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17A-160 (8) 35 FOX FARMS RD BP-2019-1179 GIs#: COMMONWEALTH OF MASSACHUSETTS Mao'Block: 17A- 160 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Bath reno BUILDING PERMIT Permit BP-2019-1179 Protect# JS-2019-001913 Est Cost,$16300.0 Fee: 8106.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: STEPHEN D ROSS 079160 Lot Size(so.ft.), 17990.28 Owner: DITKOVSKI JACOB&EMILY B zoning: URA(1001/ Applicant: STEPHEN D ROSS AT: 35 FOX FARMS RD ApplicantAddress: Phone: Insurance., 36 SERVICE CENTER RD (413) 584-1224 0 WC NORTHAM PTONMA01 D60 ISSUED ON.412412019 0.00:00 TO PERFORM THE FOLLOWING WORK REMODEL 1 ST FLOOR BATHROOM 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: Qil: 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: FeeTvpe: Date Paid: Amount: Building 424/20190:00:00 $106.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-1179 APPLICANT/CONTACT PERSON STEPHEN D ROSS ADDRESS/PHONE 36 SERVICE CENTER FID NORTHAMPTON (413)584-1224 O PROPERTY LOCATION 35 FOX FARMS RD MAP 17A PARCEL 160 001 ZONE URALIgO / THIS SECTION FOR OYER IAL IJSE ONLY: PERMir APPLKCATIONO ECKLIST E OSE REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Pennit Filled out Fee Paid Typeof Construction: REMODEL 1 ST FLOOR BATH OOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans included' Owner/Statement or License 079160 3 sets of Plans/Plot Plan THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: _ZffApproved_Additional permits required(see below) PLANNING BOARD PERMIT REQUIREDUNDER-, , Intermediate Projecb Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plop AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER:$ r. Finding Special Peflnit ' ' - °` Variance- Received&Recorded at Registry of DeedsProof 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. 1 �G1 Y1 To ;�O' wU rvl( 'i Depsadnii use only i. City of Northampton Status af#?anniC % ..>' Building Department Curb Culy rivilw"Ationit i 212 Main Street Savrerlsoptic Availability '{ Room 100 watwAslalIMWiabil Northampton, MA 01060 Tom Sob ofStruetural Plans phone 413-587-1240 Fax 41 - C I C ` ,C Iryad R APPLICATION TO CONSTRUCT,ALT411,R PAIR,RENOCVATEE OR DE OLI H A ONE OR TWO FAMILY DWELLING r� / SECTIONI -SITE INFORMATION APR 23 2019 //79 1.1 Prooeriv Address: This action to be completed by office � DEPNOHTHAMPTO IN✓'AP01pa0 NS / �Vo—Unit. Zone Overlay District Elm SL District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record. Jc. ron l���kavtki �,u„�c Name(Print) Current Malling Address: Telephone Siitgatere G/7 - -70 "OL l'L_ 2.2 Authorized Agent: Name(P ) 4 Current MailingAddress. orLtjQ natuT�poh •/,,/Jon. /�f�A 117-9 N-r22q SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit apphicant 1. Building 12 ,OG (a)Building Permit Fee 2. Electrical (b)Estimated Total Cast of OO' Construction from 6 3. Plumbing J-7 S%v r� Building Permit Fee II 4. Mechanical(HVAC) _ G 5. Fire Protection 1� 6. Total=(1 +2+3+4+5) ?V0', Check Number This Section For Official Use Only Building Permit Number: Date Signature: Issued: Building Commissionedlnspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Atltlltlon ❑ Replacement Wintlows Alleration(s) Roofing Or Doon O Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Sidini Other[[7J Brief De=of proposed F4 Work: ��+sy(-t l If Irk ./-'a�O+n/ 1 �' Alteration of existing bedroom_Vee No Adding new bedroom Yes - No / Attached Narrative Renovating unfinished basement _Yes ✓ No Plans Attached Roll -Sheet ea. If Ne+W ittidi t and or add& 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 foot tructton. Dimensions e. Number of ries? f. Met tl of hea0ng? Fireplaces or Woodsloves Number of each 9. ergy Conservation Compliance. check Energy Compliance form attached? h. Type of construction --- i. - i. s construction within 100 R. of ends?_Yes _No. Is construction within 100 yr. floodplain_Yes_No j. Dep or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank_ CitySewer_ Private well_ City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. 'Jac- 6 1j },kdVf¢r as Owner of the subject property / hereby authorize to a y behalf, in all malfters relative to work authorized by this building permit application. 4 la.'5/lcl Sign lure// Own r Date 1.6- , T.�Ga'J�_..._ �. 17ef3 ,as Owner/Authorized Agent hereb eclare 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. Prihl Nam atu f Owmer/Ageml Date Sectional. ZONING All Information Must Be Completed. Permit Can Be Denied one To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R:- L: R:_. Rear Building Hei Bldg.Sq a Footage Open Sp a Footage (Lot area (Lm us bldg&pave arkin #of Parkin S a Fill: - .. .. ..... volume&Lucalion A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW Q YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW J@ YES O IF YES: enter Book Page �C and/or Document# B. Does the site contain a brook, body of water or wetlands? NO tOS' 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 O , Date Issued: C. Do any signs exist on the property? YES © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO JOL IF YES, describe size, type and location: E. Will the wnstruction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton a M 3/ Id8988ChII88tl8 c DEW 212 Karo SOF Be Mnici INSPECTIONS /1 x 212 Mein BtxeeG •Municipal Building Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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. The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: .v7 1/pU/L 2t tisi �•' �i( 6/vY YIY k 1, I (Pie/ase A se print na a and locatio f facintyy) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) gur oermit Applicant or O r Date If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. A`i IY CERTIFICATE I ATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER FORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE HOLDER.THIS CERTIFICATE DOES NOTAFFIRMATIVELY WTNELY AMEND,EITEND ORALTERTHE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOW NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED �_PRESENTATIVE OR PRODUCER,AND THE CERTFICATE HOLDER .d ANT: N the cerTAWabe(holder is IOD INSURED,the poficy(ias)must haw ADDITIONAL INSURED Provisions or be endorsed. N SUBROGATION IS WAIVED,subject totM iN s and condHions of the pocky,certain policies may reWBe an endorsement. A statemerd on this artifieate does not conRr rights to the c holder in Beu of su endoraemengsj. PRDOHKFR Barbara GrynAiewiQ Webber 8 Gnnmil INKYE (913)58&0111 (413)586-0981 Ac xe: B NOM Mr,Street _ blpYnkBxiQ�AabOerMhdgnmWl.am AfFORBNf COVEMGF NN[a NOMemptan MA 01060 MBUR�A. West Amwkn"Loarry 99393 INsuRFO MBURER B. A.I.M.MUtad Stephen Rosa haat.C: Atm:1Om Clairemont NSUPEit D: 36 Ser,Ii.Carter ROa9 pBURER E: NOMampWri MA (HIM ayaROyF. COVERAGES C NUMBER: ESP 711119 REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POUCIES OF IN SU E LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NALIED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANYREOUIREME T, OR CONDITION OFANY CONTRACTOR OTHER DOCUMENTWRH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAN, N I SURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDMONS OF SUCH POLICIE L ITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. allm LTR TYPEKNa1WYCe aDLICY NUMBER LWRB COYMFRCUtaENitIAL tU1BIlRY EACH OCCURRENCE S 1.000.900 CWMSLVLE EgI=UR s 100' IMEOEVI S 15.000 A BK` 0071793 03101)2019 O3tl11202O RERBGNALaADVINJURY $ 1'�'oco nENLAOOREQ UNITAI' UEBr£R: oENEWLLAfieR .TE s 2.DM000 7--[Em E. RaaoucTs-COMPICPAGG s 2•"•000 OTHER' s AVrgpBEELIABIll1Y C 84VO4E LIMIT $ ANVA"T" BOpLY IKIIIriYIPx Csf n1 E =s IM 6CHEDUtED BOgLY INJUriY(Px wbMl S AUTOSOHLY AVxOB HIM NONOWNED RimERIYOANAGE e MIrO8ONLY AVrO8ONLY E UMBAEh Uaat —R F 11 OCCURRENCE E EMOMMB UAB ClAIL6MAOF AGGREGATE $ O. I I RETENTa S S MORYJBISI h faraXRna PER OTX- ANaMMKOY9M'WMIRY YIN ANY FRCPRIETONiMRiNEWE%ECMVE E1.EACX ACCIDENT s 500,000 B OryF�FICyER�.ae. NBEHO(CLUDIDx MIA WMZ80O80O85182O18A 0710,2018 07101Q019 p�.�,MhM9 E.L.DSEM'c.FAEMPLorEE s SOD'S eWa ber CE6CRWTONnOH OF OFOPEMTIIXIB pNPN EL.OI8EI8E-VttICV Lehr a SQ)'00O olacRPrloxaFaRMMnahBrLxmHowlvFraclFs m,ammwe.�.rs.aN.as..wM'm MMM.e Maan.P.e.ar.9Mr.m CERTIFICATE HOLDER CANCELLATION SHCULDANY OF THEABMlE O69CRIBFDPONCIE8 BE CANCELLED BEFORE WE EX%RATAN DATE F,NOTWE VOL BE DEUVEREDIN ..For Insurance Into Only" ACCORDANCE MITI THE POLICY PROVISIONS. A V rlpRltFD REPAEBEMATYE 14- ®19811.2015ACORD CORPORATION. AN rights reserved. ACORD 25(2019103) Incl ACORD name and logo are registared marks of ACORD SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suoery sor: TT Not Applicable El Nam.muraa..NaNar:ys*40 . ROSS M 79/60 p (� U..Numbeerr V4 'ler{ /ej ll./fLCr ��/511QJ)'fO AN I� �•KBd(//�� Address t- Expiration Date Signahre Telephone Not Applicable ❑ lSOf3�'1 Compam me Registration umbel Address cSG/✓/lL l/&t! a irl��d 41060 Is--1 -e�W �6 Expiration.Date Telephone��3•Jyy-/22 SECTION 10-WORDS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L 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 Afhdavl Attached Yes....... ❑ No...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwdtiinas oform(1) or two(2)families and m allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acre as supervisor.CMH 780, Sixth Edition Section 1083.5.1. De0nition of Homeowaer 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 stmchncs.A person who constructs users than see home in a two-yeaperiod Mal not be considered a h meowner. Such"homeowner'shall submit to the Building Official,on a form acceptable to the Building Offici4 that hehbe sial be respensible for all such work performed order the building pa AWL As acting Construction Supervisor your presence on thejob site will be required from time m time,during and upon completion ofthe work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability ofEmployers to Employees for injuria not resulting in Death)ofthe Massachusetts General Laws Annotated,you easy be liable for person(s) you hive 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 ofMasmchusetts General Laws Annotated. Homeowner Signature .C'\ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 01114-1017 www.mass.gov/dia Wil,arkers'Compershation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lenribly Name (Business/Organize[ioNlndividua0: Address: 76 S'q City/State/Zip: .114,1 ore 40 Phone 7 tr 1!— l 2 e vl Areyou as employerT Check the approp utm be.: Type of project(required): L�I employer with employees(full anda,tor-time)' 7. ❑New construction 2. lam a sole proprietor or partnership and have no employees working for me in I;, ❑ Remodeling mY capacity.[No workers'comp.insurance required.] J.❑lam ehomeowner doing all work myulf lNe wonkers'comp.Insumumna,mred.11 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensurethetall conhadorseibat have workerscompensation usurarecor are sole 11.❑Electrical repairs or additions proprietors with no employees. 12,❑Plumbing repairs or additions 5❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contmdors have employees and have workers'comp.insuran 6.❑We are a cooperation and its officers have exercised their right ofexemption per MGL c. 14.❑Other 152,91(4),and we have n t employees INo workers comp.insurance regwroll 'Any applicmt that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homwwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContmctors that check this box must anwhed an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees If the subcontractors have employees,they must provide their workers'comppolicy 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.Lic.#: 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy ofthis statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby cer06utt i ins and penalties of perjury that the information provided al is//rue and correct. Shi atua �Y/ Date / c Phone#� oKZ3— re", —/ZZ L1 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.CityrPown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton SrC Massachusetts DEPARTMENT OF BUILDING INSPECTIONS Z' 212 Mom St e • Municipal Building Northrthemp[on, eN 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modemization, conversion, improvement, removal, demolition, orconstruction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which am adjacent to such residence or building"be done by registered contractors. Note:Lf the homeowner has contracted with a orporation or LLC,that entity mst be registered Type of Work: 134A / Est. C6sV U/ �Gr Address of Work: "3 r i sec f%..Fi-Ir /Z o.t+ /Xry , •-c-*-/Y) .t. '/D 2't 'L- Date of Permit Application: yLZ 7 / /--71 I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: IrORlf -7 Dal I ' Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature