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