31B DATE IMMf4D,YYY'yI
•` ' >>+�rc ` CERTIFICATE OF LIABILITY INSURANCE 1V2&2018
THIS CERTIFICATE 15 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 AFrFORDED 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(ies)must have ADDITIONAL INSURED provisions or ba andorse&
If SUBROGATION IS WAIVED,subject to the terms and conditions of The policy,certain policies may require an endorsement. A statement on
this certlticcate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER. CONTACT NAME: Bal'bafa Van MUulik
Finck 8 Perra s Inst rsnce Agancy Inc. PHONE (41:3)•5'27.55"20 fAXA,1C.Mal (413)`,27-1910
6campust.anc AtsrMpE3s: irvar}mouck�frlrkerr��rra�,Cr�m
WSkURER1S)AFFORDING COVERAGE NA.9C tl
Easlt mP1on NIA Wl 21 INSURER A: Mair)Street America Assr Co 2 39
INSURED INSURER B: NCM Insurance Company- 147&t3
AXIO?IA LANDSCAPE tt ROME IMPROVEMENT LLC INSURER c
AU PINE VALLEY RD INSURER D
INSURER E
FLORFNGF AAA 01062-36GU INSURER F:
COVERAGES CERTIFICATE NUM13ER: CI-1,9L433778 REVISION NUMBER,
TI11S IS TO CERTIFY THAT THE POLI CIES OF INSURANCE LISTED BELOW HAVE BEEN 18$JEG TO THE IN%LJR D NAA1t't7 A13OVF FOR THE POLICY PERIOD
INDICATED., NOI WJHSIANDING ANY REQUIRE MEN 1, 1'ERM OR CONDITION OF 04Y CONTRACTOR OTHER DOCUMENT WMH RESPECT TO WHICH TH S
t,r:RTIFICATF MAY HT 15$UED DR),JAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TCS ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH DOUG=.ES.LIMITS SHOON MAY HA}X,KEN WFOL313ED 5Y PAID CLAIMS,
INSR POLKYEFF POLICY EXP
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LTR TYPE OF INSURANCE i, POLICYNumeak Mmlbo1'YYY MIRDDIYYYY LIMITS
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GENL Aa RESAT£LIM T'APPLIEn PERS 4;F%JEIRAI.A1;GHE,4TE S z,Ia,O'rw
X Prxcy❑JECT i—i Lai ;IRQDUCTS-vOMProp ASS 5 2,000,0110
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AUTOMOBILE LIABILITY :NGL-LI , a'000,000
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AND EMPLOYERS'LIABILITY y+N STATUTE ER
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DESCRIPTION OF OPERATIONS U LOCATIONS i VEHICLES IACOR0101,Addilianal Remarks Suhvdulo,may be sUbchad If mora%Paco Is rm€Paroal
Proof of Coverage
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of NDrlhamplon ACCORDANCE WrIN THE POLICY PROVISIONS,
212 N401IN Street
AUTNOR PRESEk1TAt14'E J
Npnhcampion MA 010610
! 0 ISSO-2015 ACORD CORPORATION. All rights reserved.
AC ORD 25(201 6103) The ACORD name and logo are registered marks of ACORD
116�1r 0 __1 IDATE'.i1 OU NYYYI
ACC> V CERTIFICATE OF LIABILITY INSURANCE
1112ti12MA
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 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).
PRovtrr,ER NAME: Barb Van tt ourik
FINCK&PERRAS INSURANCE:AGENCYINC PH
INC (413)527,3000 Arc Rrf.
tMArL bvatirl)tsurtk firrck.anLi erras_rrarn
,ADDRESS.
6 CAMPUS LANE MSURER(Sl AFFORDING COVL-RAIGE _ , NAIC 0
EASTHA atPTON MA 01027 INSURER A: LM INS CORP 33600
..INSURED INSURER B: ._._._. ._.....__'
AXIOM LANDSCAPE 8r HOME IMPROVEMENT LLC INSURERC:
INSURER D
40 PING VALLEY ROAD INSURER E
FLORENCE N% 01062 INSURER F
COVERAGES CERTIFICATE NUMBER. 341036 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE t IS TFD Aft t1W HAVE BEEN ISSUED TO THE€NSURED NAMED ABOVF FOR,rHF POLICY PERIOD
iNDCATED: NOTVOTH aTANDINO ANY REQUIREMENT„TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANIZ AFFORDED BY THE POLICIES DESCRIBED HEREIN IS S4Jt]JFv TO ALL TIIE TER1,13
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAII)CLAIMS.
V..
"IT TYPE TYPE 4F INSURANCEW ...Vmo 68LtCY NUMBER POLICY F8 MDLaCY LIMITS
COMMERCIAL GENERAL LIAO,ILITY I EACH GCCUr RENC __ $
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y EXCESS LIAR ._... (A AIVS MIF; WA L. AC..Rk f.a�1 F. b
DE LTENTIQN �,�+
WORKERS COMPENSATION /\ STiRiTU"rC - F
AND 9M PL0`YERS7 LIA[3iL{'ry Y t N
A OFFICER.MEMSE EXCLUDED' euT NA
}WA NIA WC,531$612523017 04872017 04,"1 b'2018
F-1 ox�EnSECIDENT S 504GfiO
Ea EMPLOYED
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it cs,jcrnee ,ve-
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I
DESCRIPTION OF OPERATIONS t LOCATIONS f VEHICLES¢ACORD apt,AgdiNortal Ramamo Schsduls,marc be e460104 4 more ulsece ie r"uired)
Workers'Compensation benefits will be paid to Massachvsetts employees only.Pursuant to Endorsement WC 20 03 06 8,no authrrlirlalttm is given to pay
Claims for benefits to employees in states other than Massauhuselis if the insured hires,or has hired those ernployeas outsilta rad fvla achusettS.
This cart€finale of insurance<shows the policy in force on the data that this cortiftato was tissued(URI*s%the expiration date on the above policy prOL;Wdes the
issue date CONS certificate of insurance). The status of this coverage Can be IrlrrnitCr od daily by accessing the Proof of Coverage-Coverage,Verification
Search tool at avvw.rr�ass.f�tav,�rrrdiwlsrl era Crar�Perksatior��iraves#igatlonsl.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS.
212 Main`a`tre(it AuTHWtIZEDREPREmNTATWE
Northampton MA 01060 Daniel NI.Croy ey,CPCU,Vice President-Residual Markot-WCRIaMA
ISSS-2014 ACORD CORPORAT10% All rights roserved.
ACORD 26(2014101) The ACORO name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information A „ Please Print Legibly
1T
Name (Business/Organization/Individual): y ,� �`t,{ {.�f LLC
Address: IV pt m_ V5 let, doti d
Of
City/State/Zip: t/i( ,t /'y U (�G�, Phone#: ��o
Are y`u,p employer?Check the appropriate box: Type of project(required):
1. I am a employer with_ L 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 $, emodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t
4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.M 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:]Roof re airs
These sub-contractors have employees and have workers'comp.insurance.: p
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.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I 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. I, / t
Insurance Company Name: C K PCZZ9 S L/ �f C� M lifI
Policy#or Self-ins.Lic.#: ��s3 I S ,6 I Z.,/SZ d I Expiration Date: C Z 61
Job Site Address:—15 6-0iC S� 1LJV`I w41Pt41 , /W 1911ZQ 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 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 of perjury that the information provided above is true and correct.
Signature: �0 Date:
(,� G
Phone#: I 13 -
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#:
City of Northampton
� Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS _°
212 Main Street •Municipal Building r�%•, ,��
\ Northampton, MA 01060 s
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:
0 j L - 7/P e /Vv�--4 y+b /or► N 0106 U
(Please print house number and street name)
Is to be disposed of at:
I-J,., lleL Z- eq S 04 /CAI 04i�o
(P se print n e andation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of P ant 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.
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor, l/ Nott Applicable
❑
Name of License Holder: I, N pt;//�' `S— /0637?
L� Q License Number
r o I �rh� AAm Pd 01v(, Z/Z61Z020
Address Expiration Date
Signature Telephone
9.Reaistered Home Improvement Contractor. Not Applicable ❑
Company Name I I Registration Number
yv lite4 6Flyeegee !4 01a xl e6 /Zo/5
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance afficlayit must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the bui ng permit.
