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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#: —