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17A-016 (3)
211 SPRING GROVE AVE BP-2021-1071 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-016 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2021-1071 Project# JS-2021-001813 Est.Cost: $9370.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TIMOTHY SKROCKI 060967 Lot Size(sq.ft.): 12501.72 Owner: SCHIAFFO KAREN M Zoning: RI(100)/URA(100)/WSP(28)/ Applicant: TIMOTHY SKROCKI AT: 211 SPRING GROVE AVE Applicant Address: Phone: Insurance: 81 LAUREL HILL RD (413) 529-0527 WC WESTHAMPTONMA01027 ISSUED ON:3/29/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRI P & SHINGLE ROOF ON FRONT OF HOUSE AND GARAGE 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. yQ • Certificate of Occupancy Signature 1 • FeeType: Date Paid: Amount: Building 3/29/2021 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner The Commonwealth of Massachusetts wt Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling /� This Section For Official Use Only Building P it Number: b 1",'a/-l 01/ Date Applied: /411113 4-Z05.-s Lii& 5-Z Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1. Proper Address: L. 2 / P 1.2 Assessoorrs 4 Map&Parcel Numbers 1.1 a Is this aced street?yes no Map Number Parcel Number / 0 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 24 Owner'IR1^e ✓3oct h �: f ' Hareiru. mIr Q(O62- Name(Print) , City, State,ZIP al-i I A— t,ta�,e... 't 13-.��`/—G 7 4 3 Ie--S(441 f f ii C� P,C44. hut— No. and treet Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other LEI Specify: S7xt, ci- i,ULoa/ Brief Description of Proposed Work': S✓/19) N.54 f y/ ©tc Fn.b..T or Ace,s 'P•4 Ari Ate"•, SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 73 70 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) C.C.,) Total All Fees: $ Check N0.14tletm heck Ao Cash Amount: 6.Total Project Cost: $ 9376 El Paid in F ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 06096 7 c�_127` a r Arr f A . i, ik424c -I License Number Expiration Date Name of CSL older V/ /au j e/ XJ7 /p , List CSL Type(see below) (/(� No.and Street ,* �i/ Type Description U1.1) },(J ]0 7�h 6' 010.17 1 +q R Unrestricted ed 1 2 Familyi up toel 35,000 Cu.ft.) City✓/Town,/State,Z / R Restricted 1&2 Dwelling M Masonry RC Roofing Covering WS Window and Siding / SF Solid Fuel Burning Appliances / ?-401 .`"CQ.0 r'Kew; . ►' 4 tleomerisi. i r I Insulation Telephone Email address D Demolition 5.2 Registered Home provement Contractor(HIC) C CA T ►,' t�j 2��«�e�I C— HIC Registration Number Expiration Date HIC Company Name or WC e str t N me Let t'lu/Lf / /A 1ilehT.gbiar. @,46/,•c.*' IVcr No.and Street Eail address WCi ry e i . Mil r 0/©.:? 9/) —OA C-Q M City/Town,State,ZIP i Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE ANh'1DAVIT(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 IV 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 Cf 4 T �l/i iJ�' /e7!dtk!!) e.• 4 to act on my behalf,in all matters relative to work authorized by this building Ormit application. kau^u, cutc ja ti./.f) 3/as-��-i Print Owner's Name(ElectrI ic Signature) Date SECTION 7b:OWNER1 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 this application is true and accurate to the best of my knowledge and understanding. T7 r�, F Sktto.k"k'(fireCit T 411 �/ 3 -a S- . I Print Own 's or Authorized AgenName(Electronic Si ature) 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.mass.gov/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" City of Northampton /oa HAM ro Massachusetts \\\1 * , DEPARTMENT OF BUILDING INSPECTIONS14W •,,,�,+�� 212 Main Street • Municipal Building =... pr.' 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: /1/I c fl'e° e C'! 1 r y r The debris will be transported by: Name of Hauler: /1�Ct1Cir �►��lh►"c 'e'' t.-/`i ' z-j c— Signature of Applicant: / Date: 3 c f 49 The Commonwealth of Massachusetts =Iry =am Department of Industrial Accidents t4�209 1 Congress Street,Suite 100 '•_ 311,.11121' Boston,MA 02114-2017 '? , www mass.gov/din ulkcrs'('umpcnsation Insurance Affidavit:Bui derslContractorstEkctririansirlumhers. 10 HE t7Lt.1)WITH THE Pf:RMrrl lM(:ArtnonI I . .Minlicant Information Please Print Leeiblr • Name I l3usanrtis t►igana/ataon Individual t& D• Address: V( ._ 12�I /7�I I( a. City Slate'Zip: W ,11i(j 4‘j0lo r l R r bKi11) Phone#: Q 4?G 1re sou an.tinpbnet?Chuck the appropriate but: Ty pe of project(required): i am a cuupti:s er wrih c+'k employees(full and or part-time1.• 7. New construction am a sole proprietor or partnership and haw no employees wurkeng tor ore m IL a Remodeling any capacity.[No nor►ers.comp.tnsurince moored." 30 I a a honuvwrn,doing all stork imscll•!NIP wt.tl.as'comet.insurance required. 9_ ❑ I)eui olition am 10 a Building addition 3.Q I am a lion 101114nex and s ill Ise hunt►i..mraeton to conduct all w oil,on my prop a!, t sill croon that all caRitractun rnh.r lint-wurtrn'compensation insurance or are sole I 1 a Elejeineal repairs or additions proprieIon w nth no etrtplusees. 12.0 P umhin1 repairs or additions `O I ant a pc.in-ral ctantr.rttur and I lust hired the sub-contractors lasted tin the attached sheet. Ihessub-ctmtractonbaseeinpluucs and hasastrkcn com p. 13 outre'p:t/rs 6.0 Vse are a corporation and its officers limeexcrcisd then riithi iteacmoon pc-r%KA.c. 14.0.6., 1�_. It 4i.and we have no employees. 'so Moodier.'comp I w ante rettuinsl. *Any applicant that cheeks box=I must also fill Out the MceUna below show mg then wtnkers':untpensateun ptolis s iniiarinatam. +Htrrnnourners solo,submit this atiidas it Indicatuu t .s are clomp all work and then here.0 t.sade etattra.turs moot.rabaut a crew:attadas at in.lacatin¢snch- 1Cuntractun that check this hoos.must attached an additional street sha.ss in:the name.1 the suit-corm actors aid state w tidbit or not duos.arbors Lase eattpinyecs. It tea sub-ctmtractuts(use crr;.lostes.they must prosrdc their sinkers'cs•inp.polies number I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Nante:17(XJt\��S Policy#or Self-ins.Lie.#:I- J I, -- I k-0(00 it 1 S `a- O Expiration Date: t l I I 1 Job Site Address: .2 i( ( ) `3, -trivte CityfStaleiZip: 1:71(We 1'' ne /1") 16, acco3-- Attach a copy of the workers'compeuia n policy declaration page(showing the policy number and expiration date). Failure to secure cos craw as required under MGL c. 152.*25A is a criminal violation punishable b) a line up to S1.500.00 and or one-year imprisonment.as well as cis it penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the s tolator. 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 and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone Official use only. Do not write in this area,to be completed by city or town official. ( its or Town: Permit License 1+ Issuing authority tcircle one): I. Board of Health 2.Building Department 3.('ifs:Tow Clerk 4. Electrical Inspector 5. Plumbing Inspector tr.Other ( ontact Person: Phone#: p Policy Number: MPT2437C STREET AMERICA BUSINESSOWNERS COMMON DECLARATIONS GROUP MAIN STREET AMERICA ASSURANCE COMPANY 4601 TOUCHTON ROAD EAST,SUITE 3400,JACKSONVILLE,FL 32245-6000 Item 1. Named Insured and Mailing Address Agent Name and Address ACCENT BUILDING & REMODELING AXIA INSURANCE SERVICES INC 81 LAUREL HILL RD WESTHAMPTON, MA 01027-9519 933 EAST COLUMBUS AVE SPRINGFIELD, MA 01105 Agent Phone No. (413)-788-9000 Agent No. 200402 Item 2. Policy Period From: 09-10-2020 To: 09-10-2021 at 12:01 A.M., Standard Time at your mailing address shown above. Item 3. Form of Business: LIMITED LIABILITY COMPANY Item 4. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown, there is no coverage. This premium may be subject to adjustment. COVERAGE PREMIUM Section I —Property $164.00 Section II — Liability $1,899.00 Inland Marine $1,187.00 CYBER $43.00 Total Policy Premium: $3,293.00 For Coverages subject to premium audit: Annual Audit Applies Item 5. Form(s) and Endorsement(s) made a part of this policy at time of issue: See Schedule of Forms and Endorsements Countersigned: Date: By: Authorized Representative THIS BUSINESSOWNERS COMMON DECLARATIONS AND SUPPLEMENTAL DECLARATION(S), TOGETHER WITH SECTION III—COMMON POLICY CONDITIONS, COVERAGE PARTS, COVERAGE FORMS AND ENDORSEMENTS, IF ANY, COMPLETE THE ABOVE NUMBERED POLICY. BPM D 1 1207 INSURED COPY