25-065 101 RIVERBANK RD BP-2020-1100
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25-065 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR BUILDING PERMIT
Permit# BP-2020-1100
Proiect# JS-2020-001844
Est. Cost: $65000.00
Fee: $422.50 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ACE FIRE & WATER RESTORATION INC 074416
Lot Size(sa. ft.): 12501 .72 Owner: CHETHAM
Zoning: Applicant. ACE FIRE &WATER RESTORATION INC
AT: 101 RIVERBANK RD
Applicant Address: Phone: Insurance:
18 ELIZABETH ST (413) 750-5200 Workers Compensation
WEST SPRINGFIELDMA01089 ISSUED ON.5/1/2020 0:00.00
TO PERFORM THE FOLLOWING WORK.-REPAIRS FROM WATER DAMAGE
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 Si(.,natnre:
FeeType: Date Paid: Amount:
Building 5/1/2020 0:00:00 $422.50
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
101 RIVERBANK RD BP-2020-1 100
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25 - 065 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR BUILDING PERMIT
Permit# BP-2020-1100
Project# JS-2020-001844
Est. Cost: $65000.00
Fee: $422.50 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ACE FIRE & WATER RESTORATION INC 074416
Lot Size(sq. ft.): 12501.72 Owner: CHETHAM
Zoning: Applicant: ACE FIRE & WATER RESTORATION INC
AT. 101 RIVERBANK RD
Applicant Address: Phone: Insurance:
18 ELIZABETH ST (413) 750-5200 Workers Compensation
WEST SPRINGFIELDMA01089 ISSUED ON.5/1/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.REPAIRS FROM WATER DAMAGE
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 Signature:
FeeType: Date Paid: Amount:
Building 5/1/2020 0:00:00 $422.50
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 Cut/Driveway Permit
212 Main Street �q Sewer/Septic Availability
`{. Room 100 y . � Water/Well Availability
Northampton, MQ"(�Nj
11n) Tv�Sets of Structural Plans
phone 413-587-1240 Fax =4272Plot/Site Plans
, . �.,�
."`cit,1A,,Spr`� Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OktEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map 04t> Lot— 0&6--Unit
101 Riverbank Rd Zone Overlay District
Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: c tu- -f --I-;�-od-o
Celia Chetham t- C
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address: Jr
�f13021
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. BuildingL (a) Building Permit Fee
�J
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee �/ 7
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 + 2+ 3 +4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: � de` 00 Date
Issued:
Signature: ,
` '
Building Commissioner/Inspector of Buildings Date
67—co— Fr ie-e— G zci (alit fir. CD m
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable El
Name of License Holder: �L(F�/ U, /J/'/(A� Jl� �5— 07`1 1
�n License Number
PO 6o k 104 O 034 V/#,--)0,-,w
Address Expiration Date
Signa re Telephone
9. Re ister Home Improvement Contractor: __ _ Not Applicable ❑
Company.. Name Registration Number
l,`S 1, A71%�
Address Expirati n Dat
UeMA Q Telephone ��'75�" %
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 build!pg permit.
Signed Affidavit Attached Yes....... dal No...... ❑
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement windows Alteration(s) Roofing ❑
Or Doors ID
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other[d]
Brief Description of Prosed
Work: TOW k"_ ` I` ' i
/V ecv ,�ur4ck_.
Alteration of existing bedroom Yes No Adding new bedroom Yes No U
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
1!d z Lc V� as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relatiized is building permit application.
ve ork author
Signature of Owners Date
1, cary 01 ( ;� -j+1L. as Owner/Authorized
Agent here y declare that the state ents 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.
au
Print Nam
0
Signature of Owne gent Date
City of Northampton
Massachusetts
yiGy
k� 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:
lol ver katlkl
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Mis o<S 11
(Company Name a Address)
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.
City of Northampton
.• s`s�.'"'"sic
• ' Massachusetts
�1 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 - `100
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:_ ) 004 k6 Est. Cost: ��5, my,
Address of Work: ue/L lk PA
Date of Permit Application: �k-3/20
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:
1,� 115-0 to
Date Contractor Name HIC Registration No.
OR:
Notyf�tAstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
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.
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): Ace Fire&Water Restoration Inc.
Address: 18 Elizabeth St
City/State/Zip: West Springfield, MA 01089 Phone#: 413-750-5200
Are you an employer?Check the appropriate box: Type of project(required):
I.E]I am a employer with 10 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. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.D I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10E]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.E]Plumbing repairs or additions
5.M I 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.:
14.❑✓ Other Repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
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.
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: The Dowd Agencies
Policy#or Self-ins.Lic.#: VWC10060144772019A Expiration Date: 07/01/2020
Job Site Address: e flklk� City/State/Zip: 0, r
Attach a copy of the workers'compensation policy declaration page(showing the policy number add expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a tine 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 certi under the pains and penalties of perjury that the information provided above is true and correct
Signature: U Date:
Phone#: 413-750-5200
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#:
y - Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
ConstrktoMiNiSpervisor f
CS-074416 ' ires: 09/18/2020
I
i
GARY W BRtNVELLE ;','rte
PO BOX 104
GRANVILLE M".1 34
Commissioner
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement-Contractor Registration
Type: Corporation
ACE FIRE&WATER RESTORATION,INC. Registration: 151246
18 ELIZABETH ST. Expiration: 05/25/2020
WEST SPRINGFIELD,MA 01089
SCA 1 u -05/17
Update Address and Return Card.
2'�0M
✓/(-P �!!,ry!/no/u��P.IJ.�./�C�./lil9o.'k3o,C�/.�-/./,J,
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Corporation before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
75124 05/25/2020 One Ashburton Place-Suite 1301
ACE FIRE&WATER RESTORATION,INC. Bos ,MA 02108
GARY W.BRUNELLE C�ZC
18 ELIZABETH ST. o
WEST SPRINGFIELD,MA 01089 Undersecretary acid without signature
AC rf ® DATE(MMIDD/YYYY)
ll /�AO CERTIFICATE OF LIABILITY INSURANCE 09/17/2019
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: Donna Desmarais _
THE DOWD AGENCIES LLC PHONE E (413)437-1018 A/c No:
ADDRESS: ddesmarais@dowd.com
14 Bobala Road INSURERS AFFORDING COVERAGE NAIC N
HOLYOKE MA 01041 INSURERA: AIM MUTUAL INS CO 33758
INSURED
INSURER B
ACE FIRE &WATER RESTORATION INC INSURERC:
INSURER D:
18 ELIZABETH STREET INSURER E:
WEST SPRINGFIELD MA 01089 INSURER F:
COVERAGES CERTIFICATE NUMBER: 449108 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $DAMAGE TO RENTED
CLAIMS-MADE 1:1 OCCUR PREMISES E.occurrence)
$
_ MED EXP(Any one person) $ _
N/A PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY CJ PRCOT- F—]]LOC
PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
_ ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS N/A BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION XPER STATUTE ETH
AND EMPLOYERS'LIABILITY ----
ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000
A OFFICER/MEMBER EXCLUDED? NIA NIA N/A VWC10060144772019A 07/01/2019 07/01/2020
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 _
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000
I
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this Certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/lwd/workers-compensation/investigations/.
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 Street#100
AUTHORIZED REPRESENTATIVE
Northampton MA 01060 D.-
k C�
Daniel M.Cry,CPCU,Vice President-Residual Market-WCRIBMA
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD