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43-079 (5) 41DUNPHY DR BP-2018-1160 GIs#: COMMONWEALTH OF MASSACHUSETTS YU.Block:43-079 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Cateeorv: Buildine BUILDING PERMIT Permh# BP-2018-1160 Project# JS-2018-001113 Est.Cost.$181797.00 Fee: $1177.00 PERMISSION IS HEREBY GRANTED TO: Const Class: Contractor., License: Use Group: COMPLETE RESTORATION SOLUTIONS 103014 Lot Size(su.tt.): 15376.68 Owner: KLEKOTKA KAREN I zonine: Applicant. COMPLETE RESTORATION SOLUTIONS AT: 41 DUNPHY DR ApplicantAddress: Phone: Insurance: 30 HAYES CIRC (413) 592-2772 WC CHICOPEEMA01020 ISSUED ON. TO PERFORM THE FOLLOWING WORIGREPAIR WORK DUE TO FIRE - NEW WINDOWS, DOORS, SIDING, DRYWALL, KITCHEN CABINETS-"SITE VISIT/DESCRIPTION OF WORK REQ'D 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 a 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 Sienature: FeeType: Date Paid: Amount: Building $1177.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Seg ¢�ti aC File#BP-2018-1160 APPLICANT/CONTACT PERSON COMPLETE RESTORATION SOLUTIONS T4 r b ADDRESS/PHONE 30 HAYES CIRC CHICOPEE (413)592-2772 PROPERTY LOCATION 41 DUNPHY DR MAP 43 PARCEL 079 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST OSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TypeofConstruction: REPAIR WORK DUE TO F -NEW WINDOWS DOORS SIDING DRYWALL KITCHEN CABINETS AjoTE ^ sta is) I / p6$C(LIF,10 1 of. 'mric P(RT New Construction Non Structural interior renovations Addition to Existine Accessory Structure Building Plans Included: Owner/Statement or License 103014 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 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 Demolition Delay Signatureof�g Official Date/ r 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. IVE D ity of Northampton f� uilding Department ) a E ' 11i1I1 ",3 �,;. ..• 212 Main Street Room 100 } k fill rthampton, MA 01060 - x; 41 587-1240 Faz 413-587-1272 -aF ;x '•s MA APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 'IsacUonUj tM gompktad by office 1.1 ProoerriAddress �, j p ..Map�1.-•.v.,L�'�u.��7 Unit 41 Dunphy Drive Yong Ovartay�Diaulcr Elm SL DIW40 CB,OIsMct SECTION 2-PROPERTY OWNERSHIPIAUTHORIPED AGENT 2.1 Owner of Record: Karen Klekotka 41 Dunphy Drive,Florence, N4A 01062 Name(Pln . CurrentWiling Address: 413-2103789 Q do}W y Telephone Signature 2.2 Authorized Agent: Complete Resmmti Siu[ions.Inc.30Haynes Cir.Chicapee.MA01020 Comple[e Res[oraion5ulutions,Inc.30HaynesClr.CM1iwpeq MA 01020 Name(Pont) 4Q rjQQ Current Mailing Address: Complete Resto2tion Solutions,Inc 30 H ynes Cir Chicopee,MA 01020 Signature Telephone SECTION 3'-ESTIMATED CO RUCTION COSTS Item Estimated Cast(Dollars)to be Oficial Use Only, completed by permitapplicant 1. Building $181,797.19 (a)Bullding'Permd Fee 2. Electrical (b)Estimated Total Cost of Construction from S 3. Plumbing Building Formal Fee 4. Mechanical (HVAC) 11-7700 S. Fire Protection 6. Total=(1 +2+3+4+5) $181,797.19 Check Number ill 09AIr This Section For Official Use Only Date Building Permit Number: Issuatl:. Signature: Building Commisslonerllnspmterof 6uiAings Data Kob @ EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 De,ancro l Lot Size Frontage __.. Setbacks Front " ' '-� - Side L R:!_ L>. R- - Rear -- - - -- Building Height --� Bldg.Square Footage Open Space Footage % p.ot ema minus bide&pa,el erkin 9 fParking Spaces Fill ,amme&mn„tinn - -- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW O YES O IF YES: enter Book Page' and/or Document At B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued C. Do any signs exist on the property? YES ® 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 O IF YES, describe size, type and location: F. 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 O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S DESCRIPTION OF PROPOSED WORK foheck all aodicable)' New House ❑ Addition © Replacement Windows Alteration(s) 51 Roofing d er Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding(0) Other II71 Brief Description of Proposed Hepar woh ro exisfing home tram fim. To wclude,repleoement wlndoxz,doors,sldWg,drywall,kimhen cabinets Work: Alteration of existing bedroom_Yes ' No Adding new bedroom Yes x No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet on.':N Now house and or addition to axial ta'h3 the 4N1owMa: a. Use of building :One Family X Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? J. Proposed Square footage of new construction. Dimensions e. Number of stories? 2 f. Method of heating? eleciT)C Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction X i. Is construction within 100 ft.of wetlands? Yes X No. Is construction within 100 yr. floodplain You No j. Depth of basement or cellar Floor below finished grace 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 propert Complete Restoration Solutions, Inc. hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature ooff Owner Date I, �'omPie,t2, V n^Q lUd /1'{I!`YI.S �� • as Owner/Authorized Agent hereby declare that the sG rnents antl information on the foregoi g application are true and accurate,to the best of my knowledge and belief. Signed under t e and penalties of perjury. Print Name Signature of Owner/Agent Date SECTION$-CONSTRUCTION SERVICES' 81 Licensed Construction Supervisor: Not Applicable 0 Name of License Holds, Joseph Gillette License Number 6 Shady La e, est Sitnsbur CT 06092 CS-103014 Address Expiration Date ` 04/30/2019 Signature I - Telephone 413-592-2772 9.Realstered Kdme:Improsiment Cotdrectorc Not Applicable 0 Company Name c l �,t Registration Number O'cMoiky, ' e ra�iLx1 1`DIL" e . 164927 Address �— I Expiration Data Uuyney G�rG�P. Ch'�oo FLA 4/ laphpna d 12/1/2019 SECTION 10•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,5 25C(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.......QP, No...... 0 City of Northampton F Massachusetts 1 DEPARTt OF BGZZ.OZNG INSPECTIONS ]i? Wein SC e • aun>.eal spBuilding ' S Necthampton, NA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstmetion,alteration, renovation,repair,modemization, conversion, improvement,removal,demolition, or construction of an addition to any pre-existing owneroccupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:Ifthe homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: S , Est. Cost: Address of Wok 41 hilnohe YV � F16C4nU, MA dW I Dare of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): lob under SI,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAIN INC THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION-. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: �ornnlett2es�dt�hbn rS�cr�u� mS �ThC . IG'-19� 7 Date 'ammeter Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusettssr->. ✓< <2 O ARTNRNT OF BOILOZNO INSPECTIONS vi 212 Nen. Stmt • Nwicipal building � hOi NOrt6a tm, NA 01060 ✓--:ijh Massachusetts Residential Building Code Section 110.R5.L2 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. Section I10.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 1 I0.R5,provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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 thejob 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Empensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganintioNlndividuap: Complete Restoration Solutions, Inc. Address: 30 Haynes Circle City/State/Zip: Chicopee, MA 01020 Phone #: 413-592-2772 Are you an employer"Check the appropriate box: Type of project(required): 1.2 I am a employer with 15 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. [:] Building addition [No workers' comp. insurance camp. insurance.: required.] 5. ❑ Weare a corporation and its 10.❑ 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.[31 Other Repairs from fire comp. insurance required.] Any applicant that checks box 41 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 aM than 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-conametars and state whether or not Nose entities have employees. If the sub-contactors 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: Zurich Insurance Services Policy#or Self-ins. Lia #: UBOG26388 Expiration Date: 9-1-18 Job Site Address: 41 Dunphy Drive City/State/Zip: Floren, MA 01062 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, w well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day a ainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ofd he A for insurance co era e verification. I do hereby certify a de t d alties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 413-592-2772 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#: ALi O® CERTIFICATE OF LIABILITY INSURANCE oMZ2018 THIS CERTIFICATE IS ISSUED ASA 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 pollcy(les)must have ADDITIONAL INSURED provisions or be en0orse5. If SUBROGATION IS WAIVED,subject DO the terms and contliBons of Me Policy,certain policies may require an endorsement. A statement on this eetificate does not confer rights to the certificate holder in lieu of such endom mengs). PRODUCER Get CIOBka B.Ne ilnsurance Noxw EAN ((3)586-5011 a°c Xu: (137596]9]3 88 King Street,Suite B a6gRFe , gCf'ab'Z— maWabnmurence.com aIAFFwwING.ONEIRi NAII NGM.Inni MA OIW-3257 INSURERA: Admiral lnwlance CoTFeny notlet. INSURER e: ZuriGh Insurance SBNima ZUR001 Complete Restoration Solutions Inc. INSURER c-. Hanover 22292 30 HaMee Circle IrveuRER O: NSVRER E: Chkopae MA 010M INSURER 1.. COVERAGES CERTIFICATE NUMBER: CL1781503892 REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE IN9URE0 NOMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANOING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILm TYPE OF INSUMNCE INSID enu PMICYNUMMR MMI00/YWYPAIDEDWOOL CONNERCNL 6ENEP.LL LPBILItt EACH OCCURRENCE UNITS3 1,DUg000 <IAIM6WBE 19OCCURPREMI6E6.cv— a 300,000 X CPL MED IXP IMYwGnJ a 5,000 A X Professional Liability FEI-ECC-23980.00 OIC8I2017 0812812018 PER6oNALe AOVRLU Y $ 1.000,000 GEN'LAGGREGATE LWnAPPLIE6 PER GENEPALAGGPEGATE $ 2,000,000 LICV ®°ECT EJ— 5 2000,000 Teens Poll Llab $ 1000000 AUTOMOBILE LIABILITY (��INE�EI 6INGLE LIMIT E ANY AUTO BODILY INJURY IPx Poleonl $ OWNEDSLHF➢VLED BOBILV INJURY IFx JOfne $ Au�HIPED NYNIT06 NOTo GNLE PVARGE $ TGa°NLv PmaoaWM x UMBr£LN IJAa x C OECUR Di OCCURRENCE 1 5000000 A FEI-EXS-23881-CG OBORCO17 081282018 AGGREGATE E 5.80,000 DEO RETENTION$ S WOgI(EgS CONPENyTCN PER OTX AND EMPLOYEF$'LNBNTYYIN A. 1,C00000 B ANY FFICE YSETO PARENECUTIVE O UBOG2630B 091011101] 091012018 EL EACH ACCIDENT E INa.aneym No EXCLUDED' LOVEE I$ 780,000 11 A M ee EL DISEASE ES EMP 1aDO Doo DESCRIPTION OF OPERATIONS Eekw E L DISEASE POLICY LIMIT S Bailment Coverage C RHN96595102 082812017 082812018 Des$11100 $3500011 BESERIPPONOFOPERATICNIOLOCATONSINE14ICUM(AWMtO1.Mftoul RAnu 6ftMCUN.mLyWW MGUmomsy., '.I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of NOrLhani ACCORDANCE WITH THE POLICY PROVISIONS. 212 main Street Suite 100 PIONGEE NEPPESENTATNE n NOMairri MA 01000 01MB--2a�00111555 ACORD CORPORATION. All rights Reserved. ADDED 2B(201&03) The ACORD name and logo are registeretl marine of ACORD City of Northampton 14 // Massachusetts c 3 is .3 DSPART.dBNT OP BUILDING INSPECTIONS Pij/j 1' Y 212 in St "t *B icipsl Building Bacthm tnn, N 01060 Debris 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. The debris from construction work being performed at: �I I dun dh�x (Please print hou a nu er and street name) Is to be disposed of at: �Ioly�a iranamkn (Please print name and lowuon of facility) Or will be disposed of in a dumpster onsite rented or leased from: a I Lt��Name Ad—d-1) (Companyres r Signature of Permit Appl of or Owner Date If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract affair. express or implied,oral or written-" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual.partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be i m employer." MGL chapter 152,¢25C(6)also slates that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,g25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till not the workerscompensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)aame(s),address(es)and phone number(s)along with their cerrificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also he sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Sclf-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact yon regarding the applicant. Please be sure to fill in the permit license number which will be used as a reference number. in addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under`Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel.#617-727-4900 ext 7406 or 1-977-MASSAFE Fax#617-727-7749 Revised 02-2115 www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity.or any tura or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of.individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three ap rtments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer" MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pernrit/license number which will be used as a reference number.In addition,an applicant that must submit multiple perma/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit most be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston,NLA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia conn ocosrd 02-23-15 �%�,Q ��n�rzo�ruvncz�z o�'G>G�activaP,C�a Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement`Cnfltractor Registration Type: Corporation COMPLETE RESTORATION SOLUTIONS,INC. Regxpration; 164927 30 HAYNES CIRCLE Eapiration: 12/01/2019 CHICOPEE,MA 01020 update Address and Ralura Card. sone 8 uiu-ovn - HOW E IMPROVEM AXalna a CONTRACTOR HOMEIMP )(pe;CfRCONTRACTOR Regrethe piratindar . Iffovalid far Irwilvidual uanardy lu TYradlan lDJlaEXI before theeapuraerntlate. arod Butrass to: Realabakan izoi=19 10 PmbWa-S er Aeaire arM auslnesa Regulation 16092] 12/01p019 10 Park Plaza�Suds 5170 COMPLETE RESTORATION SOLUTIONS,INC. Eoatan;MA 02116 JOSEPH GILLETTE C .-- 20 HAYNES CIRCLE CHICOPEE.MA 01020 Undersecretary N t van Ithout signature massacnusetts Department of Public Safety Board of Building Regulations and Standards License: CS-103014 Construction Supervisor JOSEPH M GtLLM B SWIOY LANE WEST SHMSBORY 4p,111111W Expiration: ' Commissioner "Maelll 5/2/2018 Northampton,MA:Residential Property Record Card Northampton, MA : Residential Property Record Card [ Back to Search Results] [ Start a New Search ][ He Q with Printing ] Search For Properties Parcel ID Name Street Name DUNPHY DR • Search Reset Parcel ID Card Map-Block-Lot Location Zoning State Class Acres 43 -079-001 1 41 DUNPHY DR 101 -n/a 0.353 Owner Information Property Picture Klekotka Karen] 41 Dunphy Dr Florence MA 01062 Deed Information Book/Page: 4269/283 Sale Date: 1993/08/06 Dwelling Information Living Units: 1 Style: Cal/Gam Story Height: 2 vera Exterior Wall: Frame Attic Living: None Basement: Full Year Built: 1975 Ground Floor Area: 840 Unfinished BSM Area: 840 Fin BSMT Living: 0 Tot Living Area: 1680 Rec Room: 0 x 0 Tot Rooms: 7 Bedrooms: 3 Full Baths: 1 Half Baths: 0 Has Fire Place 0 Frame Fire Place 0 Heating Type: Basic Valuation Land: $81,900 Building: $67,800 http'.//www.nodhampton.unber clt. omlvie _properly_R.php?acceunt_no=43%20-073001&series card=l 113 5/2/2018 Northampton, MA:Residential Property Record Card Total: $149,700 Sales History Document No Date Prim Type Validity ate 1993/08/01 $118,000 land + Bldg N Permit History Date Purpose Price Out Building Information Type Qty Year Sisal size] Building Sketch Desafotoi/Aiea A:2Fr/B 840 sglt B OFP 36 20 sell 4 4 4 CDFP 16 sell 24 21 840 G B 4 Notice The Information delivered through this on-line database Is provided in the spirit of open access to government information and Is intended as an enhanced service and cdlveroedce for btlzens of Northampton, Ilk The Frovitlera of this database: CIT, Big Roam stndlos, and Northampton, MA assume no liability for any ei or or onusslon In the information pro,sp,d here. http/lwww.nodhampton.universait.WM/viewyroperty_R,phplacwunt no-43%20-079-001itserus_cartl=l 2/3 5192018 City of Northampton Mail-41 Dunphy Drive "'A, aly or Louis Hasbrouck<Ihasbrouck@northamptonma.gov> ftinfimmiquillort 41 Dunphy Drive 1 message Louis Hasbrouck<Ihasbrouck@northamptonma.gov> Wed, May 9, 2018 at 12:49 PM To: Rob Balicki <rob@mycrsinc.coni rob@mycrs.com Cc. Kim Carson <kcarson@northamptonma.gov>, David Gardner<dgardner@northamptonma.gov> Rob, Before we issue the building permit for 41 Dunphy Drive, we want to meet with the contractor at the house and get a detailed write-up of the work. Call the office and set up a time to meet. Louis Hasbrouck Building Commissioner City of Northampton Town of Williamsburg (413) 587-1240 office (413) 587-1272 fax httpsllmail.google.comimaillcelull l?ui-2&ik-ec5fl9a57e&jsverawrW bOFcFs.en.&cbl=gmai l_fe_180429.15_p3&view-pt&search=sent&th-18345cece70Rfde&s