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25C-164 (3) BP-2022-0800 18 ORCHARD ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25C-164-001 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-2022-0800 PERMISSIONIS HEREBY GRANTED TO: Project# 2022 FIRE DAMAGE REPAIR Contractor: License: Est. Cost: 15000 TOSH1 KASHIMA CS-060134 Const.Class: Exp. Date: 1 1/04/2022 Use Group: Owner: LLC MZZ LUCKY Lot Size (sq.ft.) Zoning: URB Applicant: KASHIMA BUILDERS Applicant Address Phone: Insurance: 15 UNION ST (413)522-1713 WC231s376057020 GREENFIELD, MA 01301 ISSUED ON:07/11/2022 TO PERFORM THE FOLLOWING WORK: INTERIOR DEMOLITION OF SELECT FIRE DAMAGED AREAS 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: 2 3- 1 • 'tgha Fees Paid: $105.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner _ _ - Gin The Commonwealth of Massachusetts r.,. Office of Public Safety and Inspections Massachusetts State Building Code(780 CMR) C; 1 Building Permit Application for any Building other than a One-or Two-Family Dwelling In!:1 (This Section For Official Use Only) l uilam -Fermi 'ber: 7A22 06D0 Date Applied: 07/0 L j202L Building Official: SECTION 1:LOCATION ISDichard'Street I Northampton,MA No.and Street City/Town Zip Code Name of Building(if applicable) 25C -/`q-oo l Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building❑ Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other Specify: demolition of interior fire damaged areas Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 131 Is an Independent Structural Engineering Peer Review required? Yes 0 No En rntenor demolition of select fire damaged areas- Brief Description of Proposed Work: SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft)and Total Height(ft) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 ❑ A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2❑ H-3 0 H4 0 H-5 0 I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB ❑ HA CI IIB 0 IIIA ❑ IUB ❑ IV CI VA 0 VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site 0 Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be P Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify: _ permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner ton MA 01027 P.O.Box 661 Easthampton Guzik Realty,Inc P Name(Print) No.and Street City/Town Zip Property Owner Contact Information: MZZ Lucky LLC 917.560 _9207 - sicilo19@yahoo.com Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Quality Restoration 72 Montague City Road Greenfield MA 01301 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Toshi Kashima 413-522:1713 kashimabuilders@yahoo.com Name(Registrant) Telephone No. e-mail address Registration Number 15 Union Street Greenfield _MA_ 01301 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Kashima Builders Company Name Toshi Kashima CS - °Lot 34 %1 Name of Person Responsible for Construction License No. and Type if Applicable 15 Union Street Greenfield MA 01301 Street Address City/Town State Zip 413- 522 1713 - - Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1 51 000 1.Building $ 5-1 OOD Building Permit Fee=Total Construction Cost x 7—(Insert here 2.Electrical $ appropriate municipal factor)=$J O$ - 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ % 5, 000 (contact municipality)and write check number here 5 SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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 knowledge and understanding. Please print and si dame Title Telephone No. Date 0/3(4rfV GO?ltlit tk• MA 0126( CA.Ditrala.lieows a q.u,�^ Street Address City/Town State Zip Email Address l I Municipal Inspector to fill out this section upon application approval: ' �4' t 1 f as Name - ate a�N�Mx City of Northampton y•- Massachusetts ?, �,: �.- 'e� .• & Qt s' DEPARTMENT OF BUILDING INSPECTIONS y• `� .. 212 Main Street • Municipal Building\ `. Ca ..a�+;�Ste" O N:r r " Northampton, MA 01060 fMW... �� 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: Valley Recycling, 234 Easthampton Road, Northampton Location of Facility: The debris will be transported by: Amherst Trucking Name of Hauler: Amherst Trucking Signature of Applicant: Date: The Commonwealth of Massachusetts Department of Industrial Accidents Congress Street,Suite 100 was Boston. MA 0 211 4-2017 www.nutss.gov/dint 11 or ers'Compensation Insurance Affidt%it:BuildersiContractorstEkctriciansiPlumbers. 'It)BE FILED WEIN THE Pl:RMI'IT11(:AUTHORITY. Applicant Information Please Print Leeihlh Name(Business(lrganizationIndividual): Quality Restoration Address: 72 Montague City Road C /StatefZi Greenfield MA 01301 Phone#: 413-774-7737 nY p� Ate}aa as employee!Cheek Ike appropriate box Typeof project(required): la i am a cmrpkowCr with 18 cmployces tfull and to part-tune:►• 7. 0 New construction 20 I am a proprietor or partnership n hip and hat employees working for me in 3. Q Rem odeling -+any capacity.[No workers'comp.insurance reqauretii_l 9. ❑ Ihtnolition in I am a homm w n r doing all work myself.l No w Helen s'romp_inset ranee required.]r 10 0 Buckling addition 4.0 I am a honseuv mx and will be hiring,contractors to conduct all work on my property_ I will ensue that all contractors either have workers"compensation insurance en are sole no Electrical repairs Or additions proprietors with no employees. 12.0 Plumbing rspaira or additions 50 I am a i„coal contractor and I hase hired the sub-contractors listed on the attached sheet.. 13.❑ROOf repairs Thew sub-contractors have employees and hate IA oilers'comp.icruranee.= 6.O Wef an a corporation and its offie rs hate exercised their right of c enquion per Ant it_c. 14.0Other 151 i 1t4).and we have no employees.I No workers'comp.insurance required." •Any applicant that checks Iota 4'1 must also till out the section below shooing their workeus'com pens brow policy infrwtnati io_ t Ilumcowtrcn who subunit this attwknit iwdicatine they an du rn all work and then hire outside eclutracturs must submit a new affid»it indicating such. ['antraetors that check this bet intent mooched an additional sheet show inn the name of the srtb-eoior ueteas and state whither or not douse cooties have employees_ If the sub-euntractots loot to ukyecs.they mast min idetheir workers"wimp.policy member_ I am an enrplo;er that is providing wvrhen' cwttpensation insurance for nay employees. Below is the policy and job site information. Insurance cont �n� alt The Travelers Insurance Company pPolicy#or Soil-ins.Lie.#: 7PJUB-0G09579-4-22 Expo Date: 6/19/23 Job Site Address: 18 Orchard Street City/Stat&Zip: Northampton MA 01060 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverages as required under MGL c. 152,(125A is a criminal violation punishable by a tine up to SI.500.00 and or one-year impnsotlntent,as well as civil penalties in the form ofa STOP WORK ORDER and a tine of up to S250_00 a day against the violator.A copy of this statement may be tirwarded to the Office of Investigations of the DIA for insurance coverage verification. i do hereby certify under the pains and penalties ofperjury that the information provided above is trot'and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city"or town officiaL City or Town: Pernutil.icense# Issuing Authority (circle one): I.Board of Health 2.Building Department 3.('ity,ll-own Clerk 4.Electrical Inspector S. Plumbing,Inspector 6.Other Contact Person: Phone#: QUALITY 72 Montague City Road Restoration Greenfield, MA 01301 413.774.7737 FIRE WATER STORM Fed Tax ID #45-4127163 Client: Insurance Company: AAZZLMCK/ LLCI Address: 14 orclNara NA- Local Insurance Agency: 33 c(c ore- co ckr-fr City: S -ket e n f c 1 g n d nlet o�,.pher• Adjuster: State/Zip: o tot,o Policy No.: ' v Home Phone: Claim No.: Business Phone: Deductible: Date of Loss: Type of Loss: 0‘ /2-022 Client Email: Adjuster Email: StC( (0 (1 (Pyct11.oD .C''irrl WORK AUTHORIZATION AND DIRECTION TO PAY I agree to hire Quality Cleaning and Restoration("Quality")for cleaning,restoration and remediation services. I authorize Quality to enter my property and to complete the work as deemed appropriate by Quality. I represent that I am the owner of the house or property which has been damaged. I further represent that the damaged property has appropriate insurance coverage to cover the loss or damage which is the subject of Quality's work. I authorize and instruct my insurance company to pay Quality directly for its work in connection with this loss or damage,or,include Quality as a co-payee on checks for payment. I assign to Quality my right to recover payment under applicable insurance for Quality's work. I authorize Quality to send this contract to the insurance company for Quality to obtain payment directly from the insurer. If the insurance company pays me,despite my authorization and instruction to pay Quality directly, I agree to pay Quality within five(5)business days after receipt of the insurance payment. I authorize Quality to supply information about this loss or claim to the insurer,as well as a report of services provided by Quality. I understand that I am hiring Quality and I am responsible for full payment for Quality's work and services,regardless of insurance. I am responsible for paying any insurance deductible or charges not covered by insurance,or not paid by an insurer for any reason. I understand there is no guarantee that in all circumstances,items,or property can be restored to their condition prior to the loss or damage. Quality will try in its good faith discretion to ensure that its charges for services will be the amount authorized and paid by available insurance,not including any deductible,client-ordered change orders, or unforeseen damage "presently hidden. However, Quality does not and cannot promise this. Where insurance is not available,or insufficient, Quality will charge its customary rates,which are available upon request. Late charges of 18%per annum shall be charged on late payment and I shall be obligated to pay Quality's reasonable attorneys fees necessary for collection. I also agree that,in the event Quality is not paid within 3 days of completing its work, at its option, Quality shall have a lien on my property where the work was done. Owner: Date Quality Cleaning&Restoration Date