17A-280 (3) 389 BRIDGE RD BP-2021-0101
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-280 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-2021-0101
Project# JS-2021-000158
Est.Cost: $1100.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RONALD KEITH 085204
Lot Size(sa. ft.): 8668.44 Owner: O'CONNELL MARLENE A&WILLIAM
Zoning: URA(100)/ Applicant: RONALD KEITH
AT. 389 BRIDGE RD
Applicant Address: Phone: Insurance:
5 BIRCH MEADOW DR (413) 584-5589
HADLEYMA01035 ISSUED ON.7/27/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-PORCH ROOF REPAIR
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 Sicnature:
FeeType: Date Paid: Amount:
Building 7/27/2020 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
rI
The Commonwealth of Massachusetts
Board of Building Regulations and Standards MUNICI
Massachusetts State Building Code, 780 CMR USE
s
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2 ;
One-or Two-Family Dwelling "pis
This Section For Official Use Only
Buildin,g Permit Number: Date Applied:
t�,►> ( OSS 7-27-2d
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property ddres 1.2 Assesso;s Map&Parcel Nu b rfo
el
1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
W�M anny' ron ne-A VIK c )(0(00
NaZmJe$nt) IZ / City, State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': 6fr1-42 Ik Yew 1 .l, 5 f ,p�[,f e-h
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offici Tse Only 9
Labor and Materials
1. Building $ 11 ( 000, 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ (�1 b0 O Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CA .OV5 Z04
-49 Z 1
9cy\46A V--e4l, License Number Expiration Date
Name of CSL Holder
S Bch lLeqCt w 3>, List CSL Type(see below)
No.and Street Type Description
A-agtl
` ' N— a�� Unrestricted(Buildingsu to 35,000 cu.ft.
eCl F'� R Restricted 1&2 Family Dwelling
City/Town,StA,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ,�ts-t,69
P'tY1 & �t'E•tl e*oon4Vo-4�a1 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.land St eet Email ad s
l tL6 C t o3S 4Z• -�89
Ci /Town,St.4,ZIP Telephone
SECTION 6: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 .......... O No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize OX-01A ); e�
to act on my behalf,in all matters rel ive to work authorized by this building permit application.
AIAJA MIA
Prin Owner's Name lectronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in his application is true and accurate to the best of my knowledge and understanding.
! I21M
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.massgov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
i.7•:..: etit.r, +.Y .. , .frT it 7 �. .I1).:: a 1jrC' _ '!lil 1;1,
r
yr
y.•t� it '.dca ti r, ,ih.' �:` A�:(:.I"°<�• ._
s
: .r+�:r t :3«.y.� 'I;3t 1,, ... rif•ftii?'r .-.,.
e hit')r}(Si6Al: ii.' !' t ?Tiil�t,Cii ,r.f iI'! !f!',,} 1i•
neA ,) !,1 '1LtJ"1rc'. :'n%1)l ?ATJ;rs,c• , 3T!,'C Ire i,--, i�(4S r'rt',
•H' tYy rAl j } f,i: f!;�r,i F�( jl., .�t'.'j+TF' !, ..:i`}' ,. +,;ij'y, -.f„ ,CC.- ,1!I}C :.(a_e'r.1:.•) t
- r' -i' ,,. !r- :rlll:+ .t�r�•.. _,.J i) `.'(; i5:.1. ;i fi, '.i: '!''' � h.. ti:}'3 .il'. 'C Y ,t." .. .. '! .a�i1*--t"�j:.dS�:
j r
� •:!, 1. ,. ;ptf.,; .X)S`t- .fit. r ,.; .. . . 1 .�„ -
.t.3 ,,;l.S: Sit v �t :xl}�1',r S,a xi, '�,v', ..-TY ., , >lj +M1).'•. +�i.�b d,rrf., s }"A 17 -
, ti��'4•.&'r1'� ate :1
lx! yy) }St.:++ S it:..t L. ) i 1-
ilk
t,/)!' •.:i S,t j
'. fT.C....��l.:� '.Y.. t!;!T:�/�Ci"'t.'��Lr �:: .. '>rr�li\T [; f°` r.i1'f[. �sC�M.� •Y3sl�.J,S�,�a"
_ °:. ,. ,3•'1 . t+irr.,(F�,a'; ,;s: r♦ ;i(!T'Tr!i.i'K?'...' � --i a.:'a - __., _...,. ._ ._.. . .. ...._... ...._. ..
tCAlf), Al' i �::a. '1 '�.f�.•1 .. '�` l!i'-�75�d:t�„ �Y -,
Ik [•,„R q.rT '.� -'!. :�
f
;Gull
';
,t!'�.1.;',. '• .e.+':i�4til'r�'�'ir. {.:�r.At` 'i�+'i.�i�47:r: Sir i' � i, t�,{,1": ',�:Z.p. :.iP� �'�A ' D-.... � .��t.�/{a;;
C,
i - a ... - A _ '. ��' .. .�l"3. •,Ci lt'! '��i9t. T v ,.. ,�.i�(k�, _.`. ..
.:Y"sl. i'!r.e. rl: C r. t.... .i. •v
,
w 1
City of Northampton
Massachusetts
(. DEPARTMENT OF BUILDING INSPECTIONS a z
212 Main Street • Municipal Building
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: f*:DCV.-eV:nQ
The debris will be transported by:
Name of Hauler: Voce M Y-�2 cko m4xy.--r�o
Signature of Applicant: Date: -T(Nkz>
The Commonwealth of.Massachusetts
Department of Industrial.4ccidents
I Congress Street.Suite 100
Boston, .11.4 02114-201
v wwx:mass.gavtdia
11utker%'Uompensation insurancr Af idasit:BuildersN'ontractor%lEiectririantiPlumbrr%.
hU BE FILED N I`t'N 1 HE PEI01111 IM;Ali'l 11UR11'1.
Applicant Information Plea%r Print lx<`ibis
?Marne f Bus9ncss(hp;antxanon IndiN tdual b" R�����t �1 cam► Y�?C�`�1
Address: VSI g"6t w
citylstatelzip:_�6&tA) �w 6103Phone#: %13 J� gy
Are ytw m errpts}er*t hrc6 thr appngtrtate ttov:
T%pr of project(required):
i.❑(am a cmpkwcrwrth cnVioyat,s Utdl rtnd'w pan-tiro i 7. ❑ Nc%k Iona ruLtion
2R am a suit,proprxar or lowmrnhtp and ha%c no ca pkry�work mm
g for e in
Il. nu
Rexklm}
t�.r�an}e�rpawrt}.(:Vu wutkcrs'cunrp.aruetrancx tretuttud-I
301-am a hortsevwnew doing all wrack rmytif fNa waken'cutup.taanez vurmquutd.l' 9- E]Demolition
401 am a iwrrr*Amno and w off be hiring amrra don Itoc'vndw.l all work on my prrttrrrq. I will 1 O❑Building addition
noun:tltar a]I cvaurar'toestirh v Iu4c workrn'vxaplpeanaatwn UwUrance or err tuts l 10 Electrical r"r-5 or additions
pruprretm with no entployetr.
12.Q Plumbing twin or additions
< 1 ams yertcral cuntracteraad 1 borwhined the subAmetrartun listed on the attacfivd sheet_
lhcx wb�artrmctrm 13.E]Roof repairs
howtrnpbyeirsatd have wurkcn'cramp.tnsuranet,.�
14.❑Othet
h.D 1A c an a rurprtraerun and rb u(tpxn foto c rxt7tiist,d thea nglu of txv'nlQlrtrt Per\t(il_c- --------
132.$144),and wt hew Do agr"res.I No wurkm'warp,tnstrame nyutnrf.J
•Ary*Mutant that chocf:ta bin art Imin go W Cru the wcneon below show mi;t1mr titurkers'h:umpen&aturn polwy udurmatnrt.
t}k,nretvw WIN n hw.aubMit dtit a11liMi[indices th.y are doing all work and then hat:outside rxumrwturs meat wbmrt a now alydav il mdicJdng such,
tC utttractot%that ihtxk dtia boarei t brad wd an aldrttunai sheet,1 shtrwrng the name of the and sitars%hohart ut not thow tnUtics hsvc
ernptuycv, It the tfn v rmts7 pan rdc thrtr ti++r►ccs'. >nrp.puH }'ntnrrbcr
1 am an empivre•r that is providing workers'compe•nwtion insurance.(or mY entplc►►ees. Below is the/wtic)'and job site
information.
Insurance Company Name:
Policy#or Self-ms.Lic.At: Expiration Date: _
Job Site:Address: city."State:•Zip: _
Attach a copy of the Morkers'compensation policy decbtrsdan page(showing the pacy number and e=piratioa date).
Failure to secure coverage as requored under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,50(1.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator. A copy of flus statement may be fc►t'warde d to the Office of investigations of the DIA for insuranti t:
cvoverage venfication.
1 do hereby cerliitt tender the pains and penal ies of perjury•that the information provided a((bovoe is true and correct
Stsnaturc: ( 1)atc -t12�41�
phunc" U 15' S-@4.SS
Official use onh'. Do not write in this area,to be completed br c•i17'or town oJTeiat
('itv or Toon: PerwitlLicense M
l%%uing Authoril% leircle one):
1. Berard of lleaith 2. Building Department 3.Citur'iossn Clerk a. l.lectrical Inspector S. Plumbing Inspector
6.Other
('ontact Perwn: ---
ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/07,24,22020020 Y)
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 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).
CONTACT
PRODUCER NAME: Christina Barrett
Aquadro&Associates NrC N :t• (413)586-7373 No (413)584-0859
A1C
355 Bridge St,P.0 Box 357christina@aquadroinsurance.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC N
Northampton MA 01061 INSURERA: Preferred Mutual Insurance Co 15024
INSURED INSURER 8:
RONALD KEITH DBA KEITH CONSTRUCTION INSURER C:
INSURER 0:
5 BIRCH MEADOW RD INSURER E:
HADLEY MA 01035 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL1951410052 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 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.
TawPOLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER MMIDD/ MM DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000
HO
TU MEN I I:U 50,000
CLAIMS-MADE �OCCUR PREMISES Ea occurrence E
MED EXP(Any one person) E 10,000
A BOP0100726t74 04112/2020 04112/2021 PERSONAL&ADVINJURY E 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE $ 2'000'000
X POLICY PRO LOC PRODUCTS-COMP/OP AGG $ 2,000.000
JECT
$
OTHER
AUTOMOBILE LIABILITY l COMBINED SINGLE LIMIT E
Ea acatlent
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED BODILY INJURY(Per acadent) E
AUTOS ONLY AUTOS PROPERTY DAMAGE
HIRED NON-OWNED Per amdent E
AUTOS ONLY AUTOS ONLY
E
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE E
DED RETENTIONS E
P H-
WORKERS COMPENSATION I STATUTE I ER
AND EMPLOYERS'LIABILITY y/N
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT E
OFFICERIMEMBER EXCLUDED? ❑ N/A
(Mandatory In NH) EL.DISEASE-EA EMPLOYEE E
If yes,describe under E .DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS I 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.
210 MAIN STREET AUTHO D REPRESENTATIVE
NORTHAMPTON MA 01060I I �"k_/� ,( i
®19 -2016 ACORD CORPORATIO 1 Alt-rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD