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36-114 (8) BP-2022-0814 199 BROOKSIDE CIR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-114-001 CITY OF NORTHAMPTON Permit: Addition PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0814 PERMISSION IS HEREBY GRANTED TO: Project# ADD MUDROOM Contractor: License: Est. Cost: 33600 ROBERT GONZALEZ 072482 Const.Class: Exp.Date:03/05/2024 Use Group: Owner: LOVE STATHIS ERIN S&JAMES F Lot Size (sq.ft.) Zoning: WSP Applicant: ROBERT GONZALEZ Applicant Address Phone: Insurance: 143 LITTLE MOHAWK RD (413)221-3837 SHELBURNE, MA 01370 ISSUED ON:07/15/2022 TO PERFORM THE FOLLOWING WORK: ADD MUDROOM 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: ' 9 . +. i . so Fees Paid: $218.00 212Main Street, Phone(413) 587-1240,Fax:(413)587-1272 Office of the Buldine Commissioner File #BP-2022-0814 APPLICANT/CONTACT PERSON:ROBERT 143 LITTLE MOHAWK RD SHELBURNE, MA 01370(413)221-3837 PROPERTY LOCATION 199 BROOKSIDE CIR MAP:LOT 36-114-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: I PERMIT APPLICATION CHECKLIST - ,• ED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out ( I Fee Paid $218.00 Type of Construction: ADD MUDROO New Construction Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan T FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I ORMATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed OtherPerm its Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay ,'& ' iriT . 7/)ifi Sign: ure of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. r The Commonwealth of Massachusetts w Board of Building Regulations and Sya nda ds �Uj F Massachusetts State Building Code, 180 R 2022 IC PALITY ar,,r SE Building Permit Application To Construct,Repair,R�vat ftt) ' a evise Mar 2011 One-or Two-Family Dwelling �'�""oni,,4IApFcr,;06" a' This Section For Official Use Only Building Permit Number: Qu 19- • S/ Date Applied: .9' : 2 . �5 �.oZ Building Official(Print Name) I Signature SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1 fY I3 rooksocie City' 36 - IN N - 601 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 it) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided ^eks ;1Ir a $'v` 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public L� Private❑ Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Er w S-i-aftl'S F l o w V1 C-e , rvi ti 0/ O - Name(Print) City,State,ZIP , 199 13r00kcicle Cir. y13-a i -5Iy7 erirlSizti-0 gma1(. co✓VI No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building, Owner-Occupied 0 Repairs(s) J4._ Alteration(s) M Addition 41i-- Demolition 0 Accessory Bldg. 0 Number of Units Other -Specify: Brief Description of Proposed Work2: 1 7/2 � f-5.r1/ of/i�r4 J v:�� �/i�' v.i y�/�: Sr 1 D 11 �4:1, 02-7A,— ,�;c/ / ;'..// fir./ �`e.du /Z/Lc%/rxe,t t�2'�Idit," /�,2�� O7 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 3 3 c.,,a7 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ Ccx� ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ i 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: al 1 g 6.Total Project Cost: $ 1 D ElPaid in Full 0 Outstanding Balance Due: ; , g SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) eS_O 7f5/ f 3 License Number Expiration Date Name of CSL Holder List CSL Type(see below) v 1/3 No.and Street Type Description / U Unrestricted(Buildings up to 35,000 cu.ft.) ,5:n c 7;7� z�Z c Q/ d R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding _ SF Solid Fuel Burning Appliances 1,64SG—jcv8 e(' .c./Ca-r I Insulation Telephone tmail addfess D Demolition 5.2,RegisteredHome Improvement Contractor(HIC) /5 c.1.)SC 3/r/`- f use �� �' ` i1� HIC Registration Number Expiration Date HIC Company Name or HIC eg t l'/� G; / , g " e am% / ‘af1c,_ (-78Z ./_ Cc>" No.and Street Email addfess O/_)7-7c) c//3 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 Issuance of 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/ •��� - z��to act on my behalf,in all matters relative to work authorized by this building permit application. Er ► in I aLi/aoa � 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 application is true and accurate to the best of my knowledge and understanding. , / 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" The Commonwealth of Massachusetts Deportment of Industrial Accidents I Congress Street,Suite 100 " Boston, MA 02114-2017 www.mass.gov/dia %%utiters'Compensation Insurance Affidavit: Builders'ContractorsfEkctriciansiPlumbers. 11) BE FILED 1%!Ill I itt: PER.111 I I'11C At i IlORITl'. Applicant Information / Please Print ',evil*Name(BusmcssOrganrratiotulndisiduail: ( �jes%r' � Addrss://3«._,f'�� �,� City/State/Zip: ,d o637o Phone# s- `//-3 32 .ire',co an empkrver'Cheek the appropriate hot: 1 (x of project(required): 1.N am a employer with employees(full aniline part-time(,• 7. New construction proprietor partnership ' H. remodeling ��. autte oleo or nCrtlat and have no a lk1Ve3'91 wti+rktns: for the is , any capacity.[Nu workers'comp.insurance required_] 9. ❑Demolition ICI I am a homeowner doing all work:myself.