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25C-086 (5) BP-2022-0095 12 LINCOLN AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25C-086-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0095 PERMISSIONIS HEREBY GRANTED TO: Project# SIDING Contractor: License: ' Est. Cost: 14000 PHILIP SHUMWAY INC 105743 Const.Class: Exp.Date:01/14/2024 Use Group: Owner: DUNN, KAREN S Lot Size (sq.ft.) Zoning: URB Applicant: S DUNN, KARENPHILIP SHUM WAY Applicant Address Phone: Insurance: 66 I DUANA LN AMHERST, MA 01002 P O BOX 522 (413)687-9400 HADLEY, MA 01035 ISSUED ON:01/31/2022 TO PERFORM THE FOLLOWING WORK: SIDING AND 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. (} Signature: ( , • ��� y (r1 • ii Fees Paid: $60.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEIVE_) JAN78 The Commonwealth of Massachuse s ( 20c1 ' 40 7 � FO Board of Building Regulations and Sta dar OF nun DING INSPE CTJON, U Massachusetts State Building Code, 78 C ���vrF�;APT � ICI ITY .. C1N.Pv74 0 0(; Building Permit Application To Construct,Repair,Renovate Or Demolilii a - ised Afar 2011 One- or Two-Family Dwelling This Stction For Official Use Only Building Permit Number: /�' el`a Date Applied: , : l' ,/ ,� ' v ► , 131 a. Building Official(Print Name) f Signature SECTION 1: SITE INFORMATION 1.1 gco Property Address: 1.2 Assessors Map&Parcel Number 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 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 ❑ Check if yes SECTION 2: I'ROPERTY OWNERSHIP' 2.1 Owner'of Record: Karen S Dunn Northampton MA 01060 Name(Ynnt) City,State,ZIP 12 Lincoln Ave 413-336-4440 karen@jonesrealtors.com No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (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 0 Specify: Brief Description of Proposed Work': T IA 04..t( Ty It -TA c)4 1( FAcwrl TA 54.:( e, ,i`",_ 5, 1 \ 1/,ti 71 r nr,,0 C' ,-,41,lct r*are_ 5-e4-^d/N 6( f Te-t- (Wr,-,-r -) t1 acr4 S f it- 5 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ I. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: Check No.1 1 Check Amount: �O Cash Amount: 6.Total Project Cost: $ \ Uki 3 ),Q 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /1 5 ���� o 14 Li ,v ,t t�✓`�1, License Number Expiration Date Name bf CSL HolderOnir Li Type(see below) No.�d Street S �� Type Description /mil 4 i t. U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,Stag/,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding nn SF Solid Fuel Burning Appliances L\' 6g c�ln L` I Insulation Telephone Email address I) Demolition 5.2 Registered Home Improvement Contractor(HIC) l.7 S g 3 ^�i HIC Registratioh umber (Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,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 Issuanc f the building permit. Signed Affidavit Attached? Yes No ❑ 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 Shumway Services to act on my behalf,in all matters relative to work authorized by this building permit application. o\ �/—C �� do/8/2op verified EST CVA XVV-M837�-GICP 01/18/2022 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 contained in this 'c ' n is true and accurate to the best of my knowledge and understanding. f)� Print Owner' r 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.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 Massachusetts + � rr: Y may+. e 4° t',,. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 fiskj�=, �4 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 554, 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: V � S CC( Cr(LA) The debris will be transported by: Name of Hauler: ��'`'� Se('Li,cC f� �' 1. c Signature of Applicant: Date: d-5(3 ThConmonweath of Massachusetts pepartnentofhaustriaiAccents I Congress Street,Suite 100 Boston,MA02114-2017 www.mass.goviglia Worters'Compensation Insurance AMdavit:Builders.1:entractorsiElectrkiansiPlumbers. TO BE FILED'Mill THE PER.MTIIING AIITHORITY, Applicant Informatioo Please Print Legibly Name Hinsines.s,Orpnizationindividual): 5.1(s_v Al,L.‘,44 56r vy 5Address: 0 I., 41,1_ _„ ____ 4° ‘0 q L(00 City/State/Zip:_ tkc i ri k,3 Phone# 2 2- %ry!otilti ' inployee Cheek die appdpriete box; Type of project(required), 1 i am a empkter with empioyeei(full andhit part-tiresey 6 7. 0 New construction 20 lain a sok pcuprictor or pannership and have no employers working for me in 8. Erfre-i—tiodeling wry capacity.[No workers'corm).insurance requited." 30 ISM a homeowner doing all work myself No workorf comp_inserance retrieved"' 9. 0 Demolition 10 0 Building addition 4.: Tarn a homeowner and will be hiring ctors to einduct all work on my property_ I Win emoutt that all rit:iots either have workers"oompinsation insuraicx.in are 406 1 1 1-3 Electrical repairs or additions pommeling with no employees. 12.C3 Plumbing repairs or additions s.C3 1 am a general contractor and I have hired the itib-contramoni hated on the Mutated Abed, BO Roof repairs Thew!sub-contra eari ctors haw plolleees and have workers'comp.ineturarice,: -- 6.0 14.r4Offict_ ,‘ /7 live Mt'ii corporation and itS offroors have exercised their right of exemption per hIGL c 152,;1(4),and we have no ensplo,ees.[No workeni'comp.insurance requited.} 'Any applicant That eniecks box tri mint also till out the section below show in :boa',wrier,'comp:mato=pulley information. llomeoiecent who subunit this AffidiltVit tilriluatzttg they are drnn5 all week arid then hoe outside contractors must- stlinut a new ktifilItitli ibtiltaIng burls 1(ontractors that check this box soma attn.,'hed WI 4ddiLikltiLi*IWO howing the name oldie sltb-COILtraciorl and state whether ot not those entities have It the it+or,ilIrscu. have enusloyeet.thaw emit provide their swrkers"comp.pato)number I um ait employer that is providing woolen'compensation insurance for my employers. Below is the polity and job site information. Insurance Compwly Name: ii./ r -4 - Pokey#or Self-ins.Lie.d: \ej \''/ q q CcjI Expiration Datir C) -X Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage no, I Cgilited utukr MG1...c, 152, §25A is a&initial violation punishable by a fine up to$I,5001X) 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 verification. I do hereby certifttAder I palm and penal ' . -pe1/0y that the information provided shove is true and correct. Signature: ______, t, D c zo - 3- Y Phone 4: 3 C\ Offirial use only.. Do not write in this area,to be compkied b dry 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 . .. . ....„„ _„. .. _ ,• _ .. „.„ . ....._......, „ Client#: 20308 SHUPHI ACORD„, CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 7/08/2021 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 poiicy(ies)must 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 CON E.Milewski,AA! White-Jubinville Ins.Agency IAJN No,EA:413 538-8293 1FAX No):c, 413 538-5970 W 39 Lamb Street a D ESS: cindym@jubinvilie.com P.O. Box 789 INSURER(S)AFFORDING COVERAGE NAIC s South Hadley,MA 01075 INSURER A:Tors Propriety Casualty INSURED - Philip W.Shumway INSURER B:AmTrust NorthAmerica INSURER C:Commerce Insurance Company and Philip Shumway inc. INSURER D: PO Box 522 INSURER E: Hadley,MA 01035 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ITHIS 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 ADDLSUBR POLICY EFF POUCY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) UMITS A GENERAL LIABILITY 6807D23329020 10/11/2020 10/11/2021 EACH OCCURRENCE $1,000,000 PRE X COMMERCIAL GENERAL LIABILITY MISES(EaEoccuirence) $300,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 —1 POLICY JECOT LOC _ $ C AUTOMOBILE LIABIUTY RYM361 02107/2021 02/07/2022(E aBINBD)INGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WWC3509999 02/20/2021 02/20/2022 X WC TORY I I) ER AND EMPLOYERS'LIABILITY YIN TY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCI NT $1,000,000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory In NH) E.L.DISEASE-E EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE- LICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Philip Shumway,as President,has opted out of the Workers Compensation coverage. These are the limits at policy inception CERTIFICATE HOLDER CANCELLATION Town of Hadley SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 100 Middle Street ACCORDANCE WITH THE POLICY PROVISIONS. Hadley, MA 01035 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S32989/M32212 DFn