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31C-071 67 HIGGINS WAY #15 67 HIGGINS WAY#15 BP-2021-1121 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31C-071 CITY OF NORTHAMPTON Lot: -15 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:New Single Family House BUILDING PERMIT Permit# BP-2021-1121 Project# JS-2021-001849 Est.Cost: $372000.00 Fee: $1334.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SHAUL PERRY 065400 Lot Size(sq.IL): Owner: SUNWOOD BUILDERS Zoning: Applicant: SHAUL PERRY AT: 67 HIGGINS WAY#15 Applicant Address: Phone: Insurance: 84 POTWINE LN (413) 259-1000 _ WC AM H E RSTMA01002 ISSUED ON: TO PERFORM THE FOLLOWING WORK:NEW SINGLE FAMILY HOUSE 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. I e; • • )2 Certificate of Occupancy S4;natut : FeeType: Date Paid: Amount: Building 4/6/2021 0:00:00 $1334.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner act, cry . ss- .20 2/-- wig Y9 14 The Commonwealth of Massachusetts 4 l 3 LLEt J Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY LA 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 Permit Number: BY -.,'-/)}-I Date Applied: .2 . ST Li/Wai Building Official(Print Name) Signature ' Date SECTION 1:SITE INFORMATION 1.1 roger A rey§/ / [7 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an acce d street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: e 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 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' 2.1 wne '�ecord: i � - 0011Wooc� c.r / N� ©/G 7/ Name ri City,State,ZIP / / dit A/w�n�Loc./ 1// d�9-/GAD Saiwooc a CO,?1Cosf ,1 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Descript'on of Proposed Work'-: /9/a srfcl,✓ / /on► -L3 -��.' f+ w1 any SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $d80000 1. Building Permit Fee:$ Indicate how fee is determined: - ❑Standard City/Town Application Fee 2.Electrical $ (vi 000 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ (. QQQ 2. Other Fees: $ 4.Mechanical (HVAC) $ ait`QQQ List: 5.Mechanical (Fire �/� Suppression) $ Total All Fees:$ , Check N _Check Amount i t 9-Cash Amount: 6.Total Project Cost: $c_31,00 0 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Co true on Supervisor License(CSL) /r L)_D i 100 $ /p,�/ 2J'r License Number �(J[J Ex ti Date Name of CSL Hol er (� ) / n / List CSL Type(see below) /r' o irlcJ c/ No. Street Type Description Le-(61t 4 aoo pt U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 gistered Horge Iproveptght Contractor(HIC) /�301f On WOO c", Ct6 HIC Registration umber E rra on Date HIC p a e or HIC Registrant Name / C i/Y� �/ g vN WOdO' & /1el tick Str�e fe t A o, w / jt'ioo ^U Email address City/Town,State,ZIP /v /� 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 Issuan of the building permit. Signed Affidavit Attached? Yes 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information co:rain ai in this application is true and accurate to the best of my knowledge and understanding. av/ �'7r 0 Print Owner's or Autho zed Agent's Name(Electronic Signature) ate 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/des 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 psNa MpT\ +w SAC Massachusettsfil DEPARTMENT OF BUILDING INSPECTIONS �3 e�> 212 Main Street • Municipal Building yV�'U ; 4 ve50' 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: Voi/el ZCl// Location of Facility: 06ii Atrfo,rri pj/'/ /1 0/O6O The debris will be transported by: Name of Hauler: A‘)/Pe'r cvr7rvood' oliccrif Signature of Applicant: Date: Ot/ ii. .. The Commonwealth of Massachusetts . 1'==)il=_!t Department ofIndustriaiAccidents _':-�'_ 1 Congress Street,Suite 100 =:;t!i= Boston,MA 02114-2017 Makers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �t, / Please Print Legibly Name(Bush csstthganization/individual 1�J): J V�'/C�'S Address: zpi po Jw,"TC, L o/IC! City/State/Zip:�/yy/eJ- M/`f Q/OG,t Phone#: / 9-/OOD Are yea an employer?clerk the appropriate boa: Type of Project(required): 1 lama employer with kl .employees U1 I and/or pat-time)' 7.g6lew construction 201 am a sole proprietor or partnership and have no employees waiting for me in 8. 0 Remodeling • any capacity.[No workers'comp.insurance monied.] 301 am a homeowner doing all work myself.phis workers'comp.irnarenme required.] 9. El Demolition 10❑Building addition 4.01 am a homeowner and will be hiring contractors to coeducs all work on my property_ h will enure that all contractors either have workers'compensation insurance or are sole 110 Electrical repairs or additions proprietors with no employees_ 12.0 Plumbing repairs or additions 501 am a general cootracoor and I have hired the whconuractors listed on the attached sheet_ 13�Roof airs These subcnotrxwra have employees and have workers'comp. nsurance.k 6.O We are a corporation and its officers have exercised their right of exemption per MGL c. l4. Other 152.*1(4).and we have no employees.[No workers'comp.insrrancerequired:1 'Any applicant drat checks bar al must also fill out the section below showing their waters'compensation policy information. t Horneownea who submit this affidavit is icsoing they are doing all work and then hire onside contractors must submit a new affidavit indicating Sikh- ',Contractors that chess this box must attached an additional sheet showing the manse oldie xkb-oontraeias and state whether or not ranee entities have employe If the sub-cwwracwrs have employees,they mine provide their workers'rump_policy number_ i ask en employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site information. 4 J Insurance ranan cee Company Name: v (1SvrolfC.C/ Policy#or Self-ins.Lie.#: Wf/j 008005dt eladL'(/f) Expiration Date: t,�//rOf�Of� Job Site Address: .o/ 0i5/ , i1S YYA City/Statel7�p:/ ,/4/ ,c')Tt7iy/rN O/0 0 Attach a copy of the workers'co �tion policy elation page(showing the policy number and espira(ion date). Failure to secure coverage as required tinder MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisormtent,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 veritica i e•. I do hereby ter* made i n e and penalties of-perjury that the information provided above is true and correct Signature:to Date: C3O/�l Phone#: 1/2 9-� 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1 6.Other Contact Person: Phone#: A ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/02/2020 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(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 Kathy Parker NAME: Webber&Grinnell (PAHjO No,Ext): (413)586-0111 jarc,No): (413)586-6481 8 North King Street E-MAIL kparker@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC M Northampton MA 01060 INSURER A: Selective Ins Co of Southeast 39926 INSURED INSURER B: Selective Ins Co of S Carolina 19259 Sunwood Builders,Inc. INSURER C: A.I.M.Mutual/A.I.M. Attn:Shaul Perry INSURER D: 84 Potwine Lane 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 TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR INSD wVD, POLICY NUMBER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE (MOLICIYEFF _(POLICY E YY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 RENTED CLAIMS-MADE 1-1 OCCURPREMISESDAMA O(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 A S239905500 03/04/2020 03/04/2021 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY ^1 PRO- 2,000,000 ` IJECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED A910808200 03/04/2020 03/04/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X AUHIREDTOS ONLY X NATO -OWNEDSONLY PROPERTY DAMAGE (Per accident) $ _ Medical payments $ 5,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESSLIIAB CLAIMS MADE S239905500 03/04/2020 03/04/2021 AGGREGATE $ 1,000, X 000 DED RETENTION$ 0 $ - WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY v/N STATUTE ER , C ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WMZ80080056582020A 05/22/2020 05/22/2021 E.L.EACH ACCIDENT $ 500 000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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. 240 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 ILL-- . D y2 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD