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18D-021 (3) 19 PINE BROOK CURVE BP-2020-0897 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18D-021 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 P E RM I T Permit# BP-2020-0897 Proiect# JS-2020-001479 Est.Cost: $11875.00 Fee: $105.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KYLE GENDRON 108771 Lot Size(sa.ft.): 16988.40 Owner: WILMINGTON SAVINGS FUND SOCIETY Zoning:URB(100)/ Applicant. KYLE GENDRON AT. 19 PINE BROOK CURVE Applicant Address: Phone: Insurance: 1464 STATE ST SUITE 100 (413) 896-3469 WC SPRINGFIELDMA01109 ISSUED ON.2/7/2020.0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL NEW SHINGLES AND NEW BATH SURROUND 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 Sianature: FeeTvpe: Date Paid: Amount: Building 2/7/2020 0:00:00 $105.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck-Building Commissioner , Department use only ►-rr�rll. City of Northampton Sta Building Department Curb rv�A way Permit 212 Main Streeto \\ Fq wer/Se ability Room 100 do o� Ware r1,Well A �bttt( Northampton, MA 010609T mG Twos o/ �of St ru Plans Phone 413-587-1240 Fax 413-587-1272 �� otlSite fans 0 Snecifv APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR D A ON OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot �c)- I Unit Zone _ _ Overlay District Elm St.District CB District _ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ' t W,im�ilt V01u.'A/ S-ran( SOE.'t x Name(Pnn� Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name ri Current Mailing Address: —T- -It3,'S�1,-3A Signature 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 2. Electrical (b)Estimated Total Cost of Construction from(6 Plumbing Building Permit Fee Mechanical(HVAC) �KaO�= �yU.` ' IQ�+ Oct cc) / . Fire Protection 6. Total= 0 +2+3+4 +5) Check Number ' This Section For Official Use Only Building Permit Number: o Date Issued: Signature: 7 O BL: uilding Commissioner/Inspector of Buildings / Date 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 D Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [[] Siding(p] Other[EX Brief Description of Proposed Work: 'n,lt.tt ✓t { �6'iI " 1 � `ti i � n(Lc�(Y` �rfl�ullLl� Alteration of existing bedroom Yes ,."' No Adding new bedroom Yes No Attached Narrative Plans Attached Roll -Sheet Renovating unfinished basement Yes No 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 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. Tina Carter as Owner of the subject property hereby authorize r, +.r to act on my behalf, in all matters.elauve to work authorized by this building permit application. Signature of Owner Date 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 ind belief. Signed under the pains and penalties of perjury. Print-, m ature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: K J 1„r lTf l�Ar(y\ C n License Number ��5 1G5� CJUn�r n KC� �f5� AL 60, S- Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Kul, GcnJror �'6IU7b Company Name Registration Number -/IV-£,,,a �1/to�„ r R QczAl�Ad AA- QW65 7-91- () 1 Address Expiration Date Telephone 413-ata- 4600Zi 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....... A No...... ❑ City of Northampton .r. Massachusetts D"ARTMCNT OF BUZLDZNC ZXspZCTZ0XS 212 !Iain street • x Kunicipal Building Northampton, uA 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, modemiiation, conversion, improvement, removal, demolition, or construction of an addition to any pro-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 reggistered contractors. Note.If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: .U'.a.e cl.n„ <1 :... c ,�I&a�Fst.Cost: IfW Address of Work: ��r m (3c a C,V (` Al Ia M o�vn AIA Date of Permit Application: I hereby certify that. Registration is not required for the following reason(s): _Work excluded by law(explain): —Job under S 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: 1 Date 5;U. ; v Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: 2/5/2020 Wilmington Savings Fund Society -,�Zgw, G44te-� Dau, Owner Name and Signature City of Northampton Massachusettsgls s�crr� DEPARTMENT OF BUILDING INSPECTIONS ?