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36-392
BP-2022-0175 140EMERSON WAY COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-392-00I CITY OF NORTHAMPTON Permit: New Build PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0175 PERMISSION IS HEREBY GRANTED TO: Project# NEW HOUSE Contractor: License: Est. Cost: 495000 SHAUL PERRY 065400 Const.Class: Exp.Date:06/25/2022 Use Group: Owner: CORPORATION SUNWOOD DEVELOPMENT Lot Size (sq.ft.) Zoning: SR Applicant: SUNWOOD BUILDERS Applicant Address Phone: Insurance: 84 POTWINE LN (413)259-1000 WMZ80080056582021A AMHERST, MA 01002 ISSUED ON:03/22/2022 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: 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: I , • i Fees Paid: $1,796.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEIVED 5,-,.,.,--eviikt-t---3--0.--2-2 ,-_-____/.--- _____________7 FEB 2 3 ?O22 f 14 The Commonwealth of Massachusett Board of BuildingRegulations and Stan ds OR * DEFT.OF BUILDING IN0:"1 41 ;,q(..I. ITY Massachusetts State Building Code,780 MR NORTHAMPTON,MA 01060 USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Afar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 8 `oZ A /7 5 . Date Applied: I�.t:v,) /Co'SS ///L— -3-22 2622_ Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property dress: 1.2 Assessors Map&Parcel lsimbers iif0 ersotf Key -N,i e ? 1.1a Is this an accepted street?yds X no Map r 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 Q�),, d5/ b 2' 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage 'sposal System: Public 0 Private❑ Zone: Outside Flood Zone? Municipal On site disposal system ❑ Check if yes❑ !� SECTION 2: PROPERTY OWNERSHIP' 2.1 0/vinerl of Record / %vJe / `7v,rt voa1 �X�✓��o �rlur F / e6T, Ali o/Oo Name( nt) City,State,ZIP ,(� / 6 5°/wi)l�A/IU 43 r i 490 Vc>/1Woo elGo/r1GG�ST. Ire./ No.an Street Telephone Email Address SECCTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction J� Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) ❑ Addition 0 Demolition !❑ Accessory Bldg. Numbe of nits 0 Specify: Brief Descriptionof Proposed Work2: ozwe (3.° ro0,w si Di c/ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only .Labor and Materials) 1.Building $ g00900 1. Building Permit Fee: $ Indicate how fee is determined: a 0 Standard City/Town Application Fee 2.Electrical $• 00 000 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ WO00O 2. Other Fees: $ 4.Mechanical (HVAC) $ 00Q List: 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No. `i' Check Amounii t. �Q�Cash Amount: 6.Total Project Cost: $ 4000 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Con truction Supervisor License(CSL) es_o i ,loO �ad/ 2r-rV License Number 4(gs9 '/ot tiDate Name of CSL Hold r / v' /� List CSL Type(see below) 0 `O > '%,,ci No.an Streit T Description /f psi `fajr O/ 0 Unrestricted(Buildings up to 35,000 cu.ft.) City/To State,ZIP �r!/T C/Cit7` R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding 45�O(�jQ //f SF Solid Fuel Burning Appliances / "/� 3 &c c.ag I Insulation Telephone Email address D Demolition 5.2 egistere�me Improv went Contractor(HIC) /0 p3 40i )v#wO 1. )vJ/04. 'S HIC Registration Number E pir tion Date HIC o paN a or HIC gistrant Name / / J h jic/ ►C/ s,#woOd�GDMce /.N No.vd ST_Atif , ,�,/ 0 /00" ,/J ^n'?-/n Email address City/Town,State,ZIP 'J Telephone �C/C l 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 a -st under the pains and penalties of perjury that all of the information contained in this application is • and/ccur to the best of my knowledge and understanding. 4w Print ner's or Autho zed -I's Name(El onic ' attire) Date NOTES: 1. An Owner who obtains a building permit to o 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.) A .19 00 Habitable room count Number of fireplaces / _ Number of bedrooms Lc Number of bathrooms Number of half/baths Type of heating system r;u Number of decks/porches pi Type of cooling system ,�f,ic/ Enclosed Open Ol 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: /0,,5I REAR LOT DIMENSION: g‘/ Q/ REAR YARD 3 / LY r / SIDE YARD /00 / SIDE YARD 1(10 r /81 / / ' /8" / / FRONT SETBACK Q/ / FRONTAGE 81 City of Northampton oaYN_A M-Pr S . s ics { Massachusetts . : 9► ,•! i • wt c MI 'I.tcfl 4 g,, DEPARTMENT OF BUILDING INSPECTIONS ys , 5 v" r 212 Main Street • Municipal Building J :Cb yl. Northampton, MA 01060 4j.•. O. 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: sic,. k//Svrcc ail, '°�'c`.r# �c Location of Facility: iclicyZ - TAas§ia /0!1, co, A/0,- 0. Ji rr The debris will be transported by: Name of Hauler: SiVi14/O 3r1I/c S Signature of Applicant: Date: /0 __ The Commonwealth of Massachusetts iiii l e/ Department of Industrial Accidents .1__ 1 Congress Street,Suite 100 �;ii ';�;E""" Boston,MA 02114-2017 =y��4,� www.mass.gov/din Workers'Campessadeu insurance Affidavit:Builders/CoantractorsiEkctrician!JPlumbers. TOME FILED W jilt THE PERMITTING A I IIIIORIT Y. Applicant Information Please Print Leeibls Name(Business/Organization/Individual): �e�t1YVOQd aold� -- Address: a gi„„,„d IoiieJ City/State/Zip: Lyrl 0/OO� Phone#: /l dim? /000 Are yen as enpim rr'('hark the appropriate box: Typeof project(required): t. i am a employer ct with /0 employers(full onto(part-Tina:) 7. New a onstru coon _' _... i am a sole proprietor or p:utnc ship and have ma employes working for are in 8. Remodeling any capacity.[No workers-coop.insurance renparnd_] i. i ant a hunm-owner doing all work myself_[No want ors'comp_.mn a rancc rpnred_1' 9. Demolition 4.® I I am a oincan xr and will be hiring contractors to cordux all work on my property. I will 10 Q Building addition ensure that all contractors either have waken`cTwnpensarion insurance or arc sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions .3,71I ant a gemial contractor and I have hind the subcontractors listed on the anaaled sheet_ 130 Roof repairs These tubbcemtracton have employees and have workers comp.insurance.: 14.0 Other h.L1)Vt c are a corporation and its officers have exercised their right of exemption per Wit c. 152.v I14).and we lave no cniioyi-es.I No workers'map insomniac tognintidi 'Any applicant that checks own u i mum aaho bit out die maim below showing tbair wooers'compensation policy information. t Homeowners who submit this affidavit intimating they are doing all week wad lion bite onande contractors must submit a new affidavit indicating Such. :C'oo:racwn that check this box must attached as additional Abort sbiwwag tie cote of die sukrco*rrcturs and state whether or nut those amities have employees_ If ahc sub-contractors have employees.firs mint pan ode their workers'comp.policy number. I am nit employer that is providing workers'compensation insurance for my employees. Below is the policy and job site i Insurataeu Company �*/ /rr Insurance Name: �/y p v ono.,, / _ ? Pokey#or Self ins_Lie_#: 14 4 f.,QO0e0.6bC l9C IO//i`d Expiration Dale: 4/u-(f/ 1 Job Site Address: / ,G'6'O!1 i o iyf ,h11 City/Slate�&Zip: _0/Ci Attack a copy of the workers'compensation drxhlryl 4l tio e(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,*25A is a criminal violation punishable by a fine up to$1,500.00 andfor one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a tine 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 certif mule the ; f and penalties of perjtiry that the Information provided above l s a and correct Signature: Date: , 4/17 ofOZ Phone#: f/3 " 9"/O/0 Ofcial use only. Do not write in this area.to be completed by city or town official ('its or Town: Permit/License# Issuing Authority (circle one): 1.Board of I lealth 2.Building Department 3.('ity/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector G.Other Contact Person: Phone#: 41 0® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/10/2021 ,S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS .:ERTIFICATE 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 NAME: Kathy Parker Webber&Grinnell (Arc.No.Extl: A (413)586-0111 FAX No): (413)586-6481 8 North King Street ADDRESS: kparker@webberandgrinnell.com INSURERS)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Selective Ins Co of Southeast 39926 INSURED INSURER B: Selective Ins Co of S Carolina 19259 Sunwood Builders,Inc.,DBA:Sunwood Development Corp. INSURER C: A.I.M.Mutual/A.I.M. 33758 Attn:Shaul Perry INSURER D: 117 Olander Drive,Unit 4B INSURER E Northampton MA 01060 INSURER F COVERAGES CERTIFICATE NUMBER: CL2133015357 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.JLOIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AN3D ,,,,,/D POLICY NUMBER POLICY EFF POLICY EXP (MM/DD/YYYY)_(MM/OD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) 5 MED EXP(Any one person) $ 15,000 A S239905501 03/04/2021 03/04/2022 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED A910808200 AUTOS ONLY X AUTOS 03/04/2021 03/04/2022 BODILY INJURY(Per accident) $ X /HIRED N NON-OWNED PROPERTY DAMAGE AUTOS ONLY /� AUTOS ONLY (Per accident) $ Medical payments $ 5,000 X UMBRELLA LIAB OCCUR 1,000,000 — EACH OCCURRENCE $ A EXCESS LIAB CLAIMS-MADE S239905501 03/04/2021 03/04/2022 AGGREGATE $ 1,000,000 DED X RETENTION$ 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER O W ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A MZ80080056582021A 05/22/2021 05/22/2022 . (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) City of Northampton is listed as additional insured with respect to liability as per the terms and conditions of the policies. 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 Street AUTHORIZED REPRESENTATIVE �l Northampton MA 01060 J11- 1r"D r-_^.�JO 1 hh ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD