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12C-058 (4) BP-2024-0453 28 HAROLD ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 12C-058-001 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-2024-0453 PERMISSION IS HEREBY GRANTED TO: Project# SIDING 2024 Contractor: License: HAYDENVILLE WOODWORKING & Est. Cost: 44265 DESIGN INC 116208 Const.Class: Exp.Date: 04/13/2025 Use Group: Owner: MEHRMAN SHARON C& SARAH T DUNTON Lot Size(sq.ft.) Zoning: RI/WSP Applicant: HAYDENVILLE WOODWORKING &DESIGN INC Applicant Address Phone: Insurance: 35 CONZ ST (413)665-7402 WMZ-800-8007423-2022 NORTHAMPTON, MA 01060 ISSUED ON: 04/17/2024 TO PERFORM THE FOLLOWING WORK: REPLACE SIDING 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: /e4 - Fees Paid: S60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner ilk / I-' -- lki''-- , ' The Commonwealth of Massadhusetjs R d MUNI..IPALITY `,, Board of Building Regulations and Stg rds 6 �t724 FOR Massachusetts State Building Codei ,.780;1t �7N(��(n, / ,'USE Building Permit Application To Construct,Repair,Renovat@l M r�,j Revised Mar 2011 One-or Two-Family Dwelling 44 07 7/01vs t This Section For Official Use Only Building Permit Number: .6/2-01 41'415.3 Date Applied: 1401 NJ 74.5 ,// I-1-1I ZOZIt Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Prope'AHAsLu 317 t 1.2 Assessors Map&Parcel Numbers 1.1a Is thisan accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 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: Public Private 0 Zone: Outside Flood Zone? Municip4kOn site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: -Ae4)1,1 Mil tt2MqkJ IV )AM.P�13, )k411, d l o t,° Name(Print) City,State,ZIP 01(1"HAP-4)-1A (-- -e-n3- ;,;,,,9_0g)3 5ft-Afix) 511ttorpnr40400,4„, No.and Street Telephone EmailAddress SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s). Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': "RENAL-E. " Slni)O OAt - tt It i c'. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor d Materials) 1. Building $ 2-1a5 1. Building Permit Fee:$ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ x 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ ,,kiSuppression) Total All Fe Check No. Check Amount: bS Cash Amount: 6.Total Project Cost: $ 11 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1 D s- uL'N J STEED. teen a Number Expiration Dat Name of CSL Holder List CSL Type(see below) 3 c C0N 1> St No.and Street Type Description N��i�)/4A A�Al MA 0/O1 � U Unrestricted(Buildings up to 35,000 Cu.ft.) �C�(�f- !"[ f R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering •47. 1cw• WS Window and Siding 1 SF Solid Fuel Burning Appliances 1/3- Z_-D - tTyZ zfiv ch P11,44J/�Q I Insulation Telephone t Email addre Demolition 5.2 Registered- Home Improvement Contractor(HIC) 1/(�1.3 ,J410.12 �L.� �J 4i 1A J"A 1t�r"t u�1�l&� HIC Registration Number EDate H �Conrany ame or Registrant Name 4�N3- �L Z//VVJA()/ 4iiviieh t k-*Ng,. d Street Em ad ess / f,�Wl t� 0la(� �/3- Zo i 4c� City/Town,State, IP i Telephone / T- 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 . 0 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 44J 1N U)) CE ).D o000 LJ ' 4 r a,6"jl� to t on my b a , • all a elative to work authorized by this building permit application. tii tint wner's Name(Electr nic Signature) l I Date' SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this application ' true and accurate to the best of my knowledge and understanding. A� l ', 1-23 Print Ow "PT, Autho alif gent's lame - + . • Signature) Date NOTES: 1. • • • er 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" City of Northampton .(HAM O 5 •• S • 0 Massachusetts .p�S` X 'c,�! l It y: � I • '4' DEPARTMENT OF BUILDING INSPECTIONS ";41.- r' 212 Main Street • Municipal Building yJti CDC r-+' 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: The debris will be transported by: Name of Hauler: A2-01\k1 S �W)Nr67,\ Signature of Applicant: Date: / 1l)2) The Commonwealth of Massachusetts _,_ Department of Industrial Accidents ill' �i1= t Office of Investigations =ilola 1 Congress Street, Suite 100 _;�_1 • Boston,MA 02114-2017 .Mt www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Haydenville Woodworking & Design, Inc. Address:35 Conz St. City/State/Zip:Northampton, MA 01060 Phone #:413-665-7402 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 5 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 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. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any 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 affidavit indicating 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:A.I.M Mutual Insurance _ Policy#or Self-ins. Lic.#:WMZ-800-8007423-2023A Expiration Date: 12-1-2024 A Job Site Address: '26 614aL., S1 City/State/Zip:WA:-AtVlVPNt MA f Dlicel 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 certi nder the pains \I�penalties of perjury that the information provided above is true and correct. . , Signature: t. &(J Date: v Phone#: 41 657 02 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Roston,MA 02114-2017 Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 7-2013 www.mass.gov/dia THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Corporation Registration Expiration 110732 11/02/2024 HAYDENVILLE WOODWORKING & DESIGN, INC. ' Vi:i- ' r_ r „N ZINNIA STETSON 1c7-7 . ' 35 CONZ STREET - � a j16,04- NORTHAMPTON, MA 01060 Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, MA 02118 t i N t v d without signature r ff Commonwealth of Massachusetts Division of Occupational Licensure Board of Building ,,�Ra�ii ulations and Standards Const k oniS�visor 4 CS-116208 tpires:0411312025 ZINNIA WU SJETSON 1 HADFIELD RD -., ft ... SOUTH DEERFIELD MA 01373 i a i1 '�()f.tti. ,•13'i. Commissioner 10eQ.4 A'. 8t&.Jr.._ Construction Supervisor Unrestricted-Buildings of any use group which contain less than 36,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.govldpl A� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 03/13/2024 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 Hollie Kochapski NAME: Aquadro&Associates I(PHv�0No Extl: (413)586-7373 FA No): (413)584-0859 355 Bridge St.,P.O.Box 357 "AIL hollie©aquadroinsurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p Northampton MA 01061 INSURERA: Travelers Indemnity Co. 25658 INSURED INSURER B: A.I.M Mutual Insurance Companies AIM001 Duffy Willard Paving&Excavating Inc INSURER C: &Duffy Willard Trucking LLC INSURER D: Po Box 60137 INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: CL192609862 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 L1R TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DO/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN rED 300,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A 6800J976472 03/17/2024 03/17/2025 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ 1,000,000 _ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED BA1 R82809A 08/01/2023 08/01/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X ;MUTE OTH- ER AND EMPLOYERS'UABIUTY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E L.EACH ACCIDENT $ W . 1,000,000 B OFFICER/MEMBEREXCLUDED? N/A MZ-800-8006793-2024 03/17/2024 03/17/2025 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 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) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN HAYDENVILLE WOODWORKING&DESIGN INC ACCORDANCE WITH THE POLICY PROVISIONS. 54 WHATELY ROAD AUTHORIZED REPRESENTATIVE SOUTH DEERFIELD MA 01373 �tw ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD