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30A-090
70 LIBERTY ST BP-2019-0409 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30A-090 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category:ROOF BUILDING PERMIT Permit# BP-2019-0409 Project# JS-2019-000653 Est.Cost: $12400.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Cont. Class: Contractor: License: Use Group: JEREMY SAWYER 106836 Lot Size(sg A.): 30404.88 Owner: SHAUGHNESSY PETER R Zoning:URB(100)/ Applicant: JEREMY SAWYER AT: 70 LIBERTY ST Applicant Address: Phone: Insurance: 121 WEST STATE STREET (413)478-1536 WC GRANBYMA01033 ISSUED ON.101512018 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: 9: Insulation: Final: S o e: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Qgalficak qf Qccupangy l t r : FeeType: Date Paid: Am2unt: Building 10/5/2018 0:00:00 $40.00 212 Main Street,Phone(413)5871240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 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. Northampto is of Structural Plans phone 413-587-124 Fa>�1&EWE lot/s a Plans ther pecify APPLICATION TO CONSTRUCT,ALI ER,R E!MfENT�Rlk D EMOL ISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: NORTHAMPTON,MAo1oso �Tt is section to be completed by office 7 Q i t r 4') S Map Lot Unit © /D 6 a Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: PP-t-Pr" -, eSs�f 70 Le Se/ � S�- Name(Print) Curre Maiiin Address: V 3 5-e-6- 6 5-/,6 Telephone Signature 2.2 Authorized Accent: -I-r� Sc, w c, e-e-- �� / /� S'�' 7le S 7 r4 n c /77fi�D/J 3 Name(Print) T Current Mailing Address: Si Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee � O 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee #jz 4. Mechanical(HVAC) 5.Fire Protection op 6. Total= (1 +2+3+4+5) /a 41c D Check Number This Section For Official Use Only Building Permit Number: Date Issued: of Signature: / Building Commissioner/Inspector 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 Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding 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 DON'T KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW W YES 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? YESO NO 1� 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,excavation,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 lcheck all applicable) New House ❑ Addition Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[C:3] Other[p] Brief Deswy'p tion of Proposed Ip Work: X*42141 ShinsIC a2oo4-s Alteration of existing bedroom Yes >C No Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housinct, complete the followinsl: 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? �e, s — 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. 1. 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, df 4Gc/c 4 ressc, _ __ _ 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. � '7P ( l / I-- /6:AaetS -7//J Signature of Owner —� ate I, erlr+, f - �A as Owner/Authorized Agent hereby declare that the stateme s 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. F Print Name O / ature of Owner/Agent Dalre SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: IP r pM ., �� iJh �,�� /D 6 License Number 6 /-> oaa Address Expira on Date §Wgu—re Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date- Telephone ateTelephone 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....... No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS �. 212 Main Street • Municipal Building yvb•.. C��, Northampton, MA 01060 fs .• `�4 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, 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 homeowner has contracted with a corporation or LLC, that entity must be registered Type of Work: 00 Est. Cost: /d_, "/0 0 Address of Work: O Date of Permit Application: /D �- 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: /o k //k- 19// rX f- r / 7 Da�- 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 ��? ' A._ '<< DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street *Municipal Building `•.., c �• Northampton, 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: (Please print house number and street name) Is to be disposed of at: A) H �S�S�- (Please print name and location acility) Or will be disposed of in a dumpster onsite rented or leased from: �i O r S'I ,J 'S4120 J A✓;'6, ..S'f' Sp r,nf r Pll lw/f 0//ay (Company Name and dress) Signat ermit Applicant or 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. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aaalicant Information Please Print Legibly Name (Business/Organization/Individual): -a—e r g-r,-,t ell C'h YL/rla �l Address: / a / W S 7t4 4t S-A City/State/Zip: S /219 0/0_7_? Phone #: ly2 k/_�C36 Are you an employer?Check the appropriate box: Type of project(required): 1.gl am a employer with S— employees(full and/or part-time).* 7. []New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E] Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[J I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole ILE]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13�Oof repairs These sub-contractors have employees and have workers'comp.insurance3 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] IL *Any applicant that checks box#1 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: T-/-e— Ila f-D( Policy#or Self-ins.Lic.#: e S G 0 V 13 /.2 6 /9 Sr I S— Expiration Date: 151114 �! Job Site Address: 7 0 / -e r S f City/State/Zip: e e /►'z iq D/O d, Attach a copy of the workers'compensatiA 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and"ties ties of perjury that the information provided above is true and correct. Signature: Date: / Phone#: V171F_ t 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts r Division of Professional LicensurSTATE ()F CONN e ECTICUT r Board of Building Regulations and Standards Construction Supervisor HOME IMPROVEMENT CONTRACTOR CS-106835 Expires:05/26/2020 jEREMY SAWYER 121 W S'L'A'T'E ST JEREMY SAWYER - GRANBY,MA 01033-9614 { 121 WEST STATE STREET GRANBY MA 61033 LIC.I REG NO. EFFE XP! S HIC.0636067 12/0112017 11/30/2018 Commissioner SIGNED Y�f/n t!fNJ 377f'Jttttfiff!/�Jt f ^'+`Iti.iftCJJfJ.if't1+" e Office of Consumer Affairs&Business Regulation -, HOME IMPROVEMENT CONTRACTOR TYPE-IndivldUal Real�*xation �.4�4L 174W-B 02/25/2019 1kdezMly SAWYER OtBIA ALL EXTERIORS JEREMY SAWYER ` S 121 W EST STATE ST GRANBY,MA 01033 Undersecretary JEREASA-01 NICOLE r4+°Rim CERTIFICATE OF LIABILITY INSURANCE oe° ' w 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 policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,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 ovu Nicole Bushey Phillips Insurance Agency,Inc. PHONE FAX 97 Center Street (Aryc�,fig,racy:(413)594.5984 1(A/C,No):(4i 3)592-8499 Chicopee,MA 01013 1 ADpl) SS:nicole@phillipsinsuranee.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Western Wood Insurance CO. I INSURED INSURERB:Selective Ins Co of South Caro Jeremy A Sawyer Dba INSURER c:The Hartford 129459 All Exteriors 121 West State Street INSURER o: Granby,MA 01033 INSURER E: INSURER F: i COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.INSRj _ LTR TYPE OF INSURANCE I L BRPOLICY NUMBER II POUCY EFF POLICY EXP LIMITS v A ` X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE 1S 110001000 CLAIMS-MADE I X OCCUR NPP8326941 06103/2018 06/03/2019 ° E r°RENrEo 5 100,000 +MED EXP one pwson (S 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN IAGGREGATE LMITAPPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY 17 JJPEA& FI LOC PRODUCTS-COMPIOPAGG S 1,000,000 OTHER: i S B AUTOMOBILE LIABILITY CEOaMa DSINGLELIMIT S 1,000,000 ANY AUTO A 9105120 04/1612018 04/1612019 BODILY INJURY Per persw is OWNED RXAUTOS CHEDULED '— AUTOS ONLY BODILY INJURY Per accident) S R� PROPERTY DAMAGE LX AUTOS ONLY UTOS ONEY Per acdden S S UMBRELLA LAB OCCUR EACH OCCURRENCE S _ EXCESS LAB CLANS-MADE AGGREGATE S DED I I RETENTION S i S C AND MPLLORMERS YEYERS�LIAAB�WTY X S ATU X i ER El.EACH H. ANv naoPruE rowrnssnaEa�xecunve YIN N r A BS60UB 2Ei2612-8-18 04/1612018 04/16/2019 CH ACCIDENT s �i•flOD,00D oFrtcenNH occLUDmr 0 1,000,000 (M aeda E_L.DISEASE-EA EMPLOYE S My es,dewdbeunder 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY Umn-C S 1 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 'J" i ACORD 25(2016103) ©198&2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD