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38B-166 30 FORT ST BP-2017-0013 GIS a: COMMONWEALTH OF MASSACHUSETTS Man:Block: 38B- 166 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit a BP-2017-0013 Project JS-2017-000028 Est. Cost: $20000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: isGall TOSHI KASHIMA 060134 Lot Sae(so.ft.): 8363.52 Owner: BORYCZKA THADDEUS M&PATRICIA Zoning:URB(100)/ Applicant: TOSHI KASHIMA AT: 30 FORT ST Applicant Address: Phone: Insurance: 15 UNION ST (413) 774-5402 Liability GREEN FI ELDMA01301 ISSUED ON:7/8/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE ROOF SHINGLES, REPAIR 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 k 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 7/8/2016 0:00:00 $100.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner i/. 04 Department use only tk. E1 City of Northampton Status of Permit: - 1 ` is Building Department Curb Cut/Driveway Permit Cj C¢n 212 Main Street Sewer/Septic Availability'a sA. Room 100 WaterNVell Availability ore xo Northampton, MA 01060 Two Sets of Structural Plans e phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING I SECTION 1 -SITE INFORMATION `G/ 1.1 Property Address: This section to be completed by office 30 ( o t± obi— Map Lot Unit N.b R O"" Zone Overlay District ` Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT J2.1 Owner of Record: r7 -QatMU'R Ret C Z KA Name(Print) Current Mailing Address: Telephone signature 4-k3- 3a.Oct oc9 2.2 Authorized Agent: pp�� v x� : i. , o V-y1Y 4 , tovi Name(Print _ Current Mailing Address: I - - A. u13 -d?I -30 a Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee W .el: C' 2. Electrical (b) Estimated Total Cost of Construction from(6) 3 Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number i 0 . I 'in This Section For Official Use Only / Date Building Permit Number de �,. Issued_' /�7 Signature. d��/eit�!//� / �!1` �� Buil g omm loner/Inspectorr of Buildings Date •Section 4. ZONING AU 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 Side _... . .. . . Frontage _. .. Setbacks Front Side L: R __. . L: .. R: Rear Building Height Bldg. Square Footage Open Space Footage (Wt area minus bldg&paved Pulsing) R of Parking Spaces .__ _.. Fill: _. (volume&Location) _......_ __. ._.. .. ._.... A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES Q IF YES: enter Book Page and/or Document Yr B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and Location D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q 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 Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing R. Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [CI Siding M Other[DI Brief Des rrp n of Proposed Work': 43eQ (Looe Cd ute.. A ,' A112 SI OI Alteration of existing bedroom Yes ?e--, No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement YesX No Plans Attached Roll -Sheet ea. If New house and or addition to existing housing, complete the following: a. Use of building: One Family Two Family Other E Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? tl. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade 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 AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT �AJ'td y.�✓ l//�-Lf/ as Owner of the subject property ,{�, / / �(� hereby authorize [ LA-06 LP < ��ac/ion my behalf, in all matters relative to wor/<author) by this building permit application. GGlhter:Trf ' / a iBneWre of Owner Date r TI . 1 ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains ti f pellu Print Na j e 4� / � krw7l,.' L., yyy""444,, 7 Signature of Owner/Agent Date JJ� • SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: yn� /'� Not Applicable £ /-/�fn Name of License Holder C ae31 `t' w at 61 c `�v (3 License Number 1.1C LX O \ -Qtralefigg (27aN IVe) ( Addre Expiration Date -e2 LT (3 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable £ ( tea, l(1/ o C CompanyyName Name Registration Number CJNZmA I( 1t �7' Addres ti Expiration Date Telephone L� (‘ SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.G.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 £ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwelling&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 �ti The Commonwealth of Massachusetts rte..-. Department of Industrial Accidents ,..:=7,-; Ii Office of Investigations 1* = _ W 600 Washington Street =4,.„, r/ Boston, MA 02111 =; '" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �,/ APlease Print Legibly Name (Business/Organization/Individual): � c3(µ �)�-g,"tlS ja.v-i � Address: t 5 V vk,� 0n 5-i--- j.,_ Qi City/State/Zip: (cusp AtCc Qt/) Phone #: 4(3 -c - —t7 i "` Are you an employer? Check the appropriate box: Type of project(required): 11.2%2 am a employer with a— 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction listed on the attached sheet. 7. Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.H I am a homeowner doing all work officers have exercised their 11.n 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.E Other comp. insurance required.] *Any applicant that checks box at I must also fdl out the section below showing their workers'compensation policy information. rHo mcowners 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: f ce fin. K ,yn5' . 02 . Policy#or Self-ins. Lic. #: rrim6 g 170 y 7 C 3 V y Expiration Date: 7-D-0 ' / C W Job Site Address: -50 "T 5+- City/State/Zip: k[mN leve Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi ation 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 SI,500R0 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 violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby,cardf under the pains and penalties ofperjury that the information provided above is true and correct. Signature: //It / Date: 07"0S—/ lj Phone#: 4'I n) 322' it l 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#: City of Northampton Massachusetts ss y 111 ((pE ��.xr DEPARTMENT OF BUILDING INSPECTIONS , , � p«.+" • 212 Main Street • Municipal Building \`�IY►f Nor Champ ton, MA 01060 sbnLL> '"yj INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which ' he/she resides or intends 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 home owner." J The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes(before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected, If the homeowner hires other trades to perform work (electrical, plumbing &gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location 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: So covt4 S�1 The debris will be transported by: IKA Ti-uctton The debris will be received by: Building permit number: Name of Permit Applicant —ToS , V-t4.t^-k.wi / (yj Ai C( nr'/ Date Signature of Permit Applicant ACTORDATE 1MIADDInv'0 —' �� CERTIFICATE OF LIABILITY INSURANCE 5/5/2016 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 poli y(ies) 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 rtifi:3[e holder in!icy of such endorsemertlei. PRODUCER CONTACT Tracey Kuklewicz • A.H. Rist Insurance Agency, Inc. PHONE (413)863-4373 INC xo.TINA INC Nm-4131053=vfisx 159 Avenue A ADDRESS" I P.O. Box 391 _ INsysER)SI AFFORDING COVERAGE I Turners Falls MA 01396 INSURER :Phoenix Insurance Cancans; 256.23 o T-_ INSURER R: 1 _.,ornaru Kasha ma INSURERc. 15 UNION STREET INSURER o, 'I i I SURER e: GREENFIELD AfA 01301rvRER F. COVERAGES CERTIFICATE NUMBER:2015 CERT N REVISION NUMBER: T14S IS TO CERTIFY rHAT TILE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NC RMTI1STANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO pMICH LI :'. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. MP INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS PALO JSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. HEE 311SVVC POLICYPILIPOLICYEFF POLICY EXP T __. 1 TVP {qGR WV INSURANCE ONMaE0. 1MLIIDDIYTYYI IMPIogIYYVYI LIMITSS F f _ I� AeL IY P 11 L R r b S 30 00 I A I_ l .DOD- `$i OCCUR 68070420340 7/20/2015 7/20/2016 MED EYP IAD; rrs 5 0'0 1PERSONAL DV INJURYS 1,000 0O0 r _G NI v cO .fATF s 2,000;DISC AGGREGATE LIMIT APPLES PER BROMIC IS OIPOP AGO I 5 2.000 1001 1—RHOI7 LCC eI 120 IFCT j p ILITY 1 001101515118-NGLEJAC/ LITr BOD:LY INJURY pespn) 1.1 r SCHEDULES) ) 6J JV 5 _ AUTO' c ONO !E➢ . Rtt0 tA.£ TO D .Ha EACH ECCE 1 EXCESS Ila sMAEE e L I, _. - F 'ON I 1 _.. 1 I WORKERS 12.01.11.Ery soar aN o- I 1o4 - EMPLOYERS'LIABILITY No,, _ T t T R • t E CLGO - elarealopy in -❑ NIA I LE C SE EAEMPLOYEE/ 1 .,RLR 'ePn. L TJ I POLICY T 1i I I IDES nry LION OF OPERATIONS I LOCATIONS I vnnCLES reach ACDRD 101,Aed,NON.I Remarks smmvm,of mow na Ce is r,er reee ;Classification: Carpentry • CERTIFICATE HOLDER _ CANCELLATION (978)544-1138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Orange ACCORDANCE.WITH THE POLICY PROVISIONS. C 135 East Main Street 111 Orange, MA 01364 AUTHORIZED REP RESENTA INE Tracey Kuklewicz/DNP f -_:.-0--, 9 I=.e R--. - GATE 1MMmDNYYYi ACORO® CERTIFICATE OF LIABILITY INSURANCE 05/95/2016 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 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 NAMeaCT Dakota Coughlin A. H. RIST INSURANCE AGENCY INC PHOImic E„). (413)863-4373 ARINC.Nal: _. aooees5dakota�lo ahrist.com P.O.BOX 391 INSURERISIAFFORDING COVERAGE _ NAIL TURNER FALLS MA 01376 INsuRER A'. LIBERTY MUTUAL FIRE INS CO 2303.5_ IxsuREo INSURER B: TOSHIHARU KASHIMA INSURER C: 15 UNION STREET INSURER E. .._. - _. GREENFIELD MA 01301 INSURER F COVERAGES CERTIFICATE NUMBER: 50284 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 ADOLIsLBP - - POLICY EFF POLICY EXP R L TYPE OF INSURANCE INSO WV] POLICY NUMBER IMMIDDtYYYv1 1MMNDM'YYI LIMITS COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE _ 5 CLAIMS-MADE OccuR 'O GE ORE-TED I MED _ rent) S MEXP( echo ) i5 N/A PERSONAL AGGREGATE LIMIT APPLIES PEOGENERAL AGGREGaTE I S JF OC EC - - _ !LOC PRODUCTS-COMPIOP AGO _ OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 - I BODILY INJURY LY NJl Iv IPer When)!— en $ OWNEDALL - -SCHEDULED --.-. _ - _ 4uros . AUTOS N/A BODILY INJURY(Per amdenen)Is .IEOAUTOS NON-OWNEDi PROPERTY DAMAGE AUTOS ,O'er&cadent) UMBRELLA LIAO OCCUR ! ! 11 EACH OCCURRENCEFIs EXCESS LIAB C __ N/A AGGREGATE $ RED (RETE 5 I WORKERS.AlYCOMPENSATION LII X STAT TEJ Rµ EMPLOYERS' IRTYIN; 100,000 A OFFICER/MEMBER ne EXCLUDED? wA'wA MA WC23153]605]026 03/2312016 03/23I2017 ' Me4nI EL DISEASE EA EMPLOYEE S IgoBaB Janine OF OPERATONS — below E' L.DISEASE.PDucvuMlT s 500,000 N/A ;VEHICLESDESCRI (ACORD 101.Az Remarks Schedule,may be attached If awn space is remand/ WorkerrsCompensation benefits will be paid 10 Massachusetts employeeslonly.Pursuant to Endorsement WC 2D 0306 B.no authorization is given to pay claims for[tenet IIS to employees in slates other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy In force on me date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this cerliricate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search ool at www_mess_gov/Iwdlworkerswmpens atioNinvestigationsl. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of OrangeACCORDANCE WITH THE POLICY PROVISIONS. 135 East Main Street AUTHORIZEDREPRESENTATIVE ( ' Orange MA 01364 Daniel M_Crow)ey,CPCU,Vice President-Residual Market-WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. GCr1Rf1 95/>nt41n1\ The ACORn nn ma and Innn a re.anistarad marks of ACORD