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23A-005 (16) BP-2024-1222 36 MEADOW ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23A-005-001 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-2024-1222 PERMISSION IS HEREBY GRANTED TO: Project# INTERIOR DEMO Contractor: License: Est. Cost: 37000 VLADIMIR AGAPOV CS-060134 Const.Class: Exp.Date: 1 1/04/2024 Use Group: Owner: PATRICIA KYLE, Lot Size(sq.ft.) QUALITY CLEANING AND RESTORATION Zoning: URB Applicant: SERVICES Applicant Address Phone: Insurance: 72 MONTAGUE CITY RD (413)774-7737 7PJUB 0G09579-24 GREENFIELD, MA 01301 ISSUED ON: 09/23/2024 TO PERFORM THE FOLLOWING WORK: INTERIOR DEMO DUE TO FIRE DAMAGE 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: 77--P Fees Paid: $277.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner UEj 14 The Commonwealth of Mass chus tts SEp ,, Board of Building Regulations . d St ndards 1 9 2024 FOR Massachusetts State Building C de,3, M ICIPALITY N oRr � USE Building Permit Application To Construct,Repair, - °t �"b• '• ised Mar 2011 One-or Two-Family Dwelling "'A (- ?Ns This Section For Official Use Only Buildin Permit Number: d P' A,4" 13L Date Applied: eti„� » /72 9-2.3-2v2.y Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 36 Meadow Street,Florence MA 01060 23A-005-001 1.1a Is this an 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 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Alexandra Carlson&Patricia Kyle Florence MA 01060 Name(Print) City,State,ZIP 36 Meadow Street 305-484-0564 patriciaekylecrimlaw.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) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other El Specify:interior demo Brief Description of Proposed WOrk2:Interior demo of fire and water damaged ceilings,walls,floors,cabinets,fixtures. Demo all to studs. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $37,000.00 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All F $i Suppression) Check No. P Check Amount: A71 Cash Amount: 6.Total Project Cost: $37,000.00 ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-060134 11/4/2024 Toshi Kashima License Number Expiration Date Name of CSL Holder List CSL Type(see below) u 15 Union Street No.and Street Type Description Greenfield MA 01301 U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-522-1713 kashimabuilders©yahoo.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 188432 10/26/25 Vladimir Agapov,Quality Cleaning and Restoration HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 72 Montague City Road info@qualityrestoration.com No.and Street Email address Greenfield MA 01301 413-774-7737 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 . 12 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 Quality Cleaning and Restoration to act on my behalf,in all matters relative to work authorized by this building permit application. See attached authorization 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. Patrick Locklear 9/19/24 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" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton rit r s e . s,c .. Massachusetts w�l5I_ c'ct1 * c' w� :N r DEPARTMENT OF BUILDING INSPECTIONS T ?J 212 Main Street • Municipal Building y0 _ c�" Northampton, MA 01060 ,S,,, ;,:)‘'� 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: Valley Recycling,234 Easthampton Road,Northampton MA The debris will be transported by: Name of Hauler: USA Trucking Signature of Applicant: 3-t-ruZi Date: 9/19/24 The Commonwealth of Massachusetts 14�°` Department of Industrial Accidents 1 Congress Street,Suite 100 '~=i'r — Boston,MA 02114-2017 rl www:mass.gov/dla l orkers' Compensation Insurance Aflidas it:Builders/Contractors/Electricians/Plumbers. ru HE I-11.1:0 11 I al I LIE PERMMi TiNG AtriHORiT1'. :%tinlicant Information Please Print Lc ibis Name tt3usinessalrganrzation.Individual►: Quality Cleaning and Restoration Address: 72 Montague City Road City/StateZip: Greenfield MA 01301 Phone##: 413-774-7737 Are you an employee Cheek the appropriate bat: Type of project(required): 1.®1 am a employer with 18 __errrploy+eea tfoot and'or part-fume)_' 7. 0 New construction =a I am a woe proprietor or partnership and have no employers working for me in S. 0 Remodeling any capacity.[No workers:'comp.inaunmor requmxil 10 I am a humsewner doing all work myself.(too workcns'corm.Insurance required.)' 9. ❑Demolition 10 Q Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on no property. I will ensure that all cvntraturs either Lase workers'compensative insurance or are sole 1 1421 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 50 lam a general contractor and I base hired the sub-contractors fisted on the attached sheet 13 Roof rye stirs These sub-conrztors have ernployeesand Lase workers'comp.rawer � nterior demo 6.0 Nye are a corporation and its officers have excised their right of ex.emptsost feet MU.c. 141®()t}!t'Y 1 S'. Ii4).and we base no employees.(No workers'ceanp.insrnvnce ra.yuin:d.l 'Any applicant that checks boat set must also fill out lire section below showing the31 .',.n s.l: • .iiiFk•uSaiion policy information o Huaneowuera who submit this affidavit irtdieatimg they are doing all work and then hire outside contractors mina submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet show rag the MUM e of the sub-contractors and state whether or riot those entities have employees. tf the sub-contractors have employees.they must provide their workers"comp,policy number. 1 am an employer that is protidin workers'compensation inttrunce feir mr emploree+. Below is the policy and job site information. Insurance Comp;>sty Name: Travelers Insurance Company Policy#or Self-ins.Lic.#: 7pjub0g9579-24 Expiration Date. 6/19/25 Job Site Address 36 Meadow Street, Florence MA 01060 City/State/Zip: Attach a copy of the worker's'compensation police declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to SI,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 S250.00 a day against the. t iolator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage s crtlieation. 1 do hereby certify fr under the pains and penalties of perjury that the information provided above is true and correct. Si_mature: .l G.c./2.42 3-1 Date: 9/19/24 t . 413-774-7737 Official use only. Do not write in this area.to be completed by city or town official ( its or loss: Permit/License#ti Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.('ity/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector i h,Other ( untact Person: Phone If: AcoRO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) L....../" 08/09/2024 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 EA/M ktto,Est): (A/C,No): 355 Bridge St.,P.O.Box 357 ADDRESS: jenn@aquadroinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURER A: Quincy Mutual Insurance Co 15067 INSURED INSURER B: Travelers Insurance Company Quality Cleaning&Restoration Inc. INSURER C: 134 South Shelburne Rd INSURER D: INSURER E: Greenfield MA 01301 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1571006761 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMJDD/YYYY) (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ O CLAIMS-MADE pi OCCURPREM (RENTED PREMI ESSES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY piPRO- JECT E LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED v SCHEDULED Y AFV206793 12/30/2023 12/30/2024 BODILY INJURY(Per accident) $ AUTOS ONLY ^ AUTOS X 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 X STATUTE ERH AND EMPLOYERS'LIABILITY , ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1.000,000 B OFFICER/MEMBEREXCLUDED? n N/A 7PJUB OG09579-24 06/19/2024 06/19/2025 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 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) DKI Ventures,LLC,its subsidiary companies,and its and their respective officers,employees and agents are added as Named Additional Insured to the Commercial General Liability, Commercial Automobile Liability,Follow Form Excess/Umbrella Liability and Contractors Pollution/Environmental Liability Insurance with respect to liability arising out of ongoing and completed operations performed by or on behalf of the Named Insured. 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 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Quality Cleaning& Restoration,Inc. ` 72 Montague City Road QUALITY' Date: 9- >-a 2--1 Greenfield MA 01301 Restoration 413-774-7737 I info@qualityrestoration.com EIN: 45-4127163 FIRE •' ' -77" STO f MASSACffUSE3' POST-LOST ASSI N ENT OF INSURANCE RIGHTS & DIRECTION TO PAY Policyholder: ; Adjuster: Phone Number: 0 — Ins.urance.ConiP,any: N. Property Address: y C3( 4T Claim Number: • ' Date of Loss: Email Address: r Type ofLoss: 4. y ` 1. Irrevocable Post-Loss Assignment of Policyho�s' 1 is Against Insurance Company To Contractor: By execution of this irrevocable Post-Loss Assignment of Insurance Righfs'and Direction of. Pay ("Asi`gnment"), the policyholder(s) identified above ("Policyholders") completely, irrevocably, and fully assign and transfer to the Cong:actornamed above all of the Policyholders' legal and equitable rights, title, and interest under all insurance policies arising from claims for the damage Contractor was hired to address (collectively referred to as the "Assigned Rights"). The Assigned Rights include without limitation the rights to collect insurance policy benefits and proceeds, and the right but not the obligation to participate,in appraisal of the loss or the portion of the loss in which Contractor is involved. The Assigned Rights include without limitation the Policyholders' rights as a fast-party insured under the Policyholders' policy of insurance, the right to sue the insurance company to enforce the Assigned Rights, and to prosecute any applicable causes of action for breach of contract, breach of the implied coven*of good faith and fair dealing (insurance bad faith), fraud, and negligence. This Assignment shall be liberally construed to the full At extent permitted by law and so that Contractor is deemed to stand in a first party position as to the policies.The Policyholders shall remain obligated with respect to all duties and liabilities under the terms of the insurance policies, including the duty to properly d cument all claims and cooperate with the insurer's investigation. Contractor owes none of those duties..This Assignment may only be evoked by written notice to the Contractor after:the contract is terminated in writing,but is permanentlygrrevocable as to work performed before the contract is terminated. ,/ 2. Exclusions: •Nothing in this Assignment shall be construed as an:assignment of other parts of the insurance claim that are unrelated to Contractor's scope of work, such as additional living expenses,the value oflost personal property. or services pe`rrfoimed after Contractor's services are terminated.Nothing in this Assignment shall be construed as a delegation of duties. ,{ R;. 3. No Conditions: The Policyholders agree and understand that this Assignment and each of its componer�t pap are irrevocable. The Policyholders expressly aclaiowledge that it is the Policyholders' intent to assign the Policyholders' ins llance ip olicy rights and benefits under the claims to the Contractor as explained above. The Policyholders agree and understand that. ure'ocable Assignment is unconditional and effective immediately upon execution of this document, and that no further action nkedi tb be4aken to make it valid,enforceable, or binding upon the Policyholders and the Policyholders'insurance company. r y ,� 4. Cooperation: The Policyholders shall cooperate fully with Contractor's efforts to enforce tht Assi tied rights, and to collect policy benefits. Policyholders agree to execute any and all documents presented by Contractor to the Policy;olders, which are reasonably required for the prosecution of Contractor's claims against the Policyholders' insurance company an or its agents with respect to the Assigned Rights. 5. Direction to Pay: The Policyholders hereby authorize and instruct all insurance carriers wil.',"rmay lie liable to the Policyholders for this loss in whole or in part to pay directly to Contractor the amounts due or to become duejfi connection with the work Contractor has been authorized to perform, and to deliver said payments directly and exclusively to Contractor within fifteen (15) calendar days of the invoice. In the event an insurer fails to name Contractor on any check for the Work,.the 11olicyholders shall immediately notify Contractor in writing, and return the check to the insurer with a written request to the insurer to issue a replacement check payable to Contractor. 40 6. Security and Consideration: This Assignment is given to Contractor as security and is made in consideration for Contractor's agreement to perform services without immediate full payment from the Policyholders upon completion of services. The Policyholders acknowledge the sufficiency of this consideration. •7. No Release: The Policyholders remain primarily and ultimately responsible for payment for services rendered by Contractor. This Assignment does not relieve the Policyholders from the duty to compensate Contractor for any amount due to Contractor that is not paid by insurance, including the cost of the work, deductibles, betterments, depreciation and other amounts not paid by insurance, all of which are ultimately the Policyholders'responsibility. Quality will try in its good faith discretion to ensure that its charges for services will be the amount authorized and paid by available insurance.However.Quality does not and cannot promise this. Late charges of 18% per annum shall be charged on late payment and I shall be obligated to pay Quality's reasonable attorneys' fees necessary for collection. "Po 'cyholder"(I Rea this and understand it.) 1--Ty.,..Acci..r s.seigu V::::t. Signature. Check one: er nPolicyholder's Agent Print Name and Title