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35-228 (5) 62 LADYSLIPPER LN BP-2022-0148 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:35-228 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Bath reno BUILDING PERMIT Permit# BP-2022-0148 Project# JS-2022-000258 Est.Cost: $28605.00 Fee: $188.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HAYDENVILLE WOODWORKING & DESIGN INC 115879 Lot Size(sq. ft.): 32452.20 Owner: FEIN SARI &CASEY Zoning: Applicant: HAYDENVILLE WOODWORKING & DESIGN INC AT: 62 LADYSLIPPER LN Applicant Address: Phone: Insurance: 35 CONZ ST (413) 665-7402 () Workers Compensation N O RTHAM PTO N MA01060 ISSUED ON:8/9/20210:00:00 TO PERFORM THE FOLLOWING WORK:RENOVATE PRIMARY AND HALF BATH 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 , I ,9 1V-1 • Certificate of Occupancy Signatur': 1 0 FeeType: Date Paid: Amount: Building 8/9/2021 0:00:00 $188.50 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner CDepartment use only KAM City of Northampton ��St of Permit: 11' T°c Building Department 4�j r beway Permit �( j: 1 ) � Room 40(5���'r o, c242/Wat /Well vailability „,, Northampton, MRl. op4, Tw Sets f Structural Plans n \ - phone 413-587-1240 Fax 41 - '2i p P ot/Sit laps °"q o.4.---,-, o they pecify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE EM LISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map 3 Lot ,? / Unit 62 Ladyslipper Lane Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Sari+Casey Fein 62 Ladyslipper Lane,Northampton,MA 01060 Name(Print) Current Mailing Address: 51$ Telephone Signature 2.2 Authorized Agent: Haydenville Woodworking&Design,Inc. 35 Conz Street,Northampton,MA 01060 Name(Print) Current Mailing Address: ' ' - . / - ' 1.,._.,..., 413-665-7402 ,Signatu a Telephone ION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 13,985 (a)Building Permit Fee 2. Electrical 5,360 (b)Estimated Total Cost of Construction from(6) 3. Plumbing 9,260 Building Permit Fee Q g .- lA 4. Mechanical(HVAC) ((�� 5. Fire Protection 6. Total=(1 +2+3+4+5) 28,605 Check Number ,a 0-OS �{� This Section For Official Use Only Building Permit Number: (6 ''3 A r/c/f ate Issued: ___/ i Signature: U• c ZO ) Building Commissioner/Inspector of Buildings Date Zinnia HaydenvilleWD.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: l,: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing i Or Doors D Accessory Bldg. ❑ Demolition 0 New Signs [0] Decks [EZ1 Siding[D] Other{CA Brief Description of Proposed Renovate Primary and Half baths Work: Alteration of existing bedroom Yes x No Adding new bedroom Yes x No Attached Narrative Renovating unfinished basement Yes r 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 Sari+Casey Fein I, , as Owner of the subject property Haydenville Woodworking&Design, Inc. hereby authorize to act on my ehalf, in matters relative to work authorized by this building permit a plication. / /1 Signature o wner Date /�j I, 2 i N NIA ;Sr Jh, H 4 y.�>\1 Vl L .. COP 4 CD✓�,0 41 i\6�} 16�", /N" — , as Owner/Authorized Agent hereby declare that the statements 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. 21/VA,2,4, 5 jA Print Name Sig at ner/Age t Date f SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Christopher L. Burkhardt License Number 35 Conz Street, Northampton, MA 01060 115879 Address Expiration Date 413-665-7402 06/22/2025 Signatu lephone L�,C� �t'G t_ / '4 Gt Mat 9.Registered Home Improvement Contractor: Not Applicable 0 Company Name ` �"%�T Registration Number Haydenville Woodw & Design, Inc. 110732 Address Expiration Date 35 Conz Street, Northampton, MA 01060 Tel611ng65-7402 11/8/22 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 0 City of Northampton S/C Massachusetts �?. ..-- I �.: ( �" 'W y} DEPARTMENT OF BUILDING INSPECTIONS �`• # r 212 Main Street • Municipal Building . Northampton, MA 01060 s s dwo. 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: Renovate Primary and Half baths Est.Cost: 28,605 Address of Work: 62 Ladyslipper Lane,Northampton,MA 01060 Date of Permit Application: 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 the ag t o h owner: Haydenville Woodworking & Design, Inc. 110732 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton O t~4MF 0 �S ..,5, { Massachusetts 4,s ce` { !lE t DEPARTMENT OF BUILDING INSPECTIONS ! s' a` 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: 62 Ladyslipper Lane (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: Amherst Trucking, Hatfield MA (Company Name and Address) " 5 hatur of P rm t Applicant or Owner Date f 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. The Commonwealth of Massachusetts pi= g/ Department of Industrial Accidents =) 1.� Office of Investigations =IIf 600 Washington Street • v Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Haydenville Woodworking & Design, Inc. Address: 35 Conz Street, Northampton, MA 01060 City/State/Zip: Phone #: 413-665-7402 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ ❑ Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.0 Other *My 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. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A.I.M. Mutual Insurance Policy#or Self-ins.Lic.#: WMZ-800-8007423-2020A Expiration Date: 12/1/2021 Job Site Address:62 Ladyslipper Lane city/state/ziPorthampton, MA 01060 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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#: 41 66 40 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#: ..........,....„....., .._,_ , ;„„,........„.,,p, ').cf".$1.4k I L'_\— I . q, P .... . 0 4 ' .�00�.10%egkpeo ---1 _ 6 CP SkIr''" _______ - .-4 — 1 _.= 2 'PArteck*- — ' c lane.-vor-v1- =I _ P19 F--- )4 ACitatelA Al 1 0 F.CrOi 14 TA"h tp%eick. •, cii ! 2- C4 40 ot v. ` ® El-s%enez4ky., 4 f x..."-,14 v.....i.ofedit.g.,,,ph...-.•‘,.. ...,-A., lal [1000 E3 E3 La 7......7 Amila 0 . - Aiii - -P t PLUMBING CARPENTRY LAV FAUCET NEW 48"VANITY+TOP UNDERMOUNT LAV SINK ADD CABINET ABOVE TOILET CHAIR HEIGHT TOILET+SEAT REPLACE FLOORING-LVT,TBD FIBERGLASS/ACRYLIC SHOWER SURROUND RETRIM BASEBOARD,WINDOW+DOOR TRIM SHOWER TRIM+VALVE(HANDLE/FAUCET) INSTALL SURFACE MOUNT MEDICINE CABINET INSTALL FOUR ACCESSORIES(TOWEL BARS,TP ELECTRICAL HOLDER,TOWEL RINGS,ROBE HOOKS,ETC) OUTLETS TO CODE DEMO ALL EXISTING FIXTURES REPLACE FAN/LIGHT PATCH/REPAIR DRYWALL REPLACE VANITY LIGHT PAINT BATHROOM Ilk REVISIONS 1-4 in Haydenville Woodworking& Design,Inc. BIM/DRAT REMARKS 0 PRIMARY BATH 1PM) FEIN 62 LADYSLIPPER LANE NORTHAMPTON 4 _-/_-/__ Q� 5 --/--/__ ... c C-1--T-4-* IIP J/ . 1 ‘ el,_j,_._ is \� ii II fiRl PL.UMBING CARPENTRY PEDESTAL SINK RETRIM BASEBOARD+DOOR TRIM • ) (.. ,-,____. LAV FAUCET NEW FLOORING,LVT,TBD CHAIR HEIGHT TOILET+SEAT MIRROR OR MED CAB CABINET OVER TOILET ELECTRICAL INSTALL 2 ACCESSORIES(TOWEL OUTLETS TO CODE BARS,TP HOLDERS,ETC) REPLACE FAN/LIGHT DEMO ALL EXISTING FIXTURES REPLACE VANITY LIGHT PATCH/REPAIR DRYWALL PAINT BATHROOM I I I REVISIONS ��1D Haydenville Woodworking & Design, Inc. MM/DD/n REMARKS N HALF BATH 1 06/15/21 _zs O 3 __/__/__ ••• FEIN 62 LADYSLIPPER LANE NORTHAMPTON 4 --/_-/___ . Q4 �'1 HAYDENW001 CKELLY '4�oRo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/5/2021 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 NRMEACT AXIA Insurance Services PHONE FAX 933 East Columbus Ave (NC,qESS c�,No,Eat):(413)788-9000 I(ac,No):(413)886-0190 Springfield,MA 01105 AD DR :info@axiagroup.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of America INSURED INSURER a:A.I.M.Mutual Insurance Co. Haydenville Woodworking&Design Inc. INSURER C: 35 Conz Street INSURER D: Northampton,MA 01060 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY1 IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR S 2377902 12/1/2020 12/1/2021 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ — OWNED ^ SCHEDULED _ AUTOSO ONLY — AUTOS BODILYBODILY INJURY(Per accident) $ AUTOS ONLY _ AUUTOS ONLY (Per accidentDAMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE WMZ-800-8007423-2020A 12/31/2020 12/31/2021 1,000,000 MFFICER/MEMg ER EXCLUDED? NIA E.L.EACH ACCIDENT $ andatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Street Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD