16B-001 (18) 41 Mark Warner Dr BP-2017-1522
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 168-001 CITY OF NORTHAMPTON
Lot-031 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REMODEL BUILDING PERMIT
Permit# BP-2017-1522
Project# J8-2017-002545
Est.Cost:$14300.00
Fee:$93.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: STEPHEN D ROSS 150847
Lot Size(sq. ft.): Owner: Marcy Eisenberg
Zoning:SRt1JRAJRUWSP Applicant: STEPHEN D ROSS
AT: 41 Mark Warner Dr
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584-1224 O
NORTHAMPTONMA01460 ISSUED ON:6/28/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:remodel 2nd floor bath add soaking tub
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 %nature:
FeeType: Date Paid: Amount:
Building 6/28;20170:00:00 $93.00
212 Main Street, Phone(413)5871240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton Slaps ofPemut
2 8 Building Department dvaweyPe mR
212 Main Street
Septi
Room 100
Northampton, MA 01060 TwoSOP
phone 413-587-1240 Fax 413-587-1272 plans
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address This section to be completed by office
Z o `fI Jam' ig_,,,`1_ Map Lot Unit
ton;Peg ( Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT /
2.1 Owner of Record: r%late A - :l0 1$n'dc, acid
� **q1 �
`�ouctOiVi a'
.me Print) I � � S Current Mailing Addr s:
" W c " ✓/ 5-eit i o-erod Telephon 3� E 1.�
Signature (� gip-t O
2.2 Authorized Agent:
S.4--4P1.-Opt toS ✓ � C----/—
P. ss 34 ,rc1e 4/41/4-filer-
Name
(Pn ) Current Mailing Address'.
. vL 'y/] rBv i ny
ign re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
comple by permit applicant
1. Building 9 w c.' (a)Building Permit Fee
2. Electrical C-4" (b)Estimated Total Cost of
d CO ' Construction from(6)
3. Plumbing K 1 0 Building Permit Fee ��
4. Mechanical(HVAC) (_ o -
5. Fire Protection
6. Total=(1 +2+3+4 +5) el/ Si
pi9 id O. d" Check Number Sik
"(his Section For Official Use Only
Building Permit Number.....---- Issued:
Date
/ ii
Signature: A� ' // //!/Sk ef— p- 2--/17
Building Commissioner/Inspector of Buildings Date
•
fig iN.1-pfd7
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required to Zoning
Buil column be filled in by
Building
Department
Lot Size
MIMI
Setbacks Front
Side L: R.
Rear-
Building Heig 11.1l_
41.1111
Bldg. Square .Drage '-�-
Open Snu F %
aarea minus bldg
&dg paved
• rkin_I
MEM
Fill:
----
(volume&Location)
A. Has a Special Permit/Variance/Finding er been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page a /or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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 O , Date Issued:
C. Do any signs exist on the property? YES O NO la
--------
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, exc ation, 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.
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 [C] Decks [p Siding(p] Other[CI]
Bnef Description of Proposgd
Work'. I t • �t / rry I`L..n/ roe,A`
Alteration of existing bedroom Yes No Adding new bedroom Yes No_/
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. 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?
I Method of heatin• ' eplaces or Woodstoves Number of each
g. Energy Cons: ation Compliance. Masscheck Energy Compliance form attached?
h. Type of co truction
i. Is construe ion within 100 ft. ofwetla.: . Yes •.. •• . •• ithin 100 yr. floodplain Yes No
j. Depth of ba .• ent or c- oor 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
I, la r�-CiEi �N , as Owner of the subject
property ,. "L}TrQr� 9 � T n u
hereby authorize L3 f�--{� heyi "' - .J.J.
to act on my behalf, in all ma {s relative to work authorized by this building permit appliction.
'
Signature of O t Date C9 �Ls' acd
I, c1 N-._1,• z • "- - ,as Owner/Authorized
Agent hereliy declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed nder the pains and penalties of perjury.
`{ -an"
• (( Y�
Print Name
�� L/eat
natu of Owner/Agent Dat
SECTION 8-CONSTRUCTION SERVICES
§,1 Licensed Construction Supervisor: Not Applicable ❑
Ennio of license Holder: t,$azph i .2). Ross CS 7914D
License Number
34 Sterna Gantt Alo gunrI/v/+N *.I "0/7
Address U/tri.D Expiration Date
41/3-Sself aa.V
Signature Telephone
iltfietsitainikatenitelkontevittnanitemtractotC" L - Not Applicable 0
d•lechRegistration/en D.� /rss Y en1 Conbaefor SDp
frobef
34 Serf/ite- a Ler tarfienLf1mo1144 01040 S-4/ '02o/B
Address / , Expiration Date
Telephone)"f 3'SgI4"1ny
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 0 No 0
Miteawneramintion
The current exemption for"homeowners"was extended to include Owner-occupied DweUlnes 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.CMN 780, Sixth Edition Section 108.3.5.14
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 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 _...—
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: J_0 p3n'4wt-0a1
The debris will be transported by: /41y 4,
The debris will be received by: 1-171, Ca-G.
