13-101 (9) City of Northampton
: .
Massachusetts
G
.. DSPARMENT OF BUILDING INSPECTIONS y,
212 Main Street *Municipal Building
Northampton, MA 01060 �SNyy `h1
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:
0, 0 601-es /&a.Wo cxj mar
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facilitJl"�
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
k�� /4�1 /
o d
Signature of Permft Appli4ffint 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
a I Congress Street,Suite 100
Boston,MA 02114-2011
www mass govldia
Workers'Compensation Insurance Affidavit:Builders/ContractorslElectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): ell, 44-ZZ d&MM-44t
ur�c�s
Address: //T Main A&W
City/State/Zip: /—R. 4l/S G Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.[311
uaam a employer with `7 employees(full and/or part-time).* 7. New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in g. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.[:]l am a homeowner doing all work myself.[No workers'comp.insurance required.]r
10[]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t 14..-0th6@r ! t
6.F1Weare a corporation and its officers have exercised their right of exemption per MGL c. L.t
152,§1(4),and we have no employees.[No workers'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.
1Contractors 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: o-, f• /j/J /�rti— � 1060—A-Ae.e 49
Mudt0,7
Policy#or Self-ins.Lic.#: ��PW, e— '141—���f+�7 004 n!LeAExpiration Date: /V �lL 41
`�'(/f
Job Site Address: r�` 5 A0,IIygdtCity/State/Zip:��
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expition date). j,,PAIld
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: A OAO /11;t 401
Phone# �—
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#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A'I'M' Mutual Insurance Company
54Third Avenue, Burlington, Massachusetts 01803-0970
(000)876~2765 NCC|NO26158
POLICY NO.
PRIOR NO.
ITEM
1. The Insured: Kelly K4Kapinoa
DBA: Ace Chimney Sweeps
Mailing address: 115 Main Blvd FEIN:°°'~°°8598
Ludlow, M&U105@
Legal Entity Type: Sole Proprietor
Other workplaces not shown above:
2. The policy period isfrom 10/08X2018 to 108X882019 12:O1a.m.standard time o1the inounod'amailing address.
3. A. Workers Compensation Insurance: Pan One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers' Liability Insurance: Patt Two of the policy applies to work in each state listed in item 3.A.
The limits oiliability under Part Two are: Bodily Injury byAccident $ 10O0Q0each accident
Bodily Injury byDisease $ 5OOU0/ policy limit
Bodily Injury by Disease $ 100000 each employee
C. Other States Insurance: Coverage Replaced byEndorsement VVO2003O68
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premiumforthispoUoywiUbndaterminndbynurNYonuoisofRu(es.Qanaificodons. Rahosand0coingPlaon.
All information nequieedbelow iesubject tuverification and change byaudit. .
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 000362813
INTER SEE CLASS CODE SCHEDU-E
Minimum Premium $259 Total Estimated Annual Premium $1.970
Deposit Premium $2.081
STATE CLASS StateAssessments/Surcharges
MA 1 9014 1
*1.605.00x3.8200% $81
__
This policy, including aUendoraemor�u.iahereby countersigned by "�^�--'� 00202018
Authorized Signature Date
Service Office: VVhdeJubinviUo}no Agcy Inc
54 Third Avenue POBox 789
Burlington MAO1803 South Hadley, W1AO1O75-O78S
VVOOOOOO1A(7-11)
Includes copyrighted material mthe National Council mnCompensation Insurance,
used with its permission.
4 Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home improvemWZentractor Registration
Type: Supplement Card
Registration: 118355
JOHN KAPINOS Expiration: 03/01/2019
D/B/A ACE CHIMNEY SWEEPS
115 MAIN BLVD
LUDLOW,MA 01056
Update Address and return card. Mark reason for change.
SCA, w 2OM-01111 0 Address 0 F ertewaf 13 Emttfoymaa-0 Lost tard
a /4e "cr�rrr �rrnce��t�rflcr,r�cfu� /l
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:SuoDlement Card before the expiration date. if found return to:
aggWr to ion Expiration Office of Consumer Affairs and Business Regulation
118355 03/01/2019 10 Park Plaza-Suite 5170
JOHN KAPINOS Boston,MA 02116
D/B/A ACE CHIMNEY SWEEPS
KELLY KAPINOS
115 MAIN BLVD Not valld<hout signature
LUDLOW,MA 01056 Undersecretary
Division of Professional Licensure
Board of Building Regulations and Standards
ConstrUcttbn'Supervisor
CS-108647 Moires: 08/07/2020
STEPHEN KOZIOLa E
87 BARNA STRf ET
LUDLOW MA 01$56
Commissioner
V""
ACE CHIMNEY SWEEPS
HIC MA#118355 CTO0544835
LUDLOW,SMA 31056 5354
(413) 547.8500
Cynthia Suopgis _- ._ .. 695-43157
120 Coles Meadow old.. _ Same
#stamp on,MA-01060 _ Same
Same
5" UL Listed Stainless Sleet Chimney Liner wfth Lifetime Warranty:
1-20 Forst Owl 48000
Rem,a,,able T ee prat} `rout
1--ee Cover 36,00
1-, _S z efra Cotta oeluxe,Cap 1 5 D
1- ,�Iearaut Door 85 DO
1- kiisc Matenal 2500
-1,006,1M SUSTOTAL-
- 85,00 Dscovnt Pmmpa€d Inspecton
- 50 00 eritor sDotint
8 00 Pelt
+ 50000 LABOR
$ 1,4 51.00 TOTAL
We Propose
One Thousand Four Hundred Fifty-One and no/100 $1,451.00
Deposit of$47500 required prior to ordering materials with balance 6r$976,00 due on oomplotion._Depo tis non-
refundable once avat+er ais have been ordered
Acceptance Proposal
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Superviso Not Applicable 0
0---1
Name of License Holder: e 5 -'O.C4 V-7
License Number
-S-7
Addre s ExpiratioA Date
4//3 J--L'(7 4 5-a
Signature Telephone
9.Registemd Home Improvement Contractor, Not Applicable 0
Company Name V Registration Number
/-/Is- MAW,
1451--kA Z.-a "&), nit- 0/,o 6-,4 �13 141,/Zlllll
Address r " - Expiration DAte
W
Telephone T(
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 Yes....... M--" No...... D
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House r__J Addition ❑ Replacement windows Alteration(s) Er Roofing F❑D
Or Doors 171 1 1
Accessory Bldg. F-1 Demolition E-1 New Signs [01 Decks I'M Siding[01 Other
L.
Brief De§cn'ppbon(of Proposed
Work: 25 'ut- SWrle.6�5_ 6?1,ee_1
Alteration of existing bedroom Yes L,-"No Adding new bedroom Yes No
Attached Narrative /5), Renovating unfinished basement Yes &---No
Plans Attached Roll -Sheet
6a.If Now house and or addition to existing housina, complete the followina:
a. Use of building:One Family Le'� 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 /V'49 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 6".'-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.
1. 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
1, 6 W n as Owner of the subject
property &
hereby authorize
to act on my behalf,in all matters relative to work aulAorized by this builkling permit application.
At6A-6k41,-41 _Al(tU�� 1119 W
Signature of owner Date
as Owner/Authorized
Agent hereby declare hat the statements and information on the foregoing 4plication are trde and accurate,to the best of my knowledge
anTFelief.
Signed under the pains and penalties of perjury.
yV,
atw K"I
Print Narne / I
AA1 - 0 —491-�A _
-gig—nature of ovker/Agent �oV Date
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 Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
-parking)
#of Parking Spaces
Fill:
_(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 1 Date Issued:
C. Do any signs exist on the property? YES 0 NO 10
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO it
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over I acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 40
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
- EIVED
Department use only
City of Northe pttatu of P it:
Building Dep me t OCT 3 1 20rurb ut/Dr veway Permit
212Main S reet Se Se Availability
Room 1 DEPT.OF dUtLDiNG INS ell vailabitity
Northampton, Q1{)2T21HAMPTON.MATA ift of tructural 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 g p_ v
This section to be completed by office
1.1 Property Address:
Ja, & .+o 5 7144` f , Map l Lot 01/ Unit
/ �Yt7 IAo y m/� a/1 G Zone Overlay District
/ Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
y r7-H i,q o i X o C,6/SS r rLQAQ0 tau t
Name Current Mailin Address:
Telephone j &� -
Signature T
2.2 Authorized Agent:
�� f�
G�irn, S�r/ s / �hLrG) ,!,l��
Name nn �T went Mailing Address: Q/U$
4113- 5317- F 5 4>6
Signature IF Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building L1 ..- (a)Building Permit Fee
2. Electrical / (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) /16—7-- Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
120 COLES MEADOW RD BP-2019-0539
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mpp:Block: 13 - 101 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category=CHIMNEY RELINE BT TILDING PERMIT,
Permit 4 BP-2019-0539
Project# JS-2019-000874
Est.Cost: $1451.00
Fee:X65.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: ACE CHIMNEY SWEEPS 108647
Lot Size(sg.ft.): 71177.04 Owner: SUOPIS CYNTHIA A&SALLY BELLEROSE
Zoning;- Applicant: ACE CHIMNEY SWEEPS
AT. 120 COLES MEADOW RD
Applicant Address: Phone: Insurance:
115 MAIN BLVD (413) 547-8500 Workers Compensation
LUDLOWMA01056 ISSUED ON.•11/612018 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL STAINLESS STEEL CHIMNEY LINER
FOR OIL HEAT
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 11/6/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck--Building Commissioner