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31B-189 (5)
75 GOTHIC ST BP-2020-0714 GIS#: COMMONWEALTH OF MASSACHUSETTS Map: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-2020-0714 Proiect# JS-2020-001218 Est.Cost: $50000.00 Fee: $325.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ALISHA PHILLIPS 106378 Lot Size(sq.ft.): 6229.08 Owner. J BIRDSALL tonin : U�RC000V Applicant. ALISHA PHILLIPS AT. 75 GOTHIC ST Applicant Address: Phone: Insurance: 40 PINE VALLEY RD (413) 586-5986 W(` FLORENCEMA01062 ISSUED ON.12/13/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.TURNING 3 SEASON PORCH INTO 4 SEASON 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 Dmartment 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 si;=nature: FeeTvpe: _ Date Paid: Amount: Building 12/13/2019 0:00:00 $325.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only air, City of Northarr�pton ; D� Sttisd�f,�ermit: r Building Department6. Curb Cutpriveway Permit 212 Main ! treetDF„r '�' �werl ptic*ailability t ;4 Room 10q��c�,� Water l ell'°}�aitability ' Northampton, MA 0106 ��oN�n�s�� wo ets of Structural Plans phone 413-587-1240 Fax 413-587-12 �q 07,,Pft'oite Pans r 6tt1+ r Spocify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: ,1This section to be completed by,office �S / �yI� rG Sflct Map Lot /Unit I�DIN Vw/d 5»1Ptbo' M� Duo Zone Overlay District 1 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: I Name IP Current MailinAddress: y,3- iza_ .7219 Telephone SignatL 2.2 Au horized Agent: s�g ,,- A //lips r/&1 /lel Ii! ! Name(Print) Current Mailing Address: (tel (a 41/3 - s g6 -s-9 g4 13J azo- ?4C� Signature elephone SECTION 3-ESTIMAT116D CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2+3 +4 +5) d DO Check Number Q This Section For Official Use Only Date Building Permit Number: Issued: Issued: Signature: Building Commissioner/Inspector of Buildings Date okyiom I ti„d hid botJ @ k ' , Ctt? EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other[Co Brief Description of Proposed Work: i t f f(,&dA 01V t� S -gee Alteration of existing bedroom Yes > No Adding new bedroom Yes j Attached Narrative Renovating unfinished basement Yes �No Plans Attached Roll -Sheet 6a,If New house and or addition to existing housing, 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 iJ,S S as Owner of the subject property hereby authorize to act o y ehal(, in II m ers relative to wok authorized by thi building permit application. �� G Signat e f Owner Date Irs I Gl P4; /t as Owner/Authorized Agent hereby declare that the statements and informal n on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name ZG SigriabKof Owner/ n Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ T t Name of License Holder: yk/ t 4�S- l D43 316 License Number An I�'l G -ZI76170220 Address Expiration Date `/r3 - 'S4- Sss Signature I Telephone 9. Renistered Horne Improvement ContractorNot Applicable ❑ T Company Name Registration Number Y4 A,04- 1/ti lr G/oG Z Z/D� / zo Z/ Address Expiration Date Telephone 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 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: -K- 6vf4,c. sf , /V,14&& 174 0/060 (Please print house number and street name) Is to be disposed of at: (Please rint nam and to tion of facility) 1 Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) j/ 2615 Signatur Vi pplicant 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. The Commonwealth of Massachusetts Department of Industrial Accidents 1 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 Please Print Legibly Name(Business/Organization/individual): Ayirwl Landsch/(,( t CIatt& 1F '�G��tla1F LG Address: yo i valtt, Ltd City/State/Zip: F#.f,4C t PI 0/0(7 Phone#: q/3 - YU - rf f� Are you an employer?Check the appropriate box: Type of project(required): ll; am a employer with J employees(full and/or part-time).* 7. E]New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in $,modeling 9. any capacity.[No workers'comp.insurance required.] . 0 Demolition IF 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 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.[3 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.' 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and Ave 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. t Homeowners who submit this affidavit indicating they are doing all work and then Erre outside contractors must submit a new affidavit indicating such. tContractors 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 far my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: If (euA�C City/State/Zip: *017460*7p�'1R /04 0119GO 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 ndpenalties of perjury that the information provided above is true and correct. Si nature: Date: �i f Phone#: y/3 — 54 — SSS fr — 1/13 -32-0-966 9 Oficial 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#: AC40R o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11/26/2019 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(ies)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). PRODUCER CONTACT NAME: Sarah Premo Martin J Clayton Insurance Agency, Inc. PHHCONE E:t: (413)536-0804 alc No: 1649 Northampton Street E-MAIL spremo@mjclayton.com ADDRESS: P. O. BOX 989 INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Safety Insurance Company 0014 INSURED INSURERB:Safety Indemnit HO Preferred 33618 Axiom Landscape b Home Improvement LLC INSURERC:AIM Mutual Ins. Co. 053 40 Pine Valley Rd INSURER D: INSURER E: Florence MA 01062 INSURERF: COVERAGES CERTIFICATE NUMBER:19 MASTER 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 MAYBE 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 INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDfYYYV MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,001 DAMAGE TO RENTED A CLAIMS-MADE FxI OCCUR PREMISES(Ea occurrence $ 100"001 S A0028548 1/11/2019 1/11/2020 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,001 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,001 X POLICY PRO LOC PRODUCTS-COMPIOP AGG $ 2,000,001 JECT OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,001 Ea accident ANYAUTO BODILY INJURY(Perperson) S B ALL OWNED SCHEDULED AUTOS X AUTOS 5907002 1/11/2019 1/11/2020 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIREbAUTOS X AUTOS Par accldent $ Medical payments $ 5,00( UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION 5 $ WORKERS COMPENSATION PER TH- AND EMPLOYERS LIABILITY YIN STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,00( OFFICER/MEMBER EXCLUDED? NIA -- O (Mandatory in NH) WCC5005020083 4/17/2019 4/17/2020 EL DISEASE-EA EMPLOYEE $ 500,00( If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00( DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101,Additional Remarks Schedule,may be attached If more space is required) RE: 75 GOTHIC STREET, NORTHAMPTON, MA 01050 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF NORTHAMPTON THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPT. ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET, #100 NORTHAMPTON, MA 01060 AUTHORIZED REPRESENTATIVE may} Michael Regtvn/F'M" vI r ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(281401) EN 31 t t- . , � a F100 40tv", " wt aVF F g 9,75 VIM v