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36-385 (2) Department use only !" City of Northampton Status of Permit: i •'�' ��` Building Department' l• Curb Cut/Driveway Permit 212 Main Street/ G ewer/Septic Availabilit � qy y Room 100���T afer/Well Availability Northampton, M p Tw~Sets of Structural Plans phone 413-587-1240 Fax T 72 ��0 .ot/Site Plans �Tn^> Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENO QTR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 7 1.1 _Property Address: ��� This section to be completed bx office 2NO �Mc!'60r1 YVa ��O{ ", Map Lot_ `S Unit r Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /✓'� Name(Pri Currer� ailing d�rQs%ODl? / Si na re Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: 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 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) I V 5. Fire Protection 6. Total= 0 +2 + 3+4+5) Check Number This Section For Official Use On � Building Permit . ber: j�JaU�7�� Nu Date Issued: Signature: 5- Zq- Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suiperviso : Not Applicable ❑ Name of License Holder: 4f.6,©l�4DO License umb u D(oO Address MM Expir tion to *3Aq- Az S' na V Telephone 9. Re istered Home Improvement ontractor: Not Applicable ❑ /Gt�3O� Company Name Registratio Num er Adss L,arl�_� ! f Expirati n Dat 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 �s.'•.'.sic Massachusetts •'r DEPARTMNT OF BUILDING INSPECTIONS a: 212 Main Street • Municipal Building �Jd& :ca' Northampton, MA olo6o s �10 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: /7,tiq Est. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): X�J 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: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit the oer of above property: /04 &LI go Date Owner Name and lignature 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): Address: 61 - "f y nA�j City/State/Zip: el,S4 / Phone #: Are you an employer?Check the appropriate box: 1�I am a employer with employees(full and/or part-time).* Type of project(required): 7. E] New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] g• [] Remodeling 3.[]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole ILEJ Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.r_1 Roof repairs 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire 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 for my employees. Below is the policy and job site information. Insurance CompanyName: r _du Policy#or Self-ins.Lic.#:_O QExpiration Date: p� Job Site Address: _ City/State/Zip: Attach a copy of the workers' compensation poli declaration page(showing the policy number and piration 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 verificatio . I do hereby certify nder pa' d penalties of perjury that the information provided abo70vo 's true and correct. Si nature: Date: 4k, Phone#: Of 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#: AIII CO R" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 03/09/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 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 CONTACT NAME: Kathy Parker Webber&Grinnell PHONE (413)586-0111 FAXX (413)586-6481 8 North Kin Street AIC No Ext: c,No King -MAIL ADDRESS: kparker@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton INSURED INSURER A MA 01060 Selective INSURER B: AIM 33758 Sunwood Builders,Inc. Attn:Shaul Perry INSURER C: 84 Potwine Lane INSURER D: INSURER E: Amherst MA 01002 INSURER F COVERAGES CERTIFICATE NUMBER: CL203512689 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 TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I R LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF --P5-Ll EXP MMIDD/YY MMIDDI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g 1,000,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence g 500,000 MED EXP(Any one person) g 15,000 4 02932000 03/04/2020 03/04/2021 1,000,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE g 2,000,000 POLICY ❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG g 2000,000 ROTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT g 1,000,000 ANY AUTO Ea accident A OWNEDSCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY X AUTOS 02932000 03/04/2020 03/04/2021 BODILY INJURY(Per accident) $ x AUTOS ONLY AUTOS ONLLYY HIRED N PROPERTY DAMAGE - (Per AUTOS Per accident S Medical payments g 5,000 X UMBRELLA UAB OCCUR 1,000,000 EACH OCCURRENCE S A EXCESSLIAe CLAIMS-MADE 02932100 03/04/2020 03/04/2021 X 1,000,000 �/ AGGREGATE S DED RETENTIONS 0 WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY PER OTH- Y/N STATUTE ER 0 B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT g 500,000 OFFICER/MEMBER EXCLUDED? NIA WMZ80080056582019A 05/22/2019 05/22/2020 (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT g 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be 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 City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 240 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 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: C/- (Please print house number and street ame) Is to be disposed of at: J7142 — ( lease pri nam location o4- � f facility) A�eng? Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 4Sigat "PermitApplica ��rOwner 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.