Building permit number: ,/
Name of Permit Applicant St-�(�1 -'-�` 7 i?o;3
GrZ� ( 7 1' / / • �`
Date Signature of Permit Applicant
ACORO° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDfYYY)
`...----- 4/13/2017
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: H 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 polity,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 CONTACT Barbara Grynkiepicz
Webber 6 Grinnell IPNNONE
C. Est (413)586-0111I we NPI'(413)SSE-6481
8 North King Street EApopR s,bgrynkiexicz@Mebberandgrinnell.com
INSURERS)AFFORDING COVERAGE NAIL I
Northampton NA 01060 INSURER A:Excelsior/Liberty 1 11045
INSURED INSURER a A.I.M. Mutual
Stephen Ross INSURER C:
Attn: Kim Clairemont INSURER D:
36 Service Center Road INSURER E:
Northampton NA 01060 INSURER F:
COVERAGES CERTIFICATE NUMBER:Exp 3/1/18 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 OMER 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L TYPE OF INSURANCE 'AODL8IISR POLICY EFF • POLICY EXP 1
I IN50 WYO I POLICY NUMBER IMMDDIYIYY) (MM'OpYYYYI LIMITS
X COMMERCIAL GENERAL LABILITY • I I •EACH OCCURRENCE $ 1,000,000
EM
I PA
A CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000
I PREMISESMGma occurrencel $
CaP889889B ' 3/1/2017 3/1/2018 MED EXP(My one lamn) $ 5,000
I PERSONAL&ADV INJURY 15 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER'. GENERAL AGGREGATE 15 2,000,000
' POLICYIX
PRO- •J LOG PRODUCTS-COMP/OP AGO ''.$ 2,000,000
OWER'. • •
1$
AUTOMOBILE LIABILIn )COMBINED SswGLE LIMIT s
aral
I^'I ANY AUTO ' ' ''I I BODILY INJURY(Per Person) $
1-1 All OWNED SCHEDULED I BODILY INJURY(Peracodeml 5
AUTOS _ UTOS 1
NON-OWNED 'PROPERTY DAMAGE
HIRED AUTOS AUTOS (Per accident) E
•
5
UMBRELLA LIAR _ OCCUR EACH OCCURRENCE S
EXCESS LAB CLAMS-MADE . AGGREGATE ''5
DED RETENTIONS :2
WORKERS COMPENSATION IPER I OTE-
AND EMPLOYERS'LABILITY YINI 'C STATUI£ AER
I ANY PROPRIETOWPARTNER/EXECUTIVE 1 I EL.EACH ACCIDENT 5 500,000
I CFFICERMEMBER EXCLUDED? 'RIA)
B I(Mandatory in NH) —I 11ME30080065462016A 7/1/2016 7/1/2017 I EL.DISEASE-EA EMPLOYEE $ 500,000
II yes.describe under
DESCRIPTION OF OPERATIONS below I EL.DISEASE-POLICY LIMIT.$ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS'VEHICLES (ACORD 101,Addniomai Remarks Schedule,may be attached if more spate i8 ruguIM)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
**For Insurance Info Only** THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
R Webber, Rio CRIS/BA i;IC CZJNo.,&C :–.)1_t e.--
t 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(201401)
The Commonwealth of Massachusetts
a*E=— Department oflndustrialAeeidents
Ems, Office oflnvestigations
3iEON a 1 Congress Street,Suite 100
ft s o Boston,MA 02114-2017
.t www mass.govfdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ,// ,/ Please Print Legibly
Name(Business'Organizatioollndividual): (/r t Y/om. j.e e S _
Address: 3 4 sta. tr-brie r C.,,.,/...r-- }E (
City/State/Zip:1M✓ �a._.�i/Jr'J_d/d(.¢ Phone#: ,r• - Z2
Are you an em er? Check the appropriate box: Type of project (required):
L 0 tan m to er with 4. 0 I am a general contractor and 1
P Y 6. 0 New construction
ployees (full and/or part-time)." have hired the sub-contractors
2. 1 am a sole proprietor or partner- fisted on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g, 0 Demolition
working for me in any capacity. employees and have workers' 9. 1-1Buildingaddition
[No workers' comp. insurance comp. insurance.•
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGI, 12.0 Roof repairs
insurance required.] ` c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t 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. Lie. #: Expiration Date: _
Job Site Address: City/State/Zip:
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 e. 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.
s
I do hereby certi under the pains and penalties of perjury that the information provided ab ve is tr e and correct
5ispatur [�'JG..... .... date: `
Phone#: (/
Official use only. Do not write in this area,to he completed by city or town official.
City or Town: PermiULieense#
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#: —