42-125 , .
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PAGE 02/02
AWL
02/24/2012 08:09 4135271162
CITY OF NORTHAMPTON
Construction Debris Affidavit
in accordance with the provisions of MG.L. c.. 40 § 54, all debris resulting from any work
covered by a Building Peru* shall be disposed of in a properly licensed disposal facility,
as claAned by M.G.L. c.111 §
Address of Work:, r 4IP 4 Ith # 1
The debris will be transported , -0"
The debris will be receilatd at:
1 •
L-A A Are
/ 40
Dotte
Building Permit Number
_ .
01/25/2012 14:E15 14135675300 BERKSHIRE INSURANCE PAGE 01/01
A /^/^Yri 1 , - f � DATE (MMIDDIY•YY)
CERTIFICATE OF LIABILITY INSURANCE 1/25/2012
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 POUCIES
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 pollcy(les) must 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 NAME: CT ICaMaY P
Berkshire insurance Group, Inc. PP"rcON NE. Exl1: (419)935 -1200 1( .140: (413)567-r,100
138 Longmeadow St . ADDRESS. . kpeters @berkel irebaak. co
INSUREN3) AFFORDING COVERAGE NAIC N
Longmeadow MA 01106 INsuentA :Trave1er>3 Property & Caeua1 25674
INSURED INSURER13:G)ranite State Insurance Company 23809
AWL Maintenance Services Inc INSURER C:
-
52 Union Street INSURER D:
INSURER el
Easthampton KA 01027 INSURER -
COVERAGES CERTIFICATE NUMBER:11 /12 mast REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE K 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 1S SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR DL PQLICYEFF POLICY EXP
LTR TYPE OF INSURANCE tar wvn POLICY NUMBER IMMIDpd_Y_TYI (Ml QDM!YY) LIMITS
GENERAL LIABILITY EACHOCcuRRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY REMISEcs{Eaoccurran01_2._ 7.00,000
A fl OCCUR $80- 7.3.877895 10/27/201110/27 /2012 MED EXpjAny one peran) $ 5,000
PERSONAL d Abv INJURY $ 1,000,000
GENERAL AGGREGATE $ , 2,000,000
GENL AGGREGATE LIMIT APPLIES PER; ' PRODUCTS - COMP/OP AGG $ _ 2,000,000
i ► POUCY � r ! L00 $
AUTOMOBILE LIABILI WMBINE bING UM -- _(,aecldentl .. $ _1.000,008
A ANY AUTO BODILY INJURY (For person} $
ALL OWNED L D SCHEDULED BA 72079053 10/27/201110/27 /2012 BODILYINJURY(Paraccklent) $
S HIRED AUTOS
NON - OWNED PROPERTYDAMAGE $
AUTOS Ear accl anti .
ill PIP•Batac $ Ian
UMBRELLA LIAR II OCCUR EACH OCCURRENCE $
EXCESS LIAR III CLAIMS - MADE AGGREGATE $ -
_ , OE01 RETENTION$ $
B AND EMPLOYERS' O LIABILITY Y / N C IY I IANWS I i a _ vvORKERS
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100 000
OFFICER/MEMBER EXCWUDED7 LJ N I A
(MendatdryIn NC 009 -94 -3899 10/25/201.1 10/25/2012 E.LDISEASE - EAEMPLOYEE $ 100,000
If yes, c;:crlbe under
DES OF OPERATIONS baiow El. DISEASE - POUCY LIMIT $ 500 , 000
., ,
DESCRIPTION OF OpERATrONs I LOCATIONS / VEHICLES (Atl eh ACORD 101, Additions! Remarks Schedule, If morn apace Is required)
rob 1ocation:142 Glendale street, Northampton, NA 01060
CERTIFICATE HOLDER CANCELLATION
(413) 527 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BEE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS,
210 Main Street
Narthampton, MA 01060 I AUTHORI2EUREPRESENTATNe
Raley Peters /PETE1W
ACORD 25 (2010/05) IP 1988 -2010 ACORD CORPORATION. Ali rights reserved.
INS025 (201005)01 The ACORD name and logo are registered marks of ACORD
Print Form
The Commonwealth of Massachusetts
u
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114 -2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): W \ � ;� ( sL 7
Address: (4) k
ch op -7
City /State /Zip: ( 5 -"};1. Y ��1 611 Phone #: 2 13— / J , )
Are you an employer? Check the appropriate box: Type of project (required):
1. aI am a employer with h 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑ 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. 215emolition
working for me in capacity. employees and have workers'
g any p n $ 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. ❑ 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
employees. [No workers' 13.0 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: Ei (UY " (V°� c
Policy # or Self -ins. Lic. #: cO9 9 Expiration Date: / 0/2 ) ` j
t `
Job Site Address: 1 4 a- i ct �� °�- i City /State / Zip: No tz C Ytk (WOO
Attach a copy of the wor rs' 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 under the pains and penalties of perjury that the information provided above is true and correct.
J _'1 1-
Signature: I. �� a e E.I� f k ` r'c_/ Datef�
J
Phone #: •! (3— Q/ — /c7, »
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 #:
\1,1ss,o, iw,,'— H. , o :ii,. , •7 , , i'lli :-..0, !-..
li k....+ 0 Constructx.r, '-;,..Qr.! - f-se
00
ot=
fr Z i
i .
RICHARD KOLOSZYC
65 MAPLE ST
EASTHAMPTON, MA 01027
1/5/2014
• - 104039
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: I^ Not Applicable ❑ 1
Name of License Holder : P� t (�'m i A<) k,s z y / . �/ ot '7 e `� 1 /
License Number
60 5 /W 1 /C ) , �C�S /Xi) fcn, /1/67. 0A�� /'/ .� / o� /
Ad ss7 , / Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
iC1l ark G / o to sz y /4 7 702 7
Company Name Registration Number
/ / Ma I 17 le 11 arlce_ 2L)i / � n`20
Address / ` Z // z Expiratio ate
, 5 — c9 Of) % d n � / 1Y,, 5 /Ia/�/ J Telepho A/�� -5,0- /1 J�4
SECTION 10- 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 buildin ermit.
Signed Affidavit Attached Yes No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own 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 homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
01/25/2012 14:35 4135271162 AWL
PAGE 03/a3
TIO 65lin• nit . -
New KUM Ej Addition J Repineernennlndows Alteration(*) 1:3
Or Doors
Accassury Sidg. EJ Demolition 12( New Signs (L DecItS LE:1 Skiing !EX Other CI]
Brief Oasorlbtiq Procosed —
work! tvela rgerewAckA
(3X I 5
Alteration of existing bedroom Yes Jr, Ni, Adding new bedroom Yes
Attached Narrative Renovating Unfinished basement Yes No
Plans Attached Roll - Sheet
a. Use of building One Family Two Family (Zither
b. Number of rooms In each family unit Number of Bathrooms
c. is there a garage attached?
d. Proposed Square footage of new construction. Oimerislons
e. Number of stories?
f. Method of heating? FirepleCeS qr WOOdstetVell Number of each
g. Energy Conservation Compliance. Massoheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft of wetlands? Yes No. Is constructioi within 100 yr, floodplain Yes No
j. Depth 0 basement or cellar floor below finished grade
k. Will building conker% to the Building and Zoning ingulatiOns? Yee No .
I. Septic Tank City Sewer Private welt City Wolter &ply
tecnoN OWNER AUTRoRgatoR wit( BE COMPLETED WHEN
owNERs AOttr OR ooNTRAOtOR APPLIEs OORBUI.O410..PERMI1
ae Owner of the suplect
property
hereby authorize
to act on my behalf, in ell matters relative te worli authorized by this gaffing permit application.
al • rotor of Owner Date
-41111"
L _R( ,4,1e." , as OwnerfAuthorized
Agent hereby dada at th l:anent and information on the foregoing applicator' are true and acculate, to the best of my knowledge
and belief.
Signed under the pain nd penalties of perjury.
iiid
Print Name
[ Si r_2LL___Irtre neriA nt
daW
Ni/N1 3Ed 1-111H 1VdOIAVH3E C9BLZ8SETPT6 .:OT ZTOZ/9T/Z0
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO a DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO a
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO a
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO ei
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Q n
COI
C �_
01/25/2012 14:35 4135271162 AWL
jlE_CEIVED r PAGE 02/�
((�� .. 1 1 ��';a 9 e',t� +�� +'.ii' �Er���'j��� � 6WIr��7 ..�~ ;..,:r B I T City of Northampton "w � j r , �?s J f. A .. ; �_,.
Building Department fl G (P y rn
4 L , 7 e1 �'L+1 AM Y
212 Main Street h Y, '.',"..t.`..
��y{y '' �� /�� MA Crime J la '1
NORTHAMPTON. Roam 100 W I ) ` -r l ,,,..1 W - y 5„- '.':''''!' r r
Northampton MA 01060 . a .rr ,. /.) ^ . > . °..,' ' >,,;Vorl:....', : nn l i,. l
phone 413-551-1240 Fax 413-587-1272 0, `' , � h "
,,1� �N �� + +� J •? 7 C�� T J� � + � r
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO PAMLY DWELLING
SECTION 1 . SITE INFORMATION
1.1 Prpa��{tr �) s; • `�•ITwle:Seot;I+Qit• lo ‘"T • plete. • iS!
}
1 . G4 E Si Mip _. . A...... .":...... ",, :: , ,,unit:.,,,.,,
'(vd� 11 ma ,
�� C] S Q Roo �+r4 ' ah
' ww� ttlilt�t 5
'i ` `#t:.B'dt rtdt : 'CB b j+it . .. i.. .
SECTION 2 4 PROPERTY OWNERSHIP /AUTHORIZED AGEN`r
2,1 owner of Reord:
Name ?rant) A Current Mellir o 8 � I
e°� C� t u t o
Telephone `i
Author1zadpaeati
`I
i _ q( ' 1, +� n . k • : 1.I;►101t V
Name (Print) Current Mailing Address! 1 4:;
Signature Telephone
SECT IC1M 1- ES t4NI�A'1"Ed.CGaAT'I U[7l4"irI CID& .
item Estimated Cost (Dollars) to be aftlal Use Only
completed by permit applicant 5 .
a
1 ) . Bu1lding OO '(a) llulidlrig Peimit Fee
2- Electrical r , (b) Eatirttat&1 - Mal ,Coe of
(matt., lion tr m; e
3. Plumbing Building Permit Fee ga 4, Mechanical (HVAC) —
5, Fire Protection - ..
6. T010=0+2+3+44.5) Check NUrntrer / ..g .,,,, 20 -
'T it Section For Ofita 1 Use.Onit, , .. .
bath '
StiElding Permlt Number. • Issued_ , .. —
Signature, _ _ _ — -
Building ComMis51 let /Inepeatar of Bulldinge , bate
Z0 /T0 39 d HlTd3H 1VdOIAdH33 696LZ$56TbT6 56:0T ZTOZ /9T /Z0
File # BP- 2012 -0731
FAX be ] ..1 (2-c Acv r�
APPLICANT /CONTACT PERSON AWL MAINTENANCE SERVICES INC /- 1 ( 67.
ADDRESS/PHONE 52 UNION ST EASTHAMPTON (413) 529 -1936 S
PROPERTY LOCATION 142 GLENDALE RD
MAP 42 PARCEL 125 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ga �D
/k ,/i
Fee Paid
Typeof Construction: DEMOLISH 10 X 15 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 104039
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Peanut With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission - Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
142 GLENDALE RD BP- 2012 -0731
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 42 - 125 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit # BP- 2012 -0731
Project # JS- 2012- 001275
Est. Cost: $2000.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: AWL MAINTENANCE SERVICES INC 104039
Lot Size(sq. ft.): 37810.08 Owner: COMMUNITY CARE RESOURCES INC
Zoning: SR(100) / /WSP II Applicant: AWL MAINTENANCE SERVICES INC
AT: 142 GLENDALE RD
Applicant Address: Phone: Insurance:
52 UNION ST (413) 529 - 1936 WC
EASTHAMPTONMAO1027 - 0865 ISSUED ON:2/24/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: DEM OLI SH 10 X 15 SHED
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 2/24/2012 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner