFRICA
NCCI CO CODE: 13439
1.
INSURED: PRODUCER:
OUIMEi it. DAVID J. 0134 FINCK & PERRAS INSURANCE
BUDGET REMODELING 6 CAMPUS LANE
P.O. BOX 1038 EASTHAMPTON MA 01027
EASTHAMPTON MA 01027
Insured Is AN INDIVIDUAL
Other work places and identification numbers are shown In the schedule(s) attached.
2. The pdicy period is from 09-24-15 to 09-24-16 12:01 A.M.at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the pdicy applies to work In each state listed in
Rem 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any,listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 068
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. M required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 08-31 -15 WC ST ASSIGN: MA
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: FINCK & PERRAS INSURANCE 28NJK
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�� 2%� City of Northampton
C/�'i//% % i� Building Department
Plan Review
212 Main Street
Northampton, MA 01060