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31A-229 II i r , !' EE 3 ! i 3 r f ri I p��e�p Proposed Y14ork E I h .0'"' Proposed Y14ork i i i i Proposed Yllork r -_ Imo- . 1 � aa1 t y f ES e" t Xsjw k15-i(N tl�o M , b f�N Proposed Nork F Vq pkq lbQJlV(ovz, a�rmp" 7!s at�1 T � 339 l M i 7� P _ n m � � a � t a. MEN Ll- 9�4- ) m � s �C w 7 EAT(t� The Commonwealth of Massachusetts Pant Form Department of Industrial Accidents =T Office of Investigations I Congress Street, Suite 100 1 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): Barron & Jacobs Associates, Inc. Address: 70 Old South Street City/State/Zip: Northampton, MA 01060 Phone #: (413) 586-8998 Are you an employer? Check the appropriate box: - Type of project(required): 1. f-]I am a employer with 11 4. I am a general contractor and I 6 �w construction employees(full and/or part-time).* have hired the sub contractors 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_ E] Demolition working for me in any capacity. employees and have workers' g E] Building addition [No workers' comp. insurance comp. insurance. required.] 5. F-1 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 LF0 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' 131-1 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. ZContractors 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. Webber & Grinnell Insurance Agency, Inc. Insurance Company Name: p Policy#or Self-ins. Lic.#: WMZ 800-8006365-2015A Ex irationDate: 3/1/201(0 �' l Job Site Address: �N N �I�11� vz NiO,11MPtM MFG City/State/Zip: OID60 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 hereb cer ' under the ins and enal o er'u that the in ormation provided above is true and correct Si ature: _ _ ._ ___ __ _ _ __ __ Date Phone#: ���✓ 5$6.�t1°I$ 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#: A °� CERTIFICATE OF LIABILITY INSURANCE 2/18 TH91 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATWELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF MMIURANCE DOE! NOT CONSTITUTE A CONTRACT BETWOM THE ISSUNO pNiURER(i), AUTHORIZED REPRE31ENTATNE OR PRODUCER,AND THE CERTIFICATE HOI DSt 11101PORTAN : 6 ft csrttOmc holder is an A00MONAL MUNW,the poicyoft)must be endorsed. M SWROOATION•WAIM,wbjsd to the/arms and corAdons of to Policy,osrton policies my rww1m an sndorwnant. A stdwwr t on this o6rtlfleab doss not can(w rights to the eartificaM hokbr in bw of such andem Lal. PwoDWER Laura Canaan WokaDar i Grinnvil (413)S94-0113, 590-64e1 S North King Straat lvsaaaaiwbbor inaall.oaa RNROMM AMOOPM NAM:6 No ton MA 01060 I AMA 9LrZW INWRED I .I.K. Mtual Barron i Jacobs Assoc. Inc. IfMI~C Attn: Cocil R. Jambs I 70 Old South Straat I Iia n M 01060-3533 COVERAGES CERTFICA NUMBER,-CL1521602750 REVNNM NUM6ER: THIS IS TO CERTIFY THAT THE POLICIES Of INSURANCE LISTED BELOW HAVE BEEN k SUED TO THE MISURED NAMED ABOVE FOR THE POLICY PERIOD M OICATIED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY OONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUWECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE Of INaURANCE MIMM 122=1 ma POLICY 1111.111101111 UM" awwo AL t.10a " EACH OCCa OWNICE S 1,000,0001 7C COMMERCIAL GENERAL LIABIUTY S S00,00 A CLAMS-MADE ITLI OCCUR 0490 /9/2015 /9/2016 MEO Ems, son _S 10,000 PERSONAL a AOV SIJURY S 1 000,00 GENERAL AGGKGATE 6 3,000,000 GEN9 A0QREGATE LIMrT APPLIES PER: PRODUCTS-COAMPRN'AGG S 3,000,000 X POUCr LOC 6 AUTOM011MLE UAM3 L"Y A ANY AUTO SOIALY INA P . lRY P.p..w> S ^_. 2 ALL AUTOS ED X SCHEDULED T0049D /3/2415 /9/2016 SMILYINx1RY(Pvomklwt) ,_ AUTOII HIRED AUT06 A j0 ® i LjS UMIIRELLA LIAM OCCUR EACH OCCURRENCE 6 A EXCESS UAH CLAM amw I AGGREGATE S HOMIXIMIRMs 10, 4fc 19/2015 /6/2016 S momma mmm"TION ANa tMPLarm UMNLtTY O .-------- ANY PROPRIETORIPARTNERIEXEICUTIVE NIA E.L.EACH ACCDEW OFFICENMEMSER EXCLUDEC» Iri..i.arx a00c36s012015A /1/201s /1/2016 I" E,L.DMSEASE-EA EMPLOYE 9 522,000 es,d..crin.unlur +r I M OF QffRATIQ-n E.L.DMSEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addttioriat Remuks Schedule,If more space Is requirad) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Informational Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE M Horan, CISR/LAURA ACORD 25(2010146) ©1988-2014 ACORD CORPORATION. All rights reserved. INS025 oninnF;ni Tho Af`nPn nom&and Inn^era rania aranri marks of Af r1Pn Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: C340 WS ♦L j/F CHRIS'TOPHBR 1 ZFA /r 70 OL©SOUTH ST s NORTHAbtP" ; N'j Expiration Camtissboner 11/1012016 1.-6943 u} Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 100809 Type: Private Corporation Expiration: 6/23/2016 Tr# 254618 BARRON & JACOBS ASSOCIATES, INC. Cecil Jacobs 70 OLD SOUTH STREET NORTHAMPTON, MA 01060 Update Address and return card.Mark reason for change. Address ❑ Renewal F] Employment Lost Card SCA 1 0 20M-05/11 Vf�e�o�rr�mao�r�t�secr,�G�i o�C�s.�cec�zuae Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: V gistration: 100809 Type: Office of Consumer Affairs and Business Regulation p1ration: 6/23/2016 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 BARRON&JACOBS ASSOCIATES„ INC. Cecil Jacobs 70 OLD SOUTH STREET NORTHAMPTON, MA 01060 Undersecretary Not valid without signature SIGNATURES By signing below,you agree to items A,B and C. DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES. A. Alternative Dispute Settlement(Arbitration Clause):The Seller and the Buyer hereby mutually agree,in advance,that in the event of a dispute concerning this Agreement,the parties shall submit such dispute to a professional,state-approved arbitration service(cost,if any,to be paid by the submitter)prior to either party proceeding to legal action in the courts. B. By signing this agreement,you,as the owner of record,are hereby authorizing Barron&Jacobs Associates Inc.to act as your authorized agent in all matters pertaining to the building permit application. C. This is a binding Agreement. You may not cancel it except as stated. This Agreement covers and supersedes all conversations,statements and agreements,expressed or implied,between the parties,their agents or representatives. ti V "t 117 01 e t You,the Buyer,may cancel this transaction Buyer �j Date at any time prior to midnight of the third '��� CtIl 2- t business day after the date of this transaction. See the attached notice of cancellation form Buyer Date for an explanation of this right. Seller retains an equal right to cancel. �Z / Barron&Jacobs Regresp6ative D e Designer/Salespersons Registration Numbers ❑ x Cecil R.Jacobs MA HIC 100809 ❑ Christopher R.Jacobs MA HIC 100809 CT HIC 0518617 CT HIS 0554397 Barron and Jacobs-Key Personnel Contact Information: Office Cell Home Office Manager: Sandy Scavotto 413.586.8998,x100 Vice President and General Manager: 413.586.8998,x103 413.250.6677 413.665.9113 Chris Jacobs President:Cecil R.Jacobs(Jake) 413.586.8998,x101 413.250.2327 Purchase Agreement Page 27 of 27 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: IJ A� The debris will be transported by: �7-RU The debris will be received by: \ { Ln� Building permit number: Name of Permit Applicant Date Signature of Permit Applicant SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �,{���C Not Applicable ❑ Name of License Holder: C.NN� y`� N�R s All fi `'� ����` License Number 90 OLD 50,* Sjkr r. k abN 1hPWM , I tllo laot 6 Address Expiration Date 5ta.89q$ ignature Telephone 9.Restistered Home Improvement Contractor: Not Applicable ❑ lcoso I Company Name Registration Number SARRW 4 kOBS /-ssoCl Oes WC. COV-DO4 6 Addressc�j� (, Expiration Date /v 06-^ c) OUTL4 ST I `y� )W`► N Telephone 13 586,M II 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 buil ing permit. 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ De olition ❑ New igns [O] Decks [Q Siding[p] Other[O] Brief Description of Proposed Work: ReMODELVwng uotAift W V-kL eM4,M%*4 Lekwe 84W()M-ft( 01 LD CUACT,%Ww2 Vel" 0P W M. 00 , 1 S'11% txs eft t BkS�w Alteration of existing bedroom 7��Yes No Adding new bedroom Yes ,\—, No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.if Now house and or addition to existing housing, complete the following: a. Use of building:One Family_ Two Family Other t3�w b. Number of rooms in each family unit: ) Number of Bathrooms ExtSll�6. c. Is there a garage attached? ET*"44t""T-), d. Proposed Square footage of new construction. No G DimensionsMO �- �� �' as SF• �7�JC"� t.�bVsG. e. Number of stories? 03/A 41?,6& ter.1� f. Method of heating? wywu(,-FOB.go NOr Uk%R. Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 40017 PRANCE i. Is construction within 100 ft.of wetlands? Yes -'X,No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade 4/ `O�, k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer. Private well City water Supply SECTION 7a-OWNER AUTHOR ION-TO BE COMPLETED WHEN OWNERS AGENT �nOhR(CONTRACTOR � APPLIES FOR BUILDING PERMIT I, I"►HJ�It f�Jl/1I V as Owner of the subject property p�/�,�II o/ fc j hereby authorize fi7�UN a 'TTV0 /!-���+' W, to act on my behalf, in all matters relative to work authorized by this building permit application. S22 TM(AC 29 Of 9� ^n 'A ►IfM e A I Signature of O ner Date I, as Owner/Authorized AgeInt hereby declare that the st nts and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and pe ies of perjury. Print Na I Z--J Signs ure of Owner/Age t Date 6/ Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information MW 31k„aa$9 Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size 13/of SGt Gh. N��- 00 WN61R5 wo Frontage !'S`. WAN613 Setbacks Front a All Side L: _ R: L: R: Rear a► Building Height SHAW-N0 04WQ5. Bldg. Square Footage 1,3 95 N.'$ 0 SArr �o�W Open Space Footage 7 l (Lot area minus bldg&paved parking) ,`1b/ b O2,r. C�} Sp rTO(,NW{ #of Parking Spaces SuN�z-��I;u1ti �� Ste-R(a�4M�21 Fill: (volume&Location A. Has a Special Permit/Variance/Findin ever been issued for/on the site? NO ® DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the ee istry of Deeds? NO O DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 6 DON'T KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO 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 © NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only' h , ,� ,,-T--- ity of Northampton Status tiff Perm: uilding Department Garb CuvDrivwway Permit . 212 Main Street Sewer/Ssptt AvallAb P Room 100 WaWNVv#A No hampton, MA 01060 Two Sots of 4utstut* . 1 87-1240 Fax 413-587-1272 Plo #ePler►s Electric,Piumeing&GT "d Northampton, MA 01060 �� APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office U1"r H PAR I.SON NA I NAN Wpw 1 M Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: N � N�Hth ft"'Mo—SIN fl&RR15W AV� ,NOINM ON,MR Name(Print) Current Mailing Address: , eft ,a�dp o�7,n a�1�21>ien} C��}ur�►Qa) Telephone C u�3 3�►� ' ��J ' Signature 1 `I 2.2 Authorized Agent: rlo OLD 1!-r. WCjtt1 M9raN , N� Name Print) Current Mailing Address: �1�3 $ro-$9�$ ignature Telephone SECTION 3-ESTIMATED C S UCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building v {+ / (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing -�8• C� Building Permit Fee 4. Mechanical(HVAC) J 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number � J r This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0376 APPLICANT/CONTACT PERSON BARRON&JACOBS ADDRESS/PHONE 70 OLD SOUTH ST NORTHAMPTON01060(413)586-8998 PROPERTY LOCATION 24 HARRISON AVE MAP 31A PARCEL 229 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out J Fee Paid Typeof Construction: REMODEL BEDROOM TO FULL BATH REBUILD CLOSET DEMO WALL& INSTALL BAEMENT FLOOR JOISTS New Construction Non Structural interior renovations Addition to Existing Accesses Structure Building Plans Included• - Owner/Statement or License 60475 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit 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 D Signa of Building O icial 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. 24 HARRISON AVE BP-2016-0376 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A-229 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2016-0376 Project# JS-2016-000613 Est. Cost: $29913.00 Fee: $195.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BARRON & JACOBS 60475 Lot Size(sq. ft.): 9321.84 Owner: MARKOSIAN NED&NAHID Zoning URB(100)/ Applicant: BARRON & JACOBS AT. 24 HARRISON AVE Applicant Address: Phone: Insurance: 70 OLD SOUTH ST (413) 586-8998 Workers Compensation NORTHAMPTONMA01060 ISSUED ON.912412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL BEDROOM TO FULL BATH,REBUILD CLOSET, DEMO WALL & INSTALL BAEMENT FLOOR JOISTS 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 9/24/2015 0:00:00 $195.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner