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17A-275 (3)
B '-2022-1244 154 OAK S COMMONWEALTH OF MASSACHUSETTS Map:Block: ot: 17A-275-00 CITY OF NORTHAMPTON Permit: Alts enovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-1244 PERMISSIONIS HEREBY GRANT sD TO: Project# 2022 BATHROOMS Contractor: License: Est. Cost: 38600 TRISTAN EVANS 114112 Const.Class: Exp.Date:09/29/2023 Use Group: Owner: B GOLDSTEIN SUZANNE Lot Size (sq.ft.) Zoning: URB Applicant: TRISTAN EVANS CONSTRUCTION I C Applicant Address Phone: Insurance: 61 PLEASANT ST 413-824-0069 WCC-500-5022784-202'A GREENFIELD, MA 01301 ISSUED ON:09/29/2022 TO PERFORM THE FOLLOWING WORK: reno 2 bathrooms 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 VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: V • >2 . 591i Fees Paid: S250.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner I The Commonwealth of Massachusetts, SEP 2 9 + Board of Building Regulations and Stan 'rds 2022 OR v;I,j" Massachusetts State Building Code,t 78 CIPAI,I1'Y tin°F rtm ninrr I USE ' Building Permit Application To Construct, Repair, Renovat ?bi:Denid ifOrio gtZevi d Mar 2011 One-or Two-Family Dwelling3° This Section For Official Use Only Building Permit Number: JP—4)-3"" 13-f y Date Applied: ,16; i i .23 4,k 0 Building Official(Print Name) 1 Signature i D h SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 154 Oak Street,Floence,MA.01062 17A-275-001 1.la Is this an accepted street?yes x no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Residential 10,700 104 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: I Public Private 0 Zone: Outside Flood Zone? Municipal On site disposal system 0 Check if yesK SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: GOLDSTEIN,SUZANNE B Florence,Ma.01062 Name(Print) City,State,ZIP 154 Oak at. 203-858-1213 suzlebgoldstein@gmall.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) Ill Alteration(s) ® AdditiOn 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: 2 bathrooms to be remodeled. f'..it-hi rt R"pt.? . /(JO CA i nS,,( 7(0 -'`ove,lei,. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 25400 1. Building Permit Fee: $ Indicate how fee is detenr,ined: 2.Electrical $ 3200 ❑ Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 10000 2. Other Fees: $ 4. Mechanical (HVAC) $ List: Text 5. Mechanical (Fire $ — Suppression) Total All Fees: IL Check No.1`+ Check Amount: pi-JD Cash Amount: 6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: e SECTION 5: CONSTRUCTION SERVICES / 5.1 Construction Supervisor License(CSL) ✓/ cs-114112 08P29/2023 Tristan Evans License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 81 Pleasant st No. and Street Type Description Greenfield,MA.01301 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-824-0089 tevans@trlstanevansconstructlon.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 198957 07/0812024 Tristan Evans Construction Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 81 Pleasant st tevans@tristanevansconstructIon.com No.and Street Email address Greenfield,MA.01301 413-824-0089 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 Tristan Evans Construction Inc. to act on my behalf,in all matters relative to work authorized by this building permit application. GOLDSTEIN,SUZANNE B O 21/2022 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. Tristan Evans 09V21/2022 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 aimer 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 [H S S Massachusetts ��5� y.. i4t I, Al. • DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building uk11, OD Northampton, MA 01060 ssbjy lt"31A 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: The debris will be transported by: Name of Hauler: Allen's roolloff Signature of Applicant: Date: 09/21/2022 The Commonwealth of Massachusetts — Department of Industrial Accidents ';_'1 = i Office of Investigations = 1 Congress Street, Suite 100 . =_4 i- I Boston, MA 02114-2017 :��V www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Tristan Evans Construction inc Address: 61 Pleasant Street City/State/Zip: Greenfield, Ma. 01301 Phone#: 413-824-0069 Are you an employer? Check the appropriate box: Type of project(required): 1.121 I am a employer with 4 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. El 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 working for me in any capacity. employees and have workers' 9. El Building addition [No workers' comp. insurance comp. insurance. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' 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 affidavitindicating 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: AIM Policy#or Self-ins. Lic.#: wcc-500-5022784-2022a Expiration Date: 08/04/2023 Job Site Address: 59 Bacon street City/State/Zip: Orange, Ma.01364 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 undi 119 Verified byptl'Fl"ls l penalties of perjury that the information provided above is true and correct. Signature:Jr141n Evans Date: 09/16/2022 Phone#: 413-824-0069 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# ; Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: V- to ` �. '"4 = Demolish and renovate 2 bathrooms , new items: 4 R T -tub i n k.�i. -windows i. . '}` d < � 5 -vanity -electrical fixtures '▪ ,, :�� -tile ctv; -vanity h . � -med cab g a e - �• ,��, - -toilet -41 f@ -- -pocket door ' x ' �� Plumbing and electrical ' work by others Y p, ''' ✓,4�3 i f' i x fig ,\ 1 lye cp 1... fiiyy s. 4 \f Tristan Evans Construction REVISIONS 6i Pleasant st. CV Greenfield,Ma.oi3oimm /nn/Yr REMARKS O 1 09/26/2022 T.E. 2 --/--/-- ... Goldstein Bathroom Remodel 3 - / / - 154 Oak Street,Florence,Ma.oio62 a __/_-/-- -- 5'-4" replace existing windows(2) i9 new pocket door Tristan Evans Construction REVISIONS 61 Pleasant st. Cr) Greenfield,Ma.oi301 MM/DD/YY REMARKS 1 09/26/2022 T.E. 2 / /- Goldstein Bathroom Remodel 3 --/--/-- 154 Oak Street,Florence,Ma. oio62 4 --/--/-- "' AWRD CERTIFICATE OF LIABILITY INSURANCE DATE`MM/DDm`YY) �►�. 09/22/22 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 NAME: Carol Shippee NE Mirick Insurance Agency f2 i .Ext): 413-625-9437 (q/c,No): 413-625-9473 POB 375 E-MAIL 28 Bridge Street ADDRESs: cshippee@miriCkinS.COm Shelburne Falls,MA 01370 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A: Concord Group INSURED INSURER B: Tristan Evans INSURER C: 61 Pleasant Street INSURER D Greenfield,MA 01301 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 ADDLSUTYPE OF INSURANCE INSD WVRD POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD {MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I $ 1,000,000 DAMAGE RENED CLAIMS-MADE IX'OCCUR PREMISESO(Ea occurrence $ MED EXP(Any one person)' $ 5,000 A 20029103 04/08/22 04/08/23 PERSONAL&ADV INJURY, $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I $ 2,000,000 H POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS 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 AND EMPLOYERS'LIABILITY Y/N STATUTE I OER� 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 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 B CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Northampton Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Puchalski Municipal Building 212 Main St AUTHORIZED REPRESENTAT Northampton,MA 01060 ah,a2174p4-A--' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AccRrJ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) Ikaa----- 09/22/2022 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. i IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IWAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does nt confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 04971 -001 'NAMEACT Number One Insurance Agency 4971/1/764 Number One Insurance Agency (A//c e Ext): 5086342900 rim No: (508)634-2930 91 Cedar St ADD12ES8: ktobin@massagent.com Milford, MA 01757 INSURER(SI AFFORDING COVERAGE NAIC#-. INSURER A• Associated Employers Insurance Company 11104 INSURED INSURER B: Tristan Evans Construction Inc - INSURER C: - 61 Pleasant St INSURERD: Greenfield, MA 01301 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 VNTH 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. ILTYPE OF INSURANCE INSR'SAD POLICY NUMBER (MPOMJ'd`� tI�DMIm`�YnC) _ -- LIMITS TR GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGES( RENTED S PREMISES PREMI (Ea occurrence) CLAIMS-MADE 1 i OCCUR MED EXP(Any one person $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY LOC AUTOMOBILE LIABILITY COMBINED SINGLE UMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ yypRKKDEEERRDgg ppMMPPRNNEggTppE7N�TIION $ yy�gTpTU TH $ AND EMPLOYERSF`LIABILITY Y x TORY LIMITS TI A o� IcTRPMA 1 ER/EXCLUDED7 ECUTIVE N/A WCC-500-5022784-2022A 8/4/2022 8/4/2023 E.L.EACH ACCIDENT $ 100,000.00 (Mandatorya in NH) �� E.L.DISEASE-EA EMPLOYEE $ 100,000.00 Inns PT ON OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Northampton Building Department Puchalski Municipal Building SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 212 Main Street#100 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Northampton, MA 01060 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD