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36-187 (7) BP-2022-0618 866 BURTS PIT RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-187-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0618 PERMISSIONISHEREBYGRANTED TO: Project# ROOF Contractor: License: Est. Cost: 16675 MAJOR HOME IMPROVEMENTS 103054 Const.Class: Exp.Date:08/24/2022 Use Group: Owner: RIGGALL, NICHOLAS S. &SMITH,TAMAR Lot Size (sq.ft.) Zoning: SR/WP Applicant: MAJOR HOME IMPROVEMENTS Applicant Address Phone: Insurance: 22 VERONA ST WS470076 WESTFIELD, MA 01085 ISSUED ON:06/01/2022 TO PERFORM THE FOLLOWING WORK: STRIP AND RE-SHINGLE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: 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 , / 51-1 ' 1 Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 1, The Commonwealth of Massachusetts 17-.- W Board of Building Regulations and Stand dsh Massachusetts State Building Code/780 MR°AY 3 Z I PALITY SE Building Permit Application To Construct,Repair, R Or Demolisi 'evis d Mar 2011 OP One-or Two-Family Dwelling .tiff Mia,NG�^�SP This Section For Official Use Only oN Z' o o'oNs , Building Permit Number: Cl-• R 7..-C.,/V Date Applied: _� /Et)i� < Ko� �� 6-/-Z.DZ2 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Pro�erty Address: _ / r1 �, / 1.2 Assessors Map&Parcel Number 66 66 wl.�s �, T �c� �(n �S� 1.1 a Is this an accepted street?yes V no Map 1 umberr 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❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owne 'of Re rd: N I CA- c105 a l F-1,0tedi Ge 0/d.6.1- Name(Print) City,State,ZIP f :) No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building[ ' Owner-Occupied K Repairs(s) Alteration(s) Cl Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': - �L�C�; ,�/L(,Yl�S U►3-1(.t,L xew �► .h,� S 1 s !l.� h J �.vrfh w-1 L _ , i SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ /6, 1, 9 S 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Costa (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No.A1 1 ICheck Amount: 1) Cash Amount: 6.Total Project Cost: $ ik, 4 9 ) 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C S (0 3 d, 7 Woi y/2, v_kJ)OA(jLL/J License Number Expiration Date Name of CSL Holder I V�Jan a `(Y List CSL Type(see below) L) No.and Street Jai Type Description /�� teJ r r U Unrestricted(Buildings up to 35,000 Cu.ft.) lJ N� �� R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances r 3 g-60Y6 IY1 Va lkyvv(D yam, I Insulation elep one Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) / y /n) Og- a _S HIC Registration / ' ion Number Expiration Date HIC Co vi4o HIC Regi t Na ` cp N . d tr (/ � �(��2/Lt�� f;,,��T T , Q,f o(v� (ioy3C -6D(f- ;/ Email address 1Ciity//Town,Statte,�ZIIP TelephoneCJ 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 Issuance of the building permit. Signed Affidavit Attached? Yes 11 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 0/0 -I J i to act on my behalf,in all matters relative to work authorized by this building permit application. lvrc 1c2A.iica U , 1Z6/Z2 Print Owner's Name(Electrotiit 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 application is true and accurate to the best of my knowledge and understanding. (Yai7 U �� (A L- Print Owner's or 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 ORYHAMPTQ ,,5 .,,.._,S. Massachusetts �� Vic'<44 < € DEPARTMENT OF BUILDING INSPECTIONS # rx'7.010.1 .J.41 212 Main Street • Municipal Building � a ' � 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: �c�`, 4i.) id k1') CT The debris will be transported by: Name of Hauler: 1) A 1-4 C L/ L(J C.ti C�-t�► Signature of Applicant: Date: S 2, /2 2_ The Commonwealth of Massachusetts Department of Industrial Accidents _; _ Office of Investigations OS Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ` N( 'Le Address: ,LL cfr / City/State/Zip:At/6 d Gi 4f 0(O 1 J Phone #: 7¼'3) 13 f Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. AI I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' p ty $ 9. ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]1' c. 152, §1(4),and we have no employees. [No workers' 13. Other comp. insurance required.] _ *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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: 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 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: `j�'7 2 Phone#: /3 b 3 Official u only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5Dlumbing Inspector 6.0Other Contact Person: Phone#: ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 411...." 04/29/2022 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 CONTACTOM David R Jerry Neill&Neil Insurance Agency Inc PHONE 662 Riverdale Street 413-732-4137 FAX 413-731-6629 (NC.No.Ex& (A1C,No): West Springfield, MA 01089 E-MAIL dj@neillandneill.com ADDRESS: J INSURERS)AFFORDING COVERAGE NAIL X INSURER A: Nautilus Insurance Company 17370 INSURED Milet,Inc. INSURER B: Liberty Mutual Insurance Company 23043 Major Home Improvements 22 Verona Street INSURER C: Westfield,MA 01085 INSURER D: 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 ADDL SUBR LTR TYPE OF INSURANCE INSD WWI POLICY NUMBER nMIDCDY/YYYYEFFY) (MWDD/YYYY) LIMITS A ✓COMMERCIAL GENERAL LIABILITY NN1398696 04/28/2022 04/28/2023 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE V OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE///��N'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $ 2,000,000 �/I POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LMBN.RY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — — OWNED SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Pef accident) S $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKNDERS ER COMPENSATION YERS' Y/N WC5-31 S-360160 06/09/2021 06/09/2022 I STATUTE EOTH- R ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? Ej 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 00a-A t IR4a..405Z> ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aff.I aNI Business Regulation 1000 Washing;:; -Suite 710 BostorptialassaChuS9442118 Home Im•ro _"- _ _-_-•istration --- v� Type: Individual VASILIE KUKHARCHUK atlon: 15 DB/A MAJOR HOME IMPROVEMENTS = E =lion: OS/03/03/2024 19HUNTERSSLOPE W = @II WESTFIELD, MA 01085 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer A &Business Regulation Registration valid for individual use only before the HOME IMPRO ONTRACTOR expiration date. H found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston,MA 02118 VASILIE CH iM D/B/A MAJOR JOR HO HOM�iIA'.`E^Ir C VASILIE KUKHARCHU —�--r 19 HUNTERS SLOPE WESTFIELD,MA 01085 Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Consitur66 cilia rvisor CS-103054 Miltp fres: 08/24/2022 VASILIE M K$KH 19 HUNTERS-,SLe • WESTFIELD MA 0 �y f/1tiS•i:ll1 Commissioner .0. f. SiErmi Pln_ E STATE OF CONNECTICUT DEPARTMENT OF CO.'SC.LMER PROTECTIO.♦ HOME IMPROVEMENT CONTRACTOR VASILIE KUKHARCHUK 22 Verona St • Westfield,MA 01085 MAJOR HOME IMPROVEMENTS Registration# Effective Expiration HIC.0611632 12/01/2021 03/31/2023 SIGNED