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15B-049 (11) BP-2022-1578 259 CHESTERFIELD RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 15B-049-001 CITY OF NORTHAMPTON Permit: Temp Structure (Tents) PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-1578 PERMISSION IS HEREBY GRANTED TO: Project# TEMP MOBLE HOME Contractor: License: EMERGENCY TEMPORARY Est. Cost: 2000 HOUSING INC 080509 Const.Class: Exp.Date: 11/29/2023 MELNICK DANIEL W&MARY HELENA Use Group: Owner: SIMMONDS-MELNIC TRUSTEES Lot Size (sq.ft.) Zoning: RR Applicant: EMERGENCY TEMPORARY HOUSING INC Applicant Address Phone: Insurance: 129 FERRY ST (508)887-8778 WLV01474101 SOUTH GRAFTON, MA 01560 ISSUED ON: 12/06/2022 TO PERFORM THE FOLLOWING WORK: TEMP MOBILE HOME 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: fnikiAL 4/(ft7 Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner 1=� iV ,-. : ,---7--____ The Commonwealth of Massachusetts i DEC 6 2022 /FOR W Board of Building Regulations and Standard Massachusetts State Building Code, 780 CMR>r o MUNICIPALITY';n�..cull orry - USE Building Permit Application To Construct,Repair, Renovate Or ljdindhs ",, PFcr4gyisedMar 2011 One-or Two-Family Dwelling — _. ° This Section For Official Use Only Building Permit Number: igt/ r 1 S 7 I Date Applied: n Ir' r 0 / . ,i' :• i 0Z, & Building Official(Print Name) � Signature to SECTION 1: SITE INFORMATION 1.1 Propertytt,' e'IA 1.2 Asseors Map&Parcel Numbrs �51 Rc i 5(6 G Lt t1 - 00) 1.1 a Is this an accepted street?yes L./no Map Number Parcel Number 1.3 Zo 'n Informatioon: 1 -(,, 1 1.4 Property Dimensions: SO(At Zoning Distri Propoejd U Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provi ed Required Provided 1 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Informati n: 1.8 Sewage Disposal System: Public 0 Private)1 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system x Check if yes❑er'° �p SECTION 2: PROPERTY OWNERSHIP' 11 Crri1 to , 1 14+(rdlA��Q�►k, (PveAn i k/ ,-e Ac nA O t 0 5 3 ame City,State ZIP No.and Street Telephone Email Addresd SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other it Specify:I JO U11bb If'or e Bri f Description of Proposed Work': 4i?D fJ n (�e 1 vie ' 7-)c c(a bej 1 -AW M11 )1�D, V\ _- t-< � u.1R, sA-- i 'l(- 1p r n ' Vow 0 CL, 1 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Costa (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: $ ( Pei Check No./007e Check Amount: Cash Amount: 6. Total Project Cost: $ ::,,) WO Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES —t 5.1 Construction Supervisor License(CSL) S 010501 l2�Ij l j0 d J ��11 l G�,,nGt�-- License Number Exp iiYation Date Name of CSL Holder n �'` ( ), Dk.S � List CSL Type(see below)o.and Street T e Description `�`I� U`A �n �1, `�t Z Unrestricted(Buildings up to 35,000 Cu.ft.) 1� b 1 1'► 1 I l lJ R Restricted 1&2 Family Dwelling ity/Town,Sta.,ZIP M Masonry RC Roofing Covering WS Window and Siding h ISF Solid Fuel Burning Appliances 5-ce'7r..._, K 3 e1'r Z' 1 an ct�F c�l) i- i A n',J c I Insulation Telephone V Em address j D Demolition 5.2 Registered Home Imp'_oXement Contractor(HIC) N \1 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address 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 IR 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 l l i4c1--1S r, --'J' 1. to act on my behalf,in all matters relative to work authorized this uilding_ermit ap lication. \/ ASa GrA di'h eel f-.- I zigz07�Print Owner's Name(Electronic46- ignature) 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 contai ' this applicatio n is,true aid ccurate to the best of my knowledge and understanding. 1 C 1 k- 1 / (z S/Z,ol z, Print er's or Authorized Agent's Name(E pnic 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" sae - EMERGENCY TEMPORARY HOUSING "We Deliver Temporary Housing to Your House" 129 Ferry Street Grafton, MA 01560 Office:508-887-8787 Fax:508-887-8786 Cell:774-261-0010 Iijr.aiN C M �ii �\ , as Owner of property located at Do authorize Emergency Temporary Housing Inc., 129 Ferry Street, South Grafton, MA 01560, to file, on behalf, for any permits including building, electrical, plumbing, zoning, BOH, zoning and gas permits, as required for placement of temporary HUD mobile home on my property. Signature ; Date j ( -? `t -2 (Practice Areas/CORP/25227/00001/A2495085.DOCX[Ver:3]) 12/5/22,3:29 PM Northampton MA,Web GIS 259 CHESTERFIELD RD Search Results Parcel Details Return To Search Results 0 259 CHESTERFIELD RD a 1 v 15B-033-001 136 1 1 "c""1", MELNICK DANIEL W& 73 259 CHESTERFIELD RD 15&049001 MA,LEEDS 01053 L04 Parcel ID:15B-049-001 !Links' I I - i, 7I r I Parcel Details Bing Bird's Eye CJ 1. _-- Photo Add Parcel --___ _— I r- 1 Google Map Remove Parcel L---I S -/-1 Abutter Distance: Print Labels _ Ty k63 - --- LI Adjacent I Export List I - -s All, Adjacent Type FEE 50 ft loon MB 15B-049 CHESTERFIELD ROAD 200 ft .- - 1 300 ft 15-023-001 400 ft RFIELD RD 4 57 500 ft "DANIEL W& 1SB 030-001 1 1.15 I Find Abutters �_`_ :STERFIELD RD 15B-001-001 7 (--------1 ClearAbutters 446 I -- --i I I __—j Copy ar iste the following string into an email to link to the current map view: 20n, Aft Close Size: Scale: 1"= ft. Title: Close Print https://hosting.tighebond.com/northamptonma public/##info-address 1/1 CITY OF NORTHAMPTON SETBACK PLAN MAP: 15 LOT: OT ,C -00D LOT SIZE: ( U C`C(C' REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton S`S .. SAC •' Massachusetts �A, Y.- ,t� iu * G kr ,k DEPARTMENT OF BUILDING INSPECTIONS 7. a 4 (, 212 Main Street • Municipal Building yJdS OCa` Northampton, MA 01060 , 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: b(iA 1 (, Hoct'r4& 0, liveA iv 0 , Al4 i The debris will be transported by: Name of Hauler: `1t, /i )L i /kJ 1 Signature of Applicant: Date: `/sX IN. The Commonwealth of Massachusetts - ° .,: f Department of Industrial Accidents s 1 Congress Street,Suite 100 ' Boston. ,1L-t 02114-2017 Wi t; www.mass.govIdia hunkers' ('0mpensation Insurance Aflidarit: Builders/Contractors/EiectriciausfPlumhers. 14)BE FILED N 1111 I DE I'k k%IITI'1NG A( 11OREI , Annlicant Information Please Print Legibly Name 413ustncs+Organization Individual l: Pis ri'1([,. -l em l o (a -�'1 f (x- Address: I2�' Fec-r .�" 11 �J City?State iZip: 5 k G ion (Y (')I SI,o Phone#: 6 ' 1?ri• 10/1 __ Are you an employ rr'Check tore sppruprta but: Type of project(required).i.Vl am a engrluyc with q employees huh .ureter part-limas 7. CI New construction `fl I am a suk prupncior or purtncnhip and have nu employers working for me in K. CI Remodeling any capacity [Nu wuuker,:comp.umuruuux nmyunal j 9. 0 Demolition 3.1:=1 I am a homeowner doing all work myself.[No workers'comp.insurance n urrcJ.) 4.0 I am a humeow no.and will be hiring einuracturs to conduct all work on my pnrperty I oil: 10 a Building addition onsure that all contra.9ur,either have workers'ci nrpensanue insurance or are sole 1 l CI Electrical repairs or additions prupneiore w rile no empluye.0 12.0 Plumbing repairs or additions S I am a general cuntructur and I has a hired the ub-cuntracton.listed on the attached sheet These ub euntracturs have cmpluyecs and have v.oilers'comp.mauramee. 13�Roof va W are a corporation and its ulIwers hove ezcn used then nght of mammon per M(it.c l�. O h@r �� j'(u 121L """ t°f vi 152.,slr4I.and we have no employees.[No workers'comp.insurance required.' i 'Any applicant that ch.x:ks lox:.I mud alai fill uut the section below show me their workers'compensauun policy ratunnution +Humeuwuers who submit this allidasit indicating,they are doing all work and then hire outside contra:tors must suhnut a new affidas it indicting such. 'Cunir:retun that cheek this box must attached an additional sheet showing the name of the sub-contractor,and date w het er or nut thus:entrtle>have cinrluv cis tI the sub-cuntracita,have ernpluy cc,.they mud pm,.idc their vs urkers'comp.pudic}uuunbct I um on employer that is providing worAers'compensation insurance for my employees. Below is the policy and job site information. klit•141 C ())34140' Insurtttie Company'Vann:: Policy#or Self-ins.Lie.#: \w01/0I91 110( Expiration Date: / 1/10 3 (7`) Job Site Address: 7-S 9 C)1JrfiePd (-A- Cuy,'Stats~..Zip: el S , mil DI O3 Attach a copy of the workers'compensation policy declaration page(showing the policy number aad expiration date). Failure to secure coverage as required under:Alit c. 152. §25A is a criminal violation punishable by a fine up to iS I.590.00 anti-or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up Oki 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA fur insurance coteraec vcriticati I do hereby certi er the pains a pe• ., t.` efpetjury that the information provided above Mee oealee elect. Signature: • ICAIt 11- J Date. /2/5' `hi,)-2- Phone r: 5 v Ili' . 7 /i Official use only. Do not write in thin urea.to be completed by city or town official Cits or Town: Perini).+l.icrnuue f Issuing Authority (circle uuet: I. Board of Health 2. Building Department 3.( ity[l ins!'Clerk 4. Electrical Inspector 5. Plumbing Inspector h.Other Contact Person: Phone#: City of Northampton Massachusetts ��? -- s,o'<on lit * DEPARTMENT OF BUILDING INSPECTIONS y . �. 212 Main Street co Municipal Building 6- orb Northampton, MA 01060 SbW 3oN^ 0 v HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born _ (insert month, day, year),hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20 . (Signature) Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards ConstCt fon S q visor CS-080509 r• l plrss:11/29 2023 JON M YANO)1( 14.47 60 DAVIS ROAD MILLBURY MJ 01527 Commissioner _',a I, (.1(01 wl Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Supplement Card Registration Expiration 141641 05/04/2022 QUALITY CONTRACTING INC. JON YANCIK 534 CAMBRIDGE STREET c .or'f:4,64/.6• WORCESTER,MA 01610 Undersecretary Commonwealth of Massachusetts 1.11• Division of Occupational Licensure Board of Building Regulations and Standards Cons ` Ir tchrl ton S rvisor ti ,. CS-080509 spires: 11/29/2023 JON M YANO)K f 60 DAVIS ROAD MILLBURY M13 01527 ACL RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/5/2022 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 Herlihy Insurance Group P ONE Sherri Tower FAX 51 Pullman Street (A/C.No,Ext): 508-471-9674 (A/c,Ne0:508-751-5747 IL Worcester MA 01606 ADDRESS: certificates©herlihygroup.com INSURER(S)AFFORDING COVERAGE MAC INSURER A:Atlantic Charter Insurance Company INSURED EMERTEM-01 INSURER B:Capitol Specialty Insurance Co. Emergency Temporary Housing, Inc. 129 Ferry Street INSURER C:Commerce Insurance 34754 South Grafton MA 01560 INSURER D:Evanston Insurance Company INSURER E: INSURER F: I COVERAGES CERTIFICATE NUMBER:1662268557 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY W MI EXP UNITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MDD/YYYY) B X COMMERCIAL GENERAL LIABILITY BR20210212-02 10/1/2022 10/1/2023 EACH OCCURRENCE $1,000,000DAmAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $100,000 _ MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY X jECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: S C AUTOMOBILE LIABILITY BJGKZD 10/1/2022 10/1/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED y NON-OWNED PROPERTY DAMAGE AUTOS ONLY ,AUTOS ONLY (Per accident) S D X UMBRELLA LIAB X OCCUR EZXS3095026 10/12/2022 10/1/2023 EACH OCCURRENCE S 3,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $3,000,000 DED RETENTION$ $ A WORKERS COMPENSATION WCV01474101 1/1/2022 1/1/2023 X OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Subject to policy terms,forms and conditions. 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. Town of North Hampton 212 Main St. North Hampton MA 01060 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD