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36-112 BP 022-0901 215BROOKSIDE CIR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-112-001 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-2022-0901 PERMISSION IS HEREBY GRANTE I TO: Project# BASEMENT BATH Contractor: License: Est. Cost: 13132 Const.Class: Exp.Date: Use Group: Owner: L EDWARDS, REBECCA Lot Size (sq.ft.) Zoning: WSP Applicant: L EDWARDS, REBECCA Applicant Address Phone: Insurance: 215 BROOKSIDE CIR FLORENCE, MA 01062 ISSUED ON:08/02/2022 TO PERFORM THE FOLLOWING WORK: ADD BATH TO BASEMENT 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 (Tsi • > � y!J ' Fees Paid: S85.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner walk vlelitr11 •!f. -e hy), vvk-, ttC me Igoe?, lam, If inc4 rm* Gw �-�a- Q, cxevt�`s�e�- The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY � ,i USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling Thi Section For Official Use Only Building Permit Number: (be- a. a• • -d . Date Applied: Ku,j (Ku: .i/Z - 8.z- zozz Building Official(Print Name) Signature Drte SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers _ 4 — rka— - sG -. ila— o-dt 1.la Is this an accepted street?yes no Ma umber Parcel Number 1.3 Zoning Informat' 1.4 Property Dimensions: 14A c:4104tV0A t!p 67 a - Zoning District Proposed Use Lot Are1a(sq fI) Frontage(11) 1.5 Building Setbacks(ft) Front Yard � Side Yards Rear Yard Required Provided Required -T Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone?Public* Private 0Municipal On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. Owner'.of Record: �.�itC` ��. Wtatirks '`c t&. v'1,1t-A 0 \d 6.. N e(Print) City,State,ZIP ��.c+id,P (1 c\ `S je 78i -IA-5_43 redwclais ta & ft\o►.\.ti:,1, 4 o.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ii4 Repairs(s) 0 Alteration(s) X Addi ion 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work `Q\j„ty,\go r. I ,\\;it A S1Ro _ .4- t 6t4ket•VDou tsk c� M SA' \ W.S.t t 1,ii 5*.lp.A.<t tI04 r, t.:4k,ixt w+t,,\ =.r.y-ALL A &-*8'�0..- QV�ki kt tC, i` SECTION 4:ESTIMATED CONSTRUCTION COSTS t- `G M. Estimated Costs: / Item Official Use Only ��'O �/ (Labor and Materials) �L��� 1. Building $ 6 94 eo 1. Building Permit Fee:$ Indicate how fee is Bete-mined: 2.Electrical $ 6-0 ❑Standard City/Town Application Fee i 6 0 Total Project Cost- (Item 6)x multiplier x 3. Plumbing $ ‘Ct t�a 2. Other Fees: $ 4. Mechanical (HVAC) $ _ List: 5. Mechanical (Fire $ Suppression) Total All Fe t� Q 6- Check No. 'I Check Amount: 400 6.Total Project Cost: $ `� `\3 O Paid in Full 0 Outstanding Balance Due: Add. k+k 4v baukite lit SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling ty M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone t...ail address D Demolition 5.2 Registered Home 1 provement C, 1 tractor(HIC) 1714047 /Jaa J o)3 C. ,',". tit%-tin cANytt• • {D Je p ttc.At HIC Registration Number Expirat on Date HIC C mpaany_Name or HIC Regrstr nt 1 ame .and Str t Email dress i�x,&.e\A gMit- D\3 D 1 41/4 1 --(4iy ity/Town.State,ZIP ephone SECTION 6:WORKERS' COMPENSATION I1VSURANCE 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 K No .0 SECTION 7a:OWNER AU HORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONT CTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize c `4 to act on my behalf,in al matter relative t authoriz this building permit.applicati n. ke(Cck l 7 -2 9 e--a4D, _ Print Owners Name(Electronic Signature Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 hereby attest under the pains and penalties of pe -ury that all of the information contained in this application is and acc ate to e est of my wledg d understanding. ` t5 ? ( .2 P 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" Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 174249 CARL KENISTON Expiration: 01/22/2023 D/B/A C.L.KENISTON HOME&YARD IMPROVEMENT 259 LOG PLAIN RD GREENFIELD,MA 01301 Update Address and Return Card. SCA 1 0 20M-05/17 OOOffice of consumer Atfairs&Business egul*Won HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration expiration Office of Consumer Affairs and Business Regulation 174249 01/22/2023 1000 Washington Street -Suite 710 CARL KENISTON Boston,MA 02118 D/B/A C.L.KENISTON HOME&YARD IMPROVEMENT CARL KENISTON259 LOG PLAIN RD �nlc✓"iO���mGf�iok GREENFIELD,MA 01301 ` Undersecretary Not valid without signature The Commonwealth of Massachusetts 4 lt�h Department of industrial Accidents .�, 1 Congress Street,Suite 100 :mi=a, . -� Boston, MA 0211 d-l01 T -,,‘Lair- ,.: fi' most ' wstntass.govidio --_ 1i'4'orkers'Compensation insurance Affidavit:BucklertiContractors&Ekctricia.nsil'luin hers. It)BE VtLL1 WITH THE PERMITTING At'I'HORI 1%. Aranlics►nt information Please l'rint Leeibtk Name(I3usirsesIg rganirationfindivicinatl: ( • -T csNSkew\ 1..ke ' r cJL `3 T Address: ` j . Nk \A. kz 1 . City/Statel'ZiP: G N._e..)St-4 Q t..\CIA 0,30 r Phone##:%-kk 5-s a l— VS 4 Axe you an employer?Check the apprapriate boa: Type of project(required l= 1.01 am a employer with .__ employees(Nisi atdfue pion-time_• 7. 0 New construction lain a sole proprietor or partnership and have no employees arurkiaog Cur rue in Remodeling ty...-apse ity_(No workers'ccirtp.en%uranc'r required" 9. 0 Demolition 30 m a homcKiwttes doing all ismk myself:.{y:o workors'comp..insurance requital i' 121 1 m a}W ow rite nt-r and will be hiring tiumtratiur.s to conduct all work on t ry peacmty. I will uottrn that all evtttrtlrWra either have worktrs'exintpcaesaitint uasuramet or are g I I)0 Building additionoer 11 a Electrical repairs or additions proprietors with no employees.. I 2.0 Plumbing repairs or additions ici lane a general ebntruetur and l have hired the auh eontrauors listed on the is tacttcd stteit 131:Roafrepairs Theat sub-euntractori have rynployees and have workers'rarnp.in raricc. f1.0 we are a co poration and ifs ofnicees have exercised the it right of ctentptiear.per Mt l c. 14.0ether I.2,.1101,and w e tame nil rrni.lu5r.�ea.[No workers'comp.insurance retruired.1 Any applicactt that rhoiks hint r 1 roust also till out the seectiun below showing their winters'compensation puta ti tnformatirrr. Homeowners who submit this afYudaiit imheating they arc dearag all work and then hire outside contractor,must.uhmit a new afTidas it rndieatin4:u;i=.. «Cerrmaciori that eheck.this hot muxt attached an additional sheet showing the name Of the srrb-c mriractor,arcs state*Better or not those emit ic,ll:r. empluvcc-i. Ir the suti-•eontraettaa haii.•emnpluycY\.they motif pio4'ide their worktri'Coop.pLitcy nuinlxr lam 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, Lie.a: Expiration Date: _. Job Site Address: CityrStatelZip:_____._.__.__.____..__.__.._ Attach a copy of the workers'compensation polio'declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.. 152. K25A is a criminal violation punishable by a fine up to SI,5(X)..t>Ol r u Vor one-year imprisonment,as well as civil p talties in the form of a STOP WORK ORDER and a fine of tip to 0.(X)a day against the violator_A copy of this statement may be forwarded to the Office at investigations of the DIA tin insurance coverage verification. I do hereby certify u er the l i s and perialtie^s of perjury that rite information provided above is true and correct ;Sill mature.. .___ - Date 7I a 7 /a te Phone': / / j' S( —I —j O 4 I Official use only. Do not write in this area,to be completed by city or town official ilCih'or Town: t'ermitll,icense a i Issuing Authority(circle one): I.Board of Health 2.Building Department 3.C:itv/Town Clerk 4. Electrical Inspector S. Plumbing inspector I,.Other [ 4 Soulac l Person: Phone t�: ��.�_ m ^—ti -- it ACC PREP CERTIFICATE OF LIABILITY INSURANCE °ATE`MM,D°"YYY' 06/06/2022 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 Susan Fleury CIC CISR CPIA NAME: King 8 Cushman Inc. PHONE (413)584-5610 FAX (413)584-9322 (A/C No,Ext): (A/C,No): P.O.Box 447 EMAIL sfleury©kingcushman.com ADDRESS: 176 King Street INSURER(S)AFFORDING COVERAGE NAIC t! Northampton MA 01061 INSURER A: Hudson Excess Ins Co INSURED INSURER B: CL Keniston Home&Yard Improvement INSURER C 259 Log Plain Rd INSURER D: INSURER E: Greenfield MA 01301 INSURER F COVERAGES CERTIFICATE NUMBER: CL226604817 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LimRB COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 DAMAGE 10 RE !ED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A HBD100030728 06/07/2022 06/07/2023 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000'000 POLICY n jECT LOC PRODUCTS-COMP/OP AGC $ 2,000,000 OTHER Employee Benefits $ AUTOMOBILE LIABILITY 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 _Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ _ $ WORKERS COMPENSATION PER 1OTH- AND EMPLOYERS'UABILITY 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 $ It 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 it 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 ©1988-2015 ACORD CORPORATION.,All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton ?o ti° N�ry �- SI Massachusetts w�' �... ,, DEPARTMENT OF BUILDING INSPECTIONS y' n tii 'w`' 212 Main Street • Municipal Building '„y.4 �e N 46 Northampton, MA 01060 ""4 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: ee./S,e \ 4, oAn The debris will be transported by: Name of Hauler: D A,- CS h0,,.. Signature of Applicant: Date: 7 /a i ' aa,