[No w orkcr.'currm insurance re]unetl.]" 0 0 Building addition 4.01 am a homeowner and will be hiring exattraeiurs to conduct all w ork on my property. I will 1 ensure that all contractors either have worker.'ce mp ensatrun msuraaci or are WIC 11.©Electrical repairs or additions proprietors with no employee. 12.0 Plumbing repairs or additions 50 I am a general contractor and I hale hired the rub-contractors listed un the attached sleet. These sub-contractors base employees and have woKlters'comp.insurance.; 13 Roof repairs 6.0 We are a corporation and its officers hate exercised their nght of exemption per MGt_e. I M. Offer 152,yc 114 t.and we have:nu employees.(No workers'comp.insurance required.] 'Any applicant that cheeks box=1 must alru till out the section below show ing their workers'compensation pulley information Homeowner.who submit this affidavit indicating,they are doing all work and then hire outside contractors must subnut a new affidavit mdiearmg such. :Contractors that cheek this box must attached an additional sheet showing the name of the stib vontraeturs and date whether in not those entities have employ cc-. If the sub-contractors have employ ees.they must pros isle their V.urkcrs'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: ,%� ��r S Policy#or Self-ins. Lic.#: / b ST Expiration Date: g' Job Site Address:/75 poi (�ire 4 1�/a',roc • City,'Statz•'Zip:^ C-S raC Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requited under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. Ido hereby certify under the pain.anti penalties ari perjury that the information provide! %,� Isand correct SSignature: � "' Date: 4'/ Phone#: Official use only. Do not write in this area.to be completed by city or town official ('iiy or Town: Permit/License it Issuing Authority (circle one): I I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: DATE(MM/DD/YYYY) ACOREP CERTIFICATE OF LIABILITY INSURANCE 06/09/2022 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 CONTACT Tracey Kuklewicz NAME: A.H.Rist Insurance Agency, Inc. PHONo,EXt): (413)863-4373 (A/C,No) (413)863-9658 159 Avenue A E-MAIL tacey@ahrist.com ADDRESS: P.O. Box 391 INSURER(S)AFFORDING COVERAGE NAIC# Turners Falls MA 01376 INSURER A: Preferred Mutual Ins.Co. 15024 INSURED INSURER B: Bob's Carpentry,Robert Gonzalez Dba INSURER C: 143 Little Mohawk Road INSURER D: INSURER E: Shelburne Falls MA 01370 INSURER F: COVERAGES CERTIFICATE NUMBER: 2021 Cert 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 CLAIMS-MADE OCCUR PREMISESO(Ea occE ence) S 100,000 MED EXP(Any one person) $ 5,000 A BOP0100720576 11/15/2021 11/15/2022 PERSONAL&ADVINJURY $ 500,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 1,000,000 X POLICY PRO JECT LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS I HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Classification: Carpenty CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Erin Stathis ACCORDANCE WITH THE POLICY PROVISIONS. 199 Brookside Circle AUTHORIZED REPRESENTATIVE ( Florence MA 01062 • ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton '' Massachusetts A4.? k_ '<< ,` DEPARTMENT OF BUILDING INSPECTIONS s Ir 212 Main Street • Municipal Building `)� _ �, \ Northampton, MA 01060 SSNjy N^~ 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: Ss-7-1,/- -' •-• The debris will be transported by: i / Name of Hauler: / .,i/4- - %mac � e-- _�(�-I i—1( !-= i Signature of Applicant: 7/��� i _ Date: ��A/ THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE: Individual Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 150096 03/05/2024 Boston,MA 02118 ERT GONZALEZ ERT GONZALEZ ) ITTLE MOHAWK RD. 1,44,,,,K� BURNE, MA 01370 Al..4...,a...141.....41..:......a...... Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re uiations and Standards Co nst.tAitidni rrvisor CS-072482 Ficpires:03/05/2024 E► e. ROBERT GONZALEZ 143 LITTLE MOHAWK RItt SHELBURNE'fALLS MA'01370 1,1,V A:N JJ Commissioner did t'. 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Itv of Northampton "` :' Massachusetts DEPARTMENT OF BUILDING INSPECTIONS I., 212 Main Street,Room ioo Northampton MA oio6o (413)587-124o Plot Plan Drawing To be submitted with permit applications for 1,- or 2-family additions, decks, porches, pools, and detached accessory structures, Property address: i / r '. / J'. -4` , r Proposed work: C.1 C{ ill(A(l :: i_ 7 dd di +? iv` -it 3-0 = e:'.. / ) ,'(,1 .. Information/detail requirements: • Septic system tank and drain field (if applicable). • Street(s) by name • All existing structures including decks, pools, • a Front of house detached garages, carports, sheds, etc. • Driveway • All proposed additions, decks, porches, pools, • Easement(s) detached garages, carports, sheds, etc. • All property line dimensions • Distances of existing and proposed structures to lot lines and other structures. /. 6'0 IC s i t ' el i- ' ' A ........ , 1: - ,S.ff ''. , '.., .,„\\ ,,,, ,,,, ,_, , 1'--'-----r , ,\. , ...,.. , , (Example on back) t'