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31B-188-002
BP-2024-0432 76 GOTHIC ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31B-188-002 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-2024-0432 PERMISSION IS HEREBY GRANTED TO: Project# REPAIR 2024 Contractor: License: Est. Cost: 1150 MICHAEL PHILLIPS CSL082683 Const.Class: Exp.Date: 10/10/2024 Use Group: Owner: DEVON RUESCH, Lot Size (sq.ft.) Zoning: Applicant: MICHAEL PHILLIPS Applicant Address Phone: Insurance: P O BOX 514 (413)250-7990 6S62UB-4N3852-5 GOSHEN, MA 01032 ISSUED ON: 04/16/2024 TO PERFORM THE FOLLOWING WORK: REMOVE ROT FROM COLUMN 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: 01444 Avg kni.4.,6 Fees Paid: $100.00 212 Main Street,Phone413( )587-1240,Fax: (413)587-1272 Office of the Building Commissioner f�pR f-tc.E/VED The Commonwealth of MassacJ ius tts 1 2024 Office of Public Safety and Inspections�E-r of �•_ Massachusetts State Building Code(780 NnRTNq koiNc'_�NSp 1 Building Permit Application for any Building other than a One-or Two- *ty � J (This Section For Official Use Only) Building Permit Number:e74/- 4/3)- Date Applied: Building Official: SECTION 1:LOCATION Tito No.and Street City/Town Zip Code Name of Building(if applicable) 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 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy ❑ Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No Is an Independent Structural Engineerin• eer Review require,. / Yes ❑ No Brief Description of Proposed W. k: P ♦. ,ram 3 - +� ►'. jam�.. 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) 0 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 0 A-4 0 A-5 0 B: Business j E: Educational ❑ F: Factory F-1 0 F2❑ H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5❑ I: Institutional I-1 0 1-2 0 I-3 0 1-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4❑ 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 ❑ IIA ❑ IIB 0 IIIA ❑ IIIB ❑ IV El VA 0 VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public/IIC Check if outside Flood Zone 0 Indicate municipal A trench 11 not be Licensed Disposal Site 0 required ror trench or specify: Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable Is Structure within airport ap roach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No Yes 0 No ❑ SECTION 8:CONTENT OF CER IFICATE 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 Proper Owner `�,Pc)t11Q �e S! Sr1 -----W° f-k�,PS P IMPS- 1 Name(Print) No.and Street City/Town Zip 1 Property Owner Contact Informa 'on: ')QJ o A s.)4 S _W°)6t6 lib►-( _ - J 3(4-`cl e Y,►0 &IPA Title Telephone No. (business) Telephone No. (cell) e-mail address If appl able,the pr perty owner hereby authorizes: I. ame Street Address ty/ own 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 S1 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) 0 Name( an 1 V 07mia' a edire f 5 Registration Number Street A dress City/Town State ip Discipline Expiration Date 10.2 General Contractor 4 n ''��/� l r � l.��l\ t��r\= Company Name c - 44 ON e :4 ;rc o �6 v U Name of Person Responsib e for ns uction License No. and Type if Ap licable cam` v . io0jl �y/Street ? ddress ' n State _Zip - - M�V l dPs Svl t1to (rNA7( 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 e ' suance of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 0 lc Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ ,,(O (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pa' and penalties of perjury that all of the information contained in this application is true and accurate to the best of my owled and understanding. 41 n e Please pe, rint and si _name 5'4' T D ^r`J\ _ li Jown -J1`hj l ` Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: ° Oakattai_ I tt 19 Name Date _ City of Northampton ai a Pr: S`g s'C /�°'��r . Massachusetts ki f`. * c ,. m i7P DEPARTMENT OF BUILDING INSPECTIONS y ' , 212 Main Street fa Municipal Building offs �e + Northampton, MA 01060 .Ps— 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: U k / ' 1 ( l( k'3 The debris will be transported by: Name of Hauler: .. \(\V l LP< � l 1 Signature of Applicant: Date: q 1 The Comm on of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 '•:.'s-, .,--,ellf-j.4.1 4. 0 Boston, MA02114-2017 ',,•,...,*iv` ,,., / www.mass.gov/dia .41M kers' Compensation Insurance ABA as it: Builders,k:ontractorsiElectriciansiPlunihrrs, JO HE FILED WITH THE PERMITTING AUTHORFTY, Alinlicutit Iliforillutiort Plemst.. Print 1.euiblv A e- ., f\,_‘ __....----, ,... , Name(Bustne- Ors,rantzation..'Inclividualt.,4n Cr ,... ivivi....yi c...- Address: —P, 6 cl, City/State/Zip: C ‘1/••_ IkAA\p424 :11 __ Phone#: tti, :-_-__ _ 0C,5_1___ __t,YX?) c.) r : ' Are you in easployer?Climb tbe appropriate boa: Type of project(required): 1.0 I am a employer with employees(full anthcer part-time t• 7. 0 New construction 201 am a auk pniprietor or pormership and have nu employees,working for me ltk 8. 0 Remodeling any capacity.[Nu workers'comp.insurance n_Nuircd_l El30 lam a homeo m wner doing al/work myself.(No workers'comp.insurance regain:11.j- 9. Demolition ID Building addition 4.9 I am a humieuvoier and will he hiring oirstraviun to conduct all work oil sity property_ I,o.ill ensure that all contractors either have workers'compensation I!Murano:or an:sok II.1:1 Electrical repairs or additions proprietors with no employees. I 2.0 Plumbing repairs or additions 50 I am a general contractor and I havt hired the sub-cunt:actors listed un the attached sheet 1 31.1 Roof re airs These sub-euraraeturs Isaw employees and have workers' ni comp.insunee.; c,rs O. 'e are a ourporation and its officers have excn:ised their nen of exemptionMI per GL c. ?:7 I 4. '52,§114 I.and we Law no employees.[No workers comp.insuracen rtuuired.] qfOthet iV- V-- *Any appticaru that chccics bul,.TI must also till out du:oection belLEA stowing their..kurkers'cunipcnsatiun policy infurinatiun.. *Hoincus.cuers who submit this afibila%it Indicating the)are doing all,,,.urk and awn hire outside contractots'twat submit a new atIfidan it indicating six+. Cut:nut:tura that check this box must attached an attaniunal alma stii..w.iiie the name of rhc suh,..-untracturs and aide whether or nut thosc entaii.-s have employees. Ville sub-contractors have employ IX!,th..."!e must pros ide their workers'vamp.policy number. Jam an employer that is providing Pl'OrA co'compen,siaion insurance for my employees. Below is the policy and job sire information. .. Insurance Company Name: i e( c4 b .v4sPolicy#or Self-iris. Lic.#: 1100 Iflt: 4A,N343%%'5-13175 Expiration Date: I •(., /4.3.3(-( Job Site Address: -7L:s 'r--3 (S- it=.".\ \-L. V/ City(State/Zip: 13:. ‹.\\"\INY\126,42\_ Wpfi Cjiiii Attach a copsof the worker. coinnenNation polic.declaration page(showing the policy number and expiration date). I Failure to secure coverage as requip..4.1 under SIGL c. 152. §25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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. l do herebr cern"),under th 1 ' . and pen ties'of p rptry that the information provided obive A., true and correct. Sienature: Li Li , Dii.,,, a A IN))--i (1-) - r)(b' 7174—e? Official use only. Da not write in this area.to be completed by city or fawn officiat City or Tow ti: PermiCticense 4 Issuing,kuthorit, (circle one): I. 13third of Health 2. Building Department 3.01y:frown Clerk 4.Electrical inspector 5. Plumbing Inspector fi. Other ( untHet Person: Phone#: .„.......,..,_„--. _ Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �.� 04/12/2024 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 Jennifer Ellinger NAME: Aquadro&Associates PHONE (413)586-7373 FAX (413)584-0859 (AIC,No,Ext): (A/C,No): 355 Bridge St.,P.O.Box 357 E-MAIL ) @q enn a uadroinsurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURERA: Main Street America Insurance 29939 INSURED INSURER B: Travelers Indemnity Co. 25658 MICHAEL PHILLIPS INC INSURER C: Chubb PO BOX 514 INSURER D INSURER E: GOSHEN MA 01032-0514 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2221710655 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 INSDA SUERD POLICY NUMBER POLICY EFF POLICY EXP LIMITS . (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 CLAIMS-MADE n OCCUR DAMAGE TO REN I LU 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A MPT6631G 12/14/2023 12/14/2024 PERSONAL&ADV INJURY $ 500,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 -1 POLICY PRO 1,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: Individual Risk Mod Prem $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 100,000 B OWNED X SCHEDULED BA8123W809 12/23/2023 12/23/2024 BODILY INJURY(Per accident) $ 300,000 AUTOS ONLY or X HIRED NON-OWNED PROPERTY DAMAGE $ 100,000 AUTOS ONLY _ AUTOS ONLY (Per accident) Uninsured motorist BI $ 100,000 • UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN 500000 C ANY PROPRIETOR/PARTNER/EXECUTIVE NIA 6S62UB-4N43852-5-22 06/24/2023 06/24/2024 E.L.EACH ACCIDENT $ , OFFICER/MEMBER EXCLUDED? (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) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 Cau; ^`'"'� � ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD