31B-099 IIBARRETTPL BP-2018-1090
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map�Block:31 B-099 CITY OF NORTHAMPTON
Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv� ROOF BUILDING PERMIT
Permit BP-2018-1090
Project# JS-2018-001964
Est Cost $39000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TEAGNO CONSTRUCTION INC 82248
Lot Size(su.ft.): 13416.48 Owner: WILLIAMS BARBARA S&STAUNTON WILLIAMS 1R
Zoning URC(100) Applicant: TEAGNO CONSTRUCTION INC
AT. 11 BARRETT PL
Applicant Address: Phone: Insurance:
228 TRIANGLE ST (413)549-0803 Workers Compensation
AMHERSTMA01002 ISSUED ON:4/25/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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: O_ 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 4/25/2018 0:00:00 540.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
470r-09
ADO 0
Departmenfuse only
Cit of Nor pt n of PRaraC
°`-SOFt�lt�ltg,` "rtm t CUTE" way Permit
N A'M
4 14
Main Street SeweD�epdo'AvidabHlty
'I Room 100 Wateri4Availability
Northampton, MA 01060 TWo Sets of Structural Plana
phone 413-587-1240 Fax 413-587-1272 PloVSne Plans
Other
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
F,07-19-SECTION t-SITE INFORMATION p v—/9_ Z`�/' 0
1.1 Property Address: This section to be completed by office
Map 3 Lot Unit
Zone Oveday District
Elm SL District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
STo.IA4na OJI htmsse.
Name(Print) 1 Curren)Malling Address
_ ,Lj l
elepM1one
Signature
2.2 Authorized Agent.
1-QJ iI GaIh4razc T / TrrG� {� a f� /�r14,M/tQO
Name(Prop Current Mailing Adtlres
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed y permitapplicant 11
1" Building3 (a)Building Permit Fee
o-
2. Electrical (b)Estimated Total Cost of
Construction from e
3. Plumbing Building Permit Fee Z1
4, Mechanical (HVAC)
5, Fire Protection
6. Total=(1 +2+3+4+5) 3 Check Number
This Section For Official Use Only
Budding Permit Number: Date
Issued.
Signatu L
Buildin ommissionerilnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
p o
Section 4. ZONING7 All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing proposed Required by Zoning
Tris column to he filled in by
Bnik1mg Department
Lot Size
Frontage
Setbacks Front
Side L:..._ R:.. L: R.......
Rear _.........
Building Height
Bldg_Secure Pootage
Open Space Foofagc °o
(Lot urea minus bids&paced _.
orlon
a of Prokure Spaces _....
Fill:
polumc&Locahnn)
A. Has a Special Permit/Variance/Finding ever been issued for/an the site?
NO O DONT KNOW (g YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW O YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 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 ® Obtained ® Date Issued:
C. Do any signs exist on the property? YES O NO 'tel
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
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over f acre or is it part of a common plan
that will disturb over 1 aci YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORN Othock all applicable)
New House ❑ Addition ❑ Replacement Windows JAfterai�R..�fmg �?r
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding[[--3] Other[DI
Brief Description of Proposed /J
Work: e-rri� -'nocF- SL.irv:�et iu;l-kl1 SKo� Cktit 4fe tf&gif flra'upfl'f�-
Alteration of existing bedroom_Yes No Adding new bedroom SA Ve3 �} o UfJo $fid uµ=F� a�RRf R
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rail -Sheet
Se.if New houseand or addition to exiStina houMnia,Complete the following:
a. Use of building One Family Two Family Other
It. Number of rooms in each family unit Number of Bathrooms
c. Is there a garage attached?
J, Proposed Square footage of new construction. Dimensions
e. Number of stories?
L Method of healing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance, Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 1D0 yr. floodplain_Yes No
I. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. SepticTark CitySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the sob act
property
hereby authorize �CU;S h blIIAJd IC.0 I 41V0 �D/JJ :u C'i-rdz.J Z%uc.
to act on my behalf,in all matters relative to work arr prized by his building Tenni(application.
Signature of Owner bate ,,
//n0UIS �A111A4P / ,as Owner( thoriz
Ag hereby deaiare that the statements and information on the foregoing application are true and accurate,to the best of my nowletlge
and belief.
Signed under the painsand penalties of perjury.
Lout GO-L/ l n o r o
Pmh N me
AZt"-, � a� y zoic'
51 alum of OwnerlAgen De
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder�� ll/S (7C{///J An i p8a-a r/
lLicense Numder
i3J /� �rNacbu �2) / s* it. Cr�9 0/0�� /3d��/�
Address q-� Expiration D�—
/Q -tel\
nature Telephone
9.Rapiatered.Home Improvement Contractor Not Applicable ❑
� ti+�' F�IJS}ruc�len TuC
Compan Name Re isVation Nu ber
,2 Tr t , A0 S,1- • a awl
Addres{§ Eigbrat n D e
,qN'( Prf+, M<]- / p'� TelephoneL��CIO
i
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 provitle this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
The Commonwealth o(Massaehusetts
Department oflndustrial Accidents
] Congress StreetSuite 7
Boston,MA 0271 14-1017
www.mass.gov/dia
MY Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibly
Business/Organization Name:_ Ai�`,e CI A.CI �1G 1 S�CTMN �"/�C
Address: ( ( r^ 1
City/State/Zip: . L Phone p:
Are you an employer?Check thea ropriate box: Business Type(required):
D® I am a employer with employees(fall and, 5. ❑Retail
11 orpart-lime)t 6. E]ReslaurantBac'Gnting Establishment
2.0 1 am a sole Its or partnership and have no 7_ ❑Office and/or Sales(incl,real estate,auto,etc)
employees working for me in any capacity.
[No workers'comp.insurance required] K. E] Non-profit
3.ElWe are a corporation and its officers hove exercised 9. ❑ Entertainment
their right of exemption per c 152,§I(4),and we have IO-❑ManuLamming
no employees. [No workers'comp.insurance required]* I I ❑Health Care
L❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workerscomp-insurance req.] 12.❑Other
"Any applicant that cask,box#1 must also fill out the rection below shoming thelnvoden'cnmpmeatitm polies information
`^IRhecoryomtenllinebat'eexemptad lhemselvc.but[M1e corpnmtion hasp0cr anplorrees,awoikers compensation policy is mgttlrcd end such an
orpeniration would checkkbrx t.L
I am an employer that is providing workers'cmnpensatinn insurance far my employees. Below is the police injarmatimi.
Insurance Company Name: 4, : vr./ /,((,Ly({�p(� tU� ��
Insurer's Address:
City/statdzip:
Policy 3 or Sa1f-ms.Lm.a Expiration Data / 2a/
Attach a copy of the workers'compensation policy declaration page(showing the policy number and .pira[ion date).
Failure to secure coverage as required under Section 25A of MCL c. 152 can lead to the imposition ofcriminal penalties of
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
Investigations of DIA for insurance coverage venfication.
I it,,hereby Cerro"under the painsand nfperjury that the information prarided above is true and correct.
S-g i Date 'f��L2.61
Phone 4. �p- Yf3 'J [ /'� W 03 /
Official use only. Do not write in this area,to be completed by city or town official
Cit, or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
"do
TEAGCON-01 CHRYSTAL
+corm CERTIFICATE OF LIABILITY INSURANCE ° 0410M2
0 410 3 8 01 01 8
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: If the Certificate holder is an ADDITIONAL INSURED,the policyIes)must have ADDITIONAL INSURED provisions a be erd.rsed.
If SUBROGATION IS WANED, suhlect to the terms..it conditions Of the policy,certain policies may require an endorsement. A wUNHm Nn on
this certificate does not confer rights to the cents icate holder In lieu of such eneorsemem(s.
PROTUCER NOME^CT Chrystal L Greenleaf
Phillips Insurance Agency,Inc. IHGD"x
97 Center Street ,EFq,(413)594-5984 �iuc.No)(413)592$489
Chicopee,MA 01010 AMS cv chrySMI hillipsinsuranee.com
INSURERfi AGGORgNG COVER4OE _ NY01
Nausar,A:MID Security Insurance Co _ 24082
INSURED INS REBS Ohl ,CaustualI 124074
Teagno Construction,Inc. INSURER D.A.1.M.Mutual Ins.Co. 93]58
Mr.Donald Teagno _ --
228 Triangle Street INSURER D. -
Amhmst,MA 01002 IxsugEg E
INBUNESI
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREI N IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
I.NSRI vEapSVpAxCE AD Um Not WD PoNCv xuMaER PoLKYEFF POOCr FIP LIM119
A I X COMMERCIALGENERALOA6ILT' 1,000,000
EACH CCCURnENCF
cLAIMSMAOE �occua 'IBKSS/TSOBZ] � 6LOtI2016 WI%I2019 DAEwGE iOREMIriEli(EavarvarDel
� son DOB
Fr MET EKE M — 10,000
PERSONALeAOV INE DRY 1,0¢0,000
`ENLAGGREGq LIMRAPPJESPER'. GENEfl LAGGREGATE 2'000,OD0
� y'PRo L¢ 2,000,000
Prij, EJECT ❑ ' PRopu Ts-COMPIOPAGG
A AurouoML
ONOMIL
s uANLm cOMNNED sIrvGi _ LE Lwrt 1,000,000
ANY AUTO BAS$]]SD62] 041018018 04/01/2019 sowLr INJUR9"NOP., e.s
AUq�O�S ONLV X NED p�N�ITHyyOEJJSyyUyyLryryEFFIOI�� BOwLY INJURY Per arlJe,M1 4
.TOBONLY '' x M. - VIR PFvrRO PERttpM1AGE r
B ' XX NMBRELLA NAB X DCCVq EACH OCCURRENCE 1 11000'000
ExcEss Lae cwMsnuOE US057]506]7 Iduot8o18 aIala"19 AGGREGATE 4 1,000,000
CET X RETENnoxa 10,000' S
D ANaEWRWYEIRa ANS IN X PC E X ER
ANYPROPwETOwP�RTNER,TJIEwrne MZ600522304018A OM018o18 Dd'o'Q019 1,000,000
FlCERINQ ELUDEDT r�IN IA' ryy EL FACHACLIOENi S
i e"e°I°'Y'"�E�11 EL.DX sE-EAEMPLOYE 11000,000
n m.1O 1,000,000
GEBLPoPTION OF OPEPATIME. IEC.DISEASE-PRICY LIMIT
DESCRIPTION OF MFMTbNS I LOCATIONS VEHICLES IACORO IM.APPRE.Ran'arLe atlWUM.May W,MaNM It Wm s NpWMIN
CERTIFICATE HOLDER CANCELLATION
I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence oflnsurence THE EXPIRATION DATE THEREOF, NOTICE WILL BE DIONERED IN
ACCORDANCE WITH THE POUCY PROVISIONS.
ALTHORQED REPRESENTATIVE
ACORD 25(2016103) IS 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
City of Northampton
Massachusetts e}`'�i JfOfr
\/
�6
t DEPARTMENT OF BUILDING INSPECTIONS
212 Nein Street • Municipal auiltling JC
Noctpampton, MA 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,modernization, convection,
improvement, removal, demolition, or construction 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 are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity most be registered.
Type of Work: — ( F Est.Cost:$ n
Address of Work: // S rrrLLL�� T/ T- ?L/KIFC
Date of Permit Application:
I hereby certify that
Registration is not required for the following reason(s):
Work excluded by law(explain):
—Job under 51,000.00
Owner obtaining own permit(explain):______
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGIS'I FRED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS'rO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILI I'ES FOR ALL WORK
PERFORMED UNDER THE BUILDING PER511 F.SEE NEXT PACE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the okcner:
4410 1 C'ac voPn rf��ifia �. �E �/
Date 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
City of Northampton
Massachusetts
x
DR OF BUILDING INSPECTIONS
212Xein
212 in Street *Municipal Building 5�.cca
XA 01060 s✓'".�\d
Debris Disposal Affidavit
In accordance of the provisions of MOL 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, 5 150A.
The debris from construction work being performed at:
11 � sis T
(Please print house number and s reef name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
a� Try — V /ky R�cycl(-4y
(Company Name and Address)
/lcK-f-hA-frc,J
Signe of P rmit Applicant or Owner 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.