24D-153 22 CARPENTER AVE BP-2019-0088
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:24D- 153 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-2019-0088
Proiect# JS-2019-000138
Est Cost,$14000.0
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 111478
Lot Size(sp.11.1: 3702.60 Owner: STERNBACH NANCY
zonine: URC(1001/ Applicant: VISTA HOME IMPROVEMENT
AT. 22 CARPENTER AVE
Applicant Address: Phone: Insurance:
2003 RIVERDALE ST 413 382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON.7/23/2018 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP SHINGLES, REMOVE CHIMNEY, INSTALL
NEW SHINGLES
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 sienature:
FeeTyoe: Date Paid: Amount:
Building 7/232018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb CuWdveway Perk
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 0106�0 y�p Two Sets of Structural Plena
phone 413-587-1240 Fax 13-TI LI�EI
APPLICATION TO CONSTRUCT,ALTER,RE AIR REjqyATFqRRWOL H A ONE OR TWO FAMILY DWELLING
SECTION 7 -SITE INFORMATION 19-1116,
1.1 PrlAooeAtny�1 1 rvoaruAMaror+.MA mos
Property
ddress: se ion to be completed by office
(�UV 1 Vie Map iZzr� Lot 0Unitt Y{j1 rt•./r �+� Zone Overlay District
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Nge( \I !:-m r
Ng
(Pont— Curr [Mailiss'-r�
Telep �
ftov
Signature
uthor zed A can
I�udrl .�D v. verr ( e_ 5� . Swr
(Print)
'a ) urrent Mailing Adtlress�t r /�O 0�1
kh-A "A ti-1 '4
ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (J 1� (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee of
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: IIsssued:
Signature: G 7`?A
T
Buildi g Commissionerllnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Acquired by Zoning
This column to be filled in by
Building Depanmrnt
Lot Size
Frontage
Setbacks Front O O
Side L:0 R:= L:= R:=
Rear 0
Building Height O O
Bldg. Square Footage
Open Space Footage
[Cot n S minus bldg a pined
arkin t
#o1'Parkin 5 aces
(voluma&Locution)
A. Has a Special Permit/Variance/Findin ever 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 Pagel and/or Document#�
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOV 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 O
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 O
IF YES, describe size, type and location:
E Will the construction activity disturb(Gearing,gradino ejcavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO V
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 Alterations) Q Roofing
Dr Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0I Decks [M Siding[0] Other[0]
Work: on of,eropp9¢[1_ , _r-
Werk: � ` /� `�111�) y• 1"� a1 t 1k' c,�j�y.�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative / _ Renovating unfinished basement Yes —X—No
Plans Attached Roll -Sheet
Ga.If New house and or addition to existing housina. complete the following:
a. Use of building : One Family Two Family Other
L. 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. Masscheck Energy Compliance form attached?
h. 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
1 ,as Owner of the subject
property, //��
herebyauthorize VCJ�arISL� 1�
to act on my behalf, in all matters relative to work authorize by this building permit application,
1 \'C2�
Signature of Owner Date
:Y \
I, an to'y//C "Cw , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under a1p-ains and penaltie erjury.
V i QLA
Print Name
Signature of /A t Date
SECTION 6-CONSTRUCTION SERVICES
6.1 Licensed Construction Supervisor: //Not Applicable ❑U Q
Name of License Holder' 0 1 1�u dl \ �_ ll 1 1� V
License Number
U11a, lal
tl s Expiration Date
ureIV Telephone
R i HOm Im ro m n n r. Not Applicable Ll\f IStGt �rnn \rn��ye�rn4nfi ICDA
C mpanv Name Registration Number
�1��c �Vc ,r ( AL2 1 �a ilU
dddrr'e'sss�(' Expiration Me
/�
V� ne
Telepho
SECTION 70-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....... No...... ❑
City of Northampton
Massachusetts
l d `
A
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, 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("H1C").
M.G.L. Chapter 142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion,
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 home nerr�h4 contracted with a corporation or LLC,that entity must be registered.ere
Type of Work: O`�I Est. Cos1-1,41-000
V
Address of Work� 0�.�ns:k 1 0�l NO�"- OI „lJI (`l 0
Date of Permit Application:
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:
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
I �
DEPARTMENT OF BUILDING INSPECTIONS 5 '
212 Hain Street •Municipal Building
Nort]u Ston, MA 01060
Debris 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.
The debris from construction work being performed at:
as ca � � e�� ,
(Please t house nu ber and street name)
print
Is to be disposed of at:
ydIU U f atir.11m - ��r1 lrnPt(�1
(Pleas�t name arld location o acility)
Or will be disposed of in a dumpster onsite rented or leased from:
\13 � r -
(Comp• y Name an Ad dress)
A14 1 A A J'] --� I " I 1�
Upir6t6re o er it dpnt or UWner 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-1017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information1111
^ Please Print Le ibly
Name (Business/Orgmixationilndividual): V
Address: wes VV_ y u Q l L �N- l
City/State/Zip. T L� Phone#: 1-1L-5 _30a H-1 —'1 Q,
Are you an empl.yer't Check the appropriate bax: Type of project(required).
*a—'In a employer with cmploycc Chill and lor,amount.` 7. ❑New construchon
2 I am a sole prupncho n partnership and have no employe.working forme In 8. ❑ Remodeling
any capacity.[No workers-comp.Insurance required.]
.❑I am a hmnwwncr doingall work Noworkcrs camrequired- 9. El Demolition
3
a y [ ,.Insurance ]`
4.❑1 on a homeowner and will be hiring wm.vm.rs m wnductnll work on my,worry_ I will 10 E] Building addition
ensu
mthataueontraemr either hate workerminpssationinsuraacoorarewk IL❑Electrical repairs or additions
pmprlefars with un envloyces. 12.❑Plumbing repairs or additions
5I am a general cono-adord I h
and hu tih
Ia sub-connaetors listed th
e. e oIn,hed she,.
❑ 13.❑Roof repairs
These suMconnacmr have rmployee.and have workers'ramp.insurnnce.t
6.❑W-u,,,anu.0 a andicoffiems have exerc ace!thdi,a rufexenption per MdiLc 14.'�Other
152,4114),and we have nn mnployecs_[No worker'comp.inns...aryuimdd
'Any applicant that checks box 4I must also till out the section below showing their workers wmpensay.n policy areonmtion.
'Homeowners who submit this aFlidavit indreting they arc doing all work end thyro bite onside c.utreu.rs thou submit anew affidean indicating such_
iComracr.rs that check this box must attached an additional shut showing the name of the sub-contractors and surd,whether or not those entities hasc
employees. If rhe subcennacmrs have employees,they must,..ride their workers wrap_policy number.
I am an employer that is providing workers'compensation insurance fir my employees. Below is the policy and job site
information. 77�� 11 11 _ ^ !! '',, �sC
Insurance Company Name:SO kl-�I Y 'W� l.� 7 U �✓�1...
Policy k or Self-ins. Lie.#: xpiration Date:
Job Site Address "P 11 I e I City/State/Zip: yth1VA mp a QDp
Attach a copy of the workers'comp r sation policy declaration page(showing the policy number and expirlution date).
Failure to secure coverage as required under MCL 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
do hereby ce nder the painsa d eualCes perjury,that the information provided above is true and correct.
Si nature: Date:
Phone#:
Oficial use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License H
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#:
08/09/2017 2.37PM FAX 4135729191 WILLIAM MIS INSURANCE 20002/0002
CERTIFICATE OF LIABILITY INSURANCE
08/09/2017
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, MEND OR ALTER THE COVERAGE AFFORDED BY THE PoLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 65UFG MSURERIS), AUTHORVED
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INGICARu. NOTWITHSTANDING ,WY RF.OUIRtMENT. TERM OR CONDITION OF MY CONTRACT OR OTAW OOCUMEMT WITH AMnEOT TO "MGI THIS
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CERTIFICATEHOLDER CANCELLATION
VISTA RQg IMPROLBILVNT
2003 RxNRIFDAIE SMRCET SHOULD MY OF THE ABOVE p6CRIBED POUCIEB BE YAWELLED BEFURE
1E EANNIGON DATE THEPNF. NONCE .1 nE p .N.Ri. IN
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Nor-2-11 6/25/2018 7:45 :45 AM PAGE 2/002 Fax Server
• CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDKYYYI
TIFICATE IS ISSUED ASA 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 ME POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
IMPORTANT.Ifthe cedffka a holder R an AODOIONAL INSURED,the policy(iesl must beendome . NSUBROGAM)N 15 WANED,subject to
Use terms and conditions ofthe policy,certain policies mayreyuIm and endorsement. Astatement on this certificate does not confer rights to
the certificate holder in Use of such endomemen s
PRODUCER CONTACT
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SOUTH W ICK INS AGENCY INC PHONE FAz
PO BOX 100 (AF.No,EMI: (A/C.Nop
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SOUTHWICK,MA 01077 AWRESS:
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immm INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
SAMBRICO LLC DB A VISTA HOME IMPROVEMENT INSURER B:
INSURER G:
lNW RD:
20D3 RIVERDALE ST INSMRER E:
WFSTSPRMGFIELD.MA 0I089 INSORERF:
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THLS REPLACES ANY PRIOR CBRI ISSUED TO ME CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
TOWN OF WESTSPRINL.FELD 9MOULD ANYOFT ABOWDESCRIBWPOLICRSBE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BEDELMU ED
26 CENTRAL STREET IN ACCORDANCE WTI THE POLICY PROVISIONS.
AUTHORISED RVR®PIVD f�
WEST SPRINGFIELD,MA 01089 ACORD29(=I=51 The ACORD name and logo are registered marks of ACORO L98e- Do ACORD CORPORATION. All rights reserved.
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2003 RIVERDALE ST
W SPRINGFIELD. MA 01089-1060 _
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Expiration: 1113012018
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