+ £ 212 Main Street •Municipal Building Northampton, MA 01060 Jy 47 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.- (Please t:(Please print namg-and I cation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Nam6 andAddress) Signature of Permit 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. UVThe 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 Please Print LeZib1V Name (Business/Organization/Individual); }��( , GLn�,(tOn kM Address: City/State/Zip: (./t5� �:�.�c.� M•4 010(65 Phone#: 4)13.- Jia- 160041 Are you an employer?Check the appropriate box: Type of project(required): 1.r_1 1 am a employer with employees(full and/or part-time).* 7. E] New construction 2.JRI am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doingall work myself. t 9. ❑Demolition y [No workers'comp.insurance required.] 4.❑I 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 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and i have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'co t 13.[:]Roof repairs mp.insurance. 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 41 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: (3� M,,J,_,Cj r 1nS01 CAW-0 Policy#or Self-ins.Lic.#: Expiration Date: 19-ao- aOa Q Job Site Address:—d LU &nnl/ L,.-,e ' City/State/Zip:f�lryr��1L._.rn�a� IVA_610( 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 andpenalties ofperjury that the information provided above is true and correct. Sign ature: Date: ff 0 Phone#: ill`3- �L7 - `C00`1 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#• �jinejomepun 68010 vW'4-j313`JNI8dS 1S-3M �-- 1S H0IH LE NOdON30 3lJJl N08ON30 3-1 i 6103/0Z/ZO 0LO l8 l u 1t gI x uoge� 1 a Ienpinlpul:3dA.L ' F; i es1O ioleln6auauis VjjgW�ewnsuo30ODWO l / � Commonwealth of Massachusetts Division of Professional Licensure Board of Budding Requlations and Standards Constrgctinn Supervisor CS-108771 Expires: 08/25/2020 KYLE MARC GENDRON 15 HAMPDEN STREET WEST SPRINGFIELD MA 01089 Commissioner �/"", �1 GENDR-2 P I ,a�oRO CERTIFICATE OF LIABILITY INSURANCE FDA'01/30/2020Yj 01/30/2020 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 413-737-0300 c ACT Eric Dembinske Ormsby Insurance Agency,Inc. PHONE 413-737-0300 FAX 413-737-0617 698 Westfield St PO Box 718 (A/C,No,Ext); A/C,No): West Springfield,MA 01090 E MAL edembi-n-s-k-e@-o-rm—s6yins.com Eric Dembinske INSURERS AFFORDING COVERAGE NAIC# INSURER A:Quincy Mutual Fire Insurance 15067 eRendron INSURER B ouunnt Ci COri�t taian LLC INSURERC: 5 East Mn Road Westfield,MA 01085 INSURER D: INSURER E: INSURER F: OVERAGES 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 CONTRACT OR 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. INSR TYPE OF INSURANCE DL UBR POLICY NUMBER POLICY EFFMMIDDNYYYI POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILrY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX�OCCUR 60207207 12/20/2019 12/2012020 DAMEMAGE TOfERENTED 300,000 occurrence) $ MED EXP(Any one erson 10,000 PERSONAL a ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY 1:1 JECT LOC 2,000,000 PRODUCTS-COMP/OP AGG OTHER: AUTOMOBILE LIABILITY CO(EaMBINED accidentlSINGLE LIMIT ANY AUTO BODILY INJURY Perperson) OWNED SCHEDULED AUTOS ONLY AUTOS ED BODILY INJURY(Per accident) AUTOS ONLY AUTOS ONLY PPerOadent AMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION 3 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/NSTA UTF ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT QFFICER/MJMW)EXCLUDED? N/A IIMfies ory n FN1FF11) E.L.DISEASE-EA EMPLOYE If es,desc ibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 1 F DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Contractor/Contractor Work&plowing CERTIFICATE HOLDER CANCELLATION NONE-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Armory Property Management ACCORDANCE WITH THE POLICY PROVISIONS. 1464 State Street Springfield,MA 01109 AUTHORQED REPRESENTATIVE Eric Dembinske ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r i4> ;� f9�{i?.FltliiiAt 'd J3',[?$ a..'^?;1► �.� r, .M , ,,riw ; �. E,4r `lt :r.�•, - 1t1:YC' -.i :•E4n„r-..'x ... � t�' _ ,tiv f�:Vt i .i•" . 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