Signed Affidavit Attached Yes....... No...... ❑
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Iteration(s) Roofing ❑
Or Doors 1:1 eK I
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[O] Other[o]
Brief Description of Proposed I A
Work: QtMoyeFia l *n 4d 5fj,t5 b-%A1*ow► t fU beboorm next >y int - ko l Cline, IV
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.—If New house and or addition to exist na housina,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 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
I, J Cq/10l't i��s�' as Owner of the subject
property D/ /
hereby authorize
to act on al , in all matter elative to wok authorized by this building permit application.
Signature of wner Date
Z ? 7
I, � Sk ti /'//L -s as Owner/Authorized
Agent hereby declare that the stater fits 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.
175 4 &J" ZIIA-s-
Print
Name
II 2G $
Signature o O er/ en Date
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 Sp al Permit/variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO;<DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO )jam
IF YES, describe size, type and location: �`�
E. Will the construction activity disturb(clearing,gradin ,excav n,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO/
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
RECEIVED
Department use only'-
City
nly
� Cityof Northa pton NOV 2 8 �uLt)tIcv
`'. Building Depart ent CurbayPermit .
212 Main Str et aillROOm 100 DEPT.OF BUILDING IN
NORTHAMPTON, ail�y
Northampton, MA 01060 Two Soft of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plod ite Plans
Other;Speclfy'.
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office'
~-�
—4.157 lr0 ftit�G S'flf L f Map c7� Lot _Unit
Iv&f t1i q*p V At w74 p l U G 0 Zone Overlay District
Elm St.District C6 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Jtg �i�d✓S't �� 'IS' Go�'ltI.0 S���tf A414 A,,7, �U 0/ Ga
Name i t) t Current Mailing Address:
yts-.lel-IN 32D — 71, 19
Telephone
Sig re
2.2 Authorized Agent: Q / n I
`I0 Ala Ua//ey [fid F/-ih ce, /yI11 O/!yG
Name(Print) Current Mailing Addres .
`Il3- S"jg c - r7,8-6
Signat re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building l s�Uu V (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing $z 1 S'0 0 Building Permit Fee f3)6
4. Mechanical(HVAC)
5. Fire Protection a.
6. Total=0 +2+3+4+5) U Gv v Check Number
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
File#BP-2019-0642
APPLICANT/CONTACT PERSON ALISHA PHILLIPS
ADDRESS/PHONE 40 PINE VALLEY RD FLORENCE (413)586-5986
PROPERTY LOCATION 75 GOTHIC ST
MAP
THIS SECTIQN FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT - Z=
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: RENO UPSTAIRS BABEDROOM
New Construction IL
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106378
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF( 1tMATION PRESENTED:
_At!!!//Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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 Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
De ' ion Del
�—
stbvuxw~udung 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.
75 GOTHIC ST BP-2019-0642
GIs#: COMMONWEALTH OF MASSACHUSETTS
MVp:Block: 3 1 B- 189 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2019-0642
Proiect# JS-2019-001045
Est. s : $5000Q.QO
E 5•5.
M .PERMISSIONIS HEREBY GRANTED TO:
const.Class: Contractor: License:
CJs ALISHA PHILLIPS ,8
Lpj izug.ft'): 9229.0 QWfigrj 12JEHL ELLIAN A&J D105ALL
zoning:,URC(1Q0)/ 99kan9 6LISH6 EMIL L,IP-
�iT,a7a GOTHIC ST
A licant A dress: ho es nsuM tce:
40 PINE VALLEY RD 41 586-5986 WC
FLORENCEMA01062 ISSUED ON.1211012018'0:00:00
TO PERFORM THE FOLLOWING WORK.-RENO UPSTAIRS BATH AND BEDROOM**NOTE
NO CHANGE TO FOOTPRINT
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 Deaartment Fireplace/Chimney:
Rough: $4i1. Insulation:
Final: 5m,o e: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Ce ificate of Qgqur)anry Si n re:
Feer e: Date PAid: AmouBt:
Building 12/10/2918 0:00:00 $325.00
212 Iain Street,Phone(41.3)587-1240,Fax: (413)587-1272
Louis Hasbrouck s-Building Commissioner