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29-283 (12) 4 PENCASAL DR BP-2017-0637 GIS#: COMMONWEALTH OF MASSACHUSETTS Map: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) Cateeorv: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.Claggs: Contractor: License: Use Group; PROSPECT BUILDERS INC 056847 Lot Size(sq.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 0 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 11/7/20160:00:00 $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 Water/Well 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 1.1 Propgerty Address: This section to be completed by office I, Address: D9- - Map Lot Unit rco{LtNCF, . MA 0IOG'a Zone Overlay District Elm St District CB District SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: )C hJIQ Stcc len y Pc-wtAsvIc Dk Fk&trE m4 Name(Print) Current Mailing Address: v!3- aba ete Telephone Signature 2.2 Authorized Agent: TC't,Poer y /6S_'vo 2A/C . Ca) PFugPea Sr eigr(outfllCiaact, MI Ne Print) Current Meiling Address: CitCrfl 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 •'�� (b)Estimated Total Cost of d Construction from(6) 3. Plumbing / 5Th Building Permit Fee 00 4. Mechanical(HVAC) p,tO 96/sc f 5.Fire Protection �\ 6. Total=(1 +2+3+4+5) , 53J vc".5 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: 0 `^" � 7 NcV Z7(6 Building Commissioner/Inspector of Buildings Date SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs SCI Decks ID Siding EDJ Other 10 Brief ,Descr'6t'V7n of Proposed Werk: vovror 7&1oaRQY Moen • Paoli Wt+n-c fs* C SS &WS ?r'gaaD60 Fags% Thee a6c 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 constnimion. 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 I, ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1, P6%tJ (d eetei ,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. Print "7/76 Signature Signature of Owner/Agent Date SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervig)gr: Not Applicable ❑ ) Name of License Nobler: peA0 vkimC CA CGttS'05 ft l License Number 61)3 PisPt?e-r SrC'sr Gnirnenoow /ttjl dead" /0/31 1$ A ss 1 ExWiralion Date fjth .✓J tin- say= 3a Signature Telephone 9.R catered Home Improvement Contractor. Not Applicable Ci (&S?L aKe3 _IMS' /03c). Company Name Registration Number PO 7))ox 36.a C rLo*J6Mtano� el a SSOas GP))/C Address y� Expiration ate Telephone 90' -3al)6 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT{M.G.L.c.152,§28C(8)) 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 qr No U 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 fans structures.A person who constructs more than one home in a two-year period shalt 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 ofthe 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.Jf2P t(owviiwn.LUe(aeo ?gitaimachaela, y Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Massac : • 02116 Home Improvement a."rt". or Registration ==__ Rp4tratlon 100216 —7L7t c= I Type: Percale Corp018Eor1 y 5p1iration: 6/12/2018 TS 410201 PROSPECT BUILDERS, INC. =s`- — Donald LoMascolo -s=*l= PO BOX 302/660 Prospect St E. Longmeadow, MA 01028 S____.711._=_:=_- . ___� } �9air- Update Address cad return card.Mirk nesse,for champ. SCA 1 0 20 -stn — ❑ Address 0 Renewal 0 Employment C Lest Card rJAe%nw.onaa/KK4.1OJ raraei o gi Omee(Cessna Alain 4 anLmr Reguietion Liam or registration valid for individual am only y 'NONEaw CO171RACTOR hefen the expiration date. If band ren to: f� (I. Rsgwndon 18 TYPE Office°,Cnnmer A>fain and Business Regabtion / 8 Priate Coryora0on IO Park Playa-Sake 5170 r -7 �-, Being MA 02116 PROSPECT BU $ .� Donk LoMasSolo Ia i Pa BOX 303/660 ...\ - I' • E.Longmeadow.MA 01••: -�.... ' U jerat iary liedwmerttery Not valid wilhoolapatare 0: Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-056847 Construction Supervisor DEAN LOMASCOLOi 672 PROSPECT ST E LONGMEADOW MA 01028 • - l x CA__- Expiration: Commissioner 10/31/2018 i- .11 TEMPHOU-01 ELEONARD b.. CERTIFICATE OF LIABILITY INSURANCE DATE(23/201 -- 6 `� 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 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 CONTACT NAME: 1070Insur6uffieleStreeof t New England,Inc PHONNo Eo.(800243-8134 I FAX �+ci"IL ) LtAc.Nm:f413)731-9539 Agawam,MA 01001 ADDRESS: _ _ --__ INSURERS)AFFORDING COVERAGE , NN<I - _ INSURER A:Hanover Insurance Company 22292 INSURED 1NsuRERe:Commeree Insurance Company 34254_ Temporary Housing Inc DSC Properties Inc 8,Donald INSURER c Torus Specialty Insurance CoI LoMascolo - 660Prospect Street INSURER D,Hartford Insurance Company East Longmeadow,MA 01028 INSURER E: 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. ILSR. - - - POL)CY EFF POLICY Uri— TYPE - - - OFINSURANCE 11BR� I IMMIDDIYYYY) IDOPIYYI1 LIMITS SD WVD' POLICY NUMBER MMI A X COMMERCIAL GENERAL LIABILITYI E1,000,000 gCN O<CUREN RLE S �!CLAIMS MADE X I OCCUR IZHN809026504 01/01/201601/01/2017IrRgEMI$E ee) ``$ .. 1,000,001.. , I MED EYP(Any One person) I s 10,000 _.. _. ` PERSONALd ADV INJURY I$ 1,000.001 GENL AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE $ 2,000.000 POLICY I-PRO-i ' JECT 'L ILOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER. - _ I S _. I 'AUTOMOBILE LABILITYICOMBIINED SINGLE LIMIT 1,000,001 • IE rockier')_ B L ANY AUTO 1BCJJNT 01/01/2016101/01/2017 BODILY IWURY(Per se;sod)S - - ALL OWNED I.)X SCHEDULED . BODILY INJURY(Per accident)I$ _ HIRED NONDWNED I X �AUTOS I '_f ciaenII -AGE $ • • X I UMBRELLA LIAB I X OCCUR EACH OCCURRENCE '$ 1,000,44O C ~EXCESS LMB ' I CLAIMS-MADE i 67009L161ALI 01/01/2016101/01/2017 I AGGREGATE 1,000,001 DEM( I RETENTIONS 10,000 I -- $ 'WgMERS COMPENSATION I PER OTM .. AND EMPLOYERS'LIABILITY X STATUTE i ER { D 'An PROPreieR/PARTNEER R)EcuTIVE �INIIxrAII �6S60UB9905L86116 1101/01/2016.01/01/2017 rEL.EACH ACCIDENT $ 500,000 .OF'Mandatory In NH) —I I`L.DISEASE EA EMPLOYEE$ 500,001 Idepends under IO yes.RImpN OF OPERATIONS below irtEL.DISEASE-POLICY LIMIT ,$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES tACORD 101,Additional Remarks Schedule.may be attached H more space Is 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. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts —4,—— Department of Industrial Accidents )a-- = t Office ofInvestigations F*ISM; 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/OrganizationfTh' lndividual): iPOS-f-a V (-p c5F)jG j Address: 666 72c7$Peer s7 City/State/Zip: EAST- LOu o va,urt-new rid e Phone#:_ @i3 -c -P 5'611 Are you an employer? Check the appropriate box: Type of project (required): 1.al I am a employer with ti 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. 9 Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.[ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.9 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.9 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.9 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' I3.9 Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. [Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. //�/ � ",, Insurance Company Name: /Y" tirf-Fd R 0 D S''0Pfiivc$ crigoppv Policy#or Self-ins.s.Lic. #: ,%O Upp 4-9 OSLg6 1-1-6 Expiration Date: O�JO//i7 lob Site Address: f lGfnR,p/4L 7R. City/State/Zip:('urRCivct Ps 0/66,7 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 pal'5 and penalties of erjury that the information provided aboveris true and correct Signature: /, l �+.-/ (N"" Date: 1� /46 Phone#: Y�3 ' CalS r - } 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#: