23D-168 (6) BP-2001-0886
GIS#: COMMONWEALTH OF MASSACHUSETTS
-, -�B1odc:23D-168 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:shed BUILDING PERMIT
Permit# BP-2001-0886
Project# JS-1999-1008
Est.Cost:$2400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 44866.80 Owner: edward harris
Zoning: URB Applicant: edward harris
AT: 134 MAPLEWOOD TERR
Applicant Address: Phone: Insurance:
134 Maplewood Terrace (413) 584-6555 ()
NORTHAMPTONMA01060 ISSUED ON:5/11/01 0:00:00
TO PERFORM THE FOLLOWING WORK:placement of pre-fab shed 8 x 12'
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 VIOLAT ON OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/10/01 0:00:00 480 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2001-0886
APPLICANT/CONTACT PERSON edward harris
ADDRESS/PHONE 134 Maplewood Terrace (413)584-6555 Q
PROPERTY LOCATION 134 MAPLEWOOD TERR
MAP 23D PARCEL 168 ZONE URB
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:placement of pre-fab shed 8 x 12'
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 LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 y.mmission Permit from CB Architecture Committee
. ��� OS f0 OV
Signature of Building fficial 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.
Y 1
Department use only
City of Northampton Status of Permit:
• Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well 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
This section to be completed by office
1.1 Property Address:/y `I,I f� y
l 3Li / �1 PPt ` AMO D " Map l Jam' Lot /( 7' Unit
rt, , e_ Zone l Overlay District
r Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
w 0 S , /-) 1Q2/S P 3 '-1 {' RPLE tv oa-o re2
iiihName(Pri Current Mailing Address: pew �� G/���
/�.lJ( g '( . k4-6I�'Y - Telephone J—�(
Signature v 7 v ✓
2.2 Authorized Agent:
N
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building cl G G (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
hf D Al Construction from (6)
3. Plumbing Building Permit Fee
No L-
4. Mechanical (HVAC) N bti(
5. Fire Protection h10 4 E
6. Total = (1 + 2 + 3 + 4 + 5) 00 c"-- Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
•
Signature:
Building Commissioner/Inspector of Buildings Date
v �
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 3 .310 A ✓
�j 3 A
Frontage 73
Setbacks Front 22
Side L: R: L: I Li O R:3j 3 3 .9 j I
Rear f� 6
log
Building Height I c/
Bldg. Square Footage % /Li ® G
too c/a
Open Space Footage
(Lot area minus bldg&paved '3533 (� G
parking) r UD/d
#of Parking Spaces Ho ` N 6 1,(�
(volume&Location) /y
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO X DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO X DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO X DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO NO
IF YES, describe size, type and location:
D. A‘rg there any proposed changes to or additions of signs intended for the property ?YES
No A
IF YES, describe size, type and location:
•
ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing ❑
Or Doors 0
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding,ir [ ] Other [ ]
Brief Description of Proposed Work:! c-/ 9 C- Yh I7- OF P -�'/�/3R /CRPP.J l 912_d 614 5r0 06e
Alteration of existing bedroom Yes x No Adding new bedroom Yes X No X S�E�
Attached Narrative D Renovating unfinished basement ' Yes No
Plans Attached Roll ❑ - Sheet
6:a, If New hot a and,or addition to xi tin•,h;US. • complete the;lello*
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. Mascheck Energy Compliance form attached?
. 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 to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I tt) 4-11 D ,S-----, J re-IS , as dr/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accura -, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
,E•A 10 A c Al/9-1 i2/S
Print Na
(41(/6t c( c, ./.:(--(ii4A<),
Signature of Owner/Agent Dafe
I SECTION 8-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
E : ,1 ' . „,.P' 0 ' Not Applicable ❑
i< I-o-re-6 k fi Kfrt s sM ,
Company Name Registration Number
' 1 t w �Sr J2Ap
Address L�/ �A /�► I �i ! �r/ z Expiration Date
L.�/1 V"/ v 1. r O t(Oa."1 Telephone floe,2_ijgr37 b�
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.
"igned Affidavit Attached Yes X No 0
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, Stat at Local ningg�Laws an State of Massachusetts General Laws Annotated.
Homeowner Signature I/ `— GO/ i ‘>1.'" ��
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�+ �� DEPARTMENT OP BUILDING INSPECTIONS 4 =__�—_
' , 212 Main Street ' Municipal Building
Northampton, Mass. 01060 '�s
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WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, lA S tr J Kc "
(license&Jpermittee)
with a principal place of business/residence at:
.). ) iP w Pi-5 r C T7 ,,,ei_L)14 G-`r"Al &T (phone#) 14-�l00-Aq-3 yb 3
(bt1 txt/city/state/np)
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job: cf' _ ( efa77 ks7 L' 1q TC
3'' PRov1 DPOict Wrni-►AJ ,I Lv C 0 / Z51 5- r /_02 cl _GL
4 (Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
f
•i;' (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(mash additioml shed iftee,T.ty to inddude information pertaining to all contractors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ persons to do mithrtm.nr, suction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto arc not generally considered to be
employe ra under the vnxk es r,c'snre++c Lion Act(GL152,31 1(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worker's Compensation Act
I understand that a copy of this statement may be forwarded to the Department of In4"drial Aceibeots'Offioo of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to$1,500.00 andlor imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
find of S I00.00 a day against erne.
For dgratmedal use city
Permit Number
Map# Lot#
A'zs?4.-e..:�, Signature of icensee/Perinittee Fate
SPECIMEN CERTIFICATE — FOR INSURED FILES
I. ACQRD. CERTIFICATE OF LIABILITY INSURANCE 0/200.1
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dowding, Moriarty & Dimock, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PO Box ##300 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Rockville, CT 06066
INSURERS AFFORDING COVERAGE
INSURED INSURER A: Providence Washington Insurance Co.
Kloter Farms, Inc. INSURERS: Star Insurance/Renaissance --
216 West Road j INSURERC: ____ _-
Ellington, CT 06029 I INSURER D. __. _
I INSURER E:
COVERAGES
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 POLICY EFFECTIVE :POLICY EXPIRATION LJMITS
LTR TYPE OF INSURANCE POLICY NUMBER M/DATE IMDD/YY) I DATE(MM/DD/YY) !
GGEENCF.AL LIABILITY EACH OCCURRENCE S 1,000,000
Ai ;COMMERCIAL GENERAL LIABILITY ; CX 00109333 01/24/01 I01/24/02 , FIRE DAMAGE(Any one fire) 1S 50,000
iCLAIMS MADE X OCCUR MED EXP(Any one person) S 5,000
PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000.000
GEN'L AGGREGATE LIMIT APPLIES PER: ( PRODUCTS-COMP/OP AGG S 2,000.000 _
POLICY!1 PROT LOC I I I I (
JEC
AUTOMOBILE LIABILITY ! COMBINED SINGLE LIMIT s 500,000
(Ea accident)
X ANY AUTO
i'' ALL OWNED AUTOS BODILY INJURY
(Per person) S
SCHEDULED AUTOS
A HIRED AUTOS AX 00109333 01/24/01 01/24/02 BODILY INJURY
(Per accident) S
NON-OWNED AUTOS
PROPERTY DAMAGE S
I (Per accident)
GARAGE LIABIUTY I I AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC S
-- AUTO ONLY: AGG S
EXCESS LIABIUTY EACH OCCURRENCE s 5,000,000
OCCUR I CLAIMS MADE AGGREGATE $ 5,000,000
A CU 00109333 01/24/01 01/24/02 S
DEDUCTIBLE S
RETENTION S S
WORKERS COMPENSATION AND I ORY LIMITS ER
EMPLOYERS'LIABILITY 100,000
E.L.EACH ACCIDENT S
B WC 0125787 01/24/01 01/24/02 i E.LDISEASE-EAEMPLOYEE s 100,00n
E.L.DISEASE-POLICY LIMIT S 50n,nnn
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER 1 ! ADDITIONAL INSURED;INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
INSURED: KLOTER FARMS, INC. DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25-S(7/97) 0 ACORD CORPORATION 1988
El/Ile e04,.../4
( LA./J.04.a
,__:.„_„
.,__ _
' __ Board of Building Regulat ons and Standards
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Registration: 127530
Type: Private Corporation
Expiration: 11/09/2002
KLOTER FARMS INC
JASON KLOTER
216 WEST ROAD - -
ELLINGTON, CT 06029 --
Update Address and return card.Mark reason for change
r I Address I l Renewal [-i Employment i Lost Card
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Quality is the foundation on which we build.
216 West Road (Re. 83), EiI±g on, Conreciout 06029 860-871-1048 1-800-289-3463