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29-283 (11)
4 PENCASAL DR BP-2017-0637 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:29-283 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: TEMPORARY TRAILER BUILDING PERMIT Permit BP-2017-0637 Project# JS-2017-001031 Est. Cost:$5350.00 Fee: $96.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PROSPECT BUILDERS INC 056847 Lot Size(sa. ft.): 12806.64 Owner: SLOCOMBE DONNA L Zoning: Applicant PROSPECT BUILDERS INC AT: 4 PENCASAL DR Applicant Address: Phone: Insurance: P 0 BOX 302 (800)486-4976 Workers Compensation EAST LONGMEADOWMA01028 ISSUED ON:II/7/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:PROVIDE TEMP MOBILE HOME WHILE HOUSE IS BEING REPAIRED FROM TREE 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: 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 11/7/2016 0:00:00 $96.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck--Building Commissioner Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 waterANell Availability Northampton, MA 01060 Two Sets of Structural Plans 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 SECTION 1 -SITE INFORMATION 7.1 Property Address: This section to be completed by office 11 P LAsAL 7t • Map Lot Unit FLoREN . MA 0106-r) Zone Overlay District Elm St District CB Diseict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: DawA Stowstrj 1] PCijCAsgc Dt Poactri 014 Name(Print) Current Mailing Address: via- ,atia• e/ ) 6 Telephone Signature 2.2 Authorized Agent: T& - PoM uy ( S_AIG 2&C. 6() f PocPoa Sr ce96'r-(outneo-ocu 6411 Na Phnt) Current Mailing Address: Qt Gat 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 • 2. Electrical •f()0 (b)Estimated Total Cost of d Construction from(6) 3. Plumbing )57 Building Permit Fee 4. Mechanical(HVAC) .[U/g 96700 5.Fire Protection 6. Total=(1 +2+3+4+5) .153S-0citCheck Number This Section For OKcial Use Only Building Permit Number: Date Daed: Signature: (/`^ `— 7 a v lolc Building Commissioner/Inspector of Buildings Date SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. 0 Demolition ❑ New Signs [O] Decks [p Siding EDI Other tj Brief Descry ttpn of Proposetl Work: _ YKO VLpc T o2nRY n'l0 ' Awe Win/ eking SS &z- u6 'k=PArno mcoe Alteration of existing bedroom Yes k No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing. complete the following: a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. 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 i. 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 ,as Owner of the subject properly hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date I, P&\ -) Cd i4-As s ' ,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 and penalties of perjury. tn4.ajd.sw Print ,Gt-t- 1,//6 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: 1o4J 1dievim co CS- 056 gj'tf / License Number 6c) ?ks/ir 5r sr (cruGnme -00ev NI ot®d8 /01311)g A en / Expira ion Date etieti Signature Telephone 9.RIstered Home Improvement Contractor: Not Applicable 0 t%sPa 2 5uZ2-06.gs _we /0o01/6 Company Name Registration Number PD 7)6x 1d,.) &ST-LnuGWILMOo--J MN &oat G /a ie Address � Expiration ate Telephone 1//3'c>s'3dy/Q 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 building permit. Signed Affidavit Attached Yesrt No 0 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 C;? 2e Wo w 1P/Ifeziotackaa Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massac 02116 =- HomeImprovement s'' . tor Registration Registration: 100216 *= Type: Private LOCDotellon Expiration: 6/122018 Tr/ 419291 PROSPECT BUILDERS, INC. -- Donald LoMascolo • = � PO BOX 302/660 Prospect St ='r t— E. Longmeadow, MA 01028 0 ( r "6ir Update Addrns ad retire card.Mut Rases for etaage. D Address 0 Renewal 0 Employment 0 Lost Card SCAo e1AOSS/ d2e irbistAlanwealig gfafl,.,.aaL..,,a 4.` Mee ofCo..mn Again t B.men Retalem Haase or registration rated kr halvahs]ase only y HONE IMPCONTRACTOR Defer lb.expiration date. If food rehire to: f. !` Rpyeadon: . cg Type: OmeeofCwamR Affairs sod 11ei n 11. ahfbn \. - =- _0 Private Corporation 10 Pare Plea-8alte 5170 i "' pr Boston,MA 02116 PROSPECT BU Ela , ai Dank loM.seolo n-_;. .I. E.Longmeadow.MA 01026-z,.a= Undersecretary Not valid witbeot signature V.. Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-056847 Construction Supervisor pyy DEAN LOMASCOLO ^ ' 672 PROSPECT ST E LONGMEADOWMA� 01028 1Z CA-- Expiration: Commissioner 10/31/1018 i.a., TEMPHOU-01 ELEONARD .a`�ixo• CERTIFICATE OF LIABILITY INSURANCE DATE Y, 5/23/2016 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 AFFQRDED 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 CONTACT NAME: Insurance Ce StreN New England Inc PHONE No.EMI:(8.00)243-8134 - 'FAX xo):(413)737A539 -- Agawam,MA 01001 ADDRESS: _ INSURER(s)AFFORDING COVERAGE NAGS INSURER A:Hanover Insurance Company 122292 INSURED INSURERS:Commerce Insurance Company _ 34754 Temporary Housing Inc DAC Properties Inc&Donald MSURER O:TOrls Specialty Insurance CO LOMescolM INSURER D,Hartford Insurance Company 660 Prospect Street - - - -- East Longmeadow,MA 01028 INSURER L _ - iNSURERF: - - • � - COVERAGES CERTIFICATE NUMBER: 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 POLICYEXP -- -- - - LTR' TYPE OF INSURANCE INSOI WND POLICY NUMBER I(MMIDDHWY) (MNNOMryY) LIMITS A , % COMMERCIAL GENERALLIABILm EACH OCCURRENCE $ 1,000,011 I I - I CLAIMS-MADE X I OCCUR IFHN899026504 101/01/2016 01/01/2017' PREMISEsjEa occurrence) E 1,00%0011. _ _ I , MED EXP(Any one person) I$ 10,011 PERSONAL 6/WV INJURY $ 1,000,001 GENLAGGREGATE LIMIT APPLIES PER HENERAL AGGREGATE I$ 2,000,001 POLICY f,i PRO- CTT r LOC 'PRODUCTS-COMPNPAGG $ 2.000,001 �'OTHER: I I 1$ I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,001 B I ANY AUTO BCJJNT 01/01/2016101/01/201] BODIL wURY(Per perso) '$ - .ALL OWNED SCHEDULED -• �. AUTOSREDAUTOS �BODI TYDAMNJURY Per accident).$ X HIRED AUTOS I X AUTOS LIPo caen�_._ — X UMBRELLA LIAB X I OCCUR I $ EACH OCCURRENCE '$ 1,000,001 C nI EXCESS LIAB CLAIMS.MA°E IB7OO9L161AL1 01/01/20161 01/01/2017 LGGREGATE yg 1,000,001 r DED 5 c TRETENTION1 10,000 I - ,$ _. I WORKERS COMPENSATION '.PER •D4 I AND EMPLOYER;LIABILITY I % STATUTE IEP D ANY PROPa ETDRIPARTHEREEcunvE ! �, xIAI I6S6OUB9905L86116 101/01/2016101/01/2017, EL EACH ACCIDENT $ 500,000 OFF CERMEMBER EXCLUDED' - - IManWtorvinxx IEL.DISEASE-EAEMPLOYEE IS 500,001 :II ESORIONOE N �EL.DISEASE.POLICY LIMIT $ 500,001 DESORPTION OPERATIONS baba,OE DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be MYCNed B more space M required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Verification of Insurance Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 624.441:-OrrH/RAHL. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents mar-cr.— , C gel.- Office of Investigations E_i ;_ 1 Congress Street, Suite 100 • _"�z�= Boston,MA 02 114-2 01 7 .� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information // ''-- Please Print Legibly � Name (Business/Organization/Individual): ( hPo3g44 V ('pu5fici6 E/3-,C _ Address: an 7imPce-SST City/State/Zip: && L.6u6 vx,tgnc c'- 04 d°2-Phone#: y 9/ (3 - 3-1 " S"t 1 Are lyou an employer? Check the appropriate box: Type of project (required): I.al I am a employer with L/ 4. ❑ 1 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 S. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. p Building addition 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 ❑ 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. tContractors 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: 741-Kik uP LIM S' r1 Iin/CC (001440 Policy#or Self-ins. p Lic. #: 6sCCO U R i 05/46 ' Expiration Date: 0//Of/it/ V Job Site Address: 75i't i-Sti-L PR. City/State/Zip:tux/L(Nc i /yIl 610 6,7 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 ce under the pai and penalties of erjury that the information provided above is true and correct. Signature: // - 7Y�/G�} Date: l(/)46 Phone#: 4r3 ' C s J(�O ! 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#: