35-296 (4) 69 WOODLAND DR BP-2019-1275
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Biock: 35 -296 CITY OF NORTHAMPTON
of-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pewit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category:ROOF BUILDING PERMIT
Permits BP-2019-1275
Proiect4 JS-2019-002064
Est.Cost:$17900.00
Fce:$40.00 PERMISSION IS HEREBY GRANTED TO:
QW-t-class: Contractor: License:
Use Grow MAJOR HOME IMPROVEMENTS_
Lot Size(sa.h.): 33628.32 Owner: KUHR KAREN HIRSCH C/O TAE H KIM
Zoning: Applicant. MAJOR HOME IMPROVEMENTS
AT: 69 WOODLAND DR
Applicant Address: Phone: Insurance:
19 HUNTER SLOPE (781) 913-6405
WESTFIELDMA01085 ISSUED OK•5/74/2079 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 4 Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough; 2+1: 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:
FeeTvve: Date Paid: Amount:
Building 5/14/2019 0:00:00 $40.00
212 Main Street Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED
City of Nortmp n
Building De nt MAY 1 0 201
212 Main tree
Room 00
"UH W.r,l.lsp_
Northampton, A 0��,,..,:�--.,m.v�,�
IQ phone 413-587-1240 Fax4 -587-
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMINDWFLLING
SECTION t.SITE,..INFORMATON 6l ('f
1.1 Property Addini
6Q wocAfand �n,ire n l� N` , .;,
r-.2_0R-e.n(_e IMA
SECTION 2-PROPERTY OWN IRSRIFIAUTHORIZEDAGEthT
2.1 Owner of Record:
` n (op boccclfclnd I�L1 P F(owt�
Name(Print) Cylrent a'iJ ldre-6
r 1 41 '">7} 1
T lephone
SigreWre
22 Authorized Agent
Q H w4cg s S LueY
Name(Pdnq — Cunem Mailing Adds.& 0102Pj
m
�u1�1 (, 36 60u�
Signat TT l�ephon
SECTION 3.ESTIMATED CONSTRUCTION DOSIS
Item Esfimatad Cost(Dollars)to be ORieial Use Only
cpm leted bv permita licant
1. Building 1,4
(a)Building Pemtit Fes
2. Electrical (b)Estimated Total Cost of
Construglal from
3. Plumbing Building Parall Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+q+5) Check Number
This Seclbn Fa Official Un On
Building Permit Numb -
Issued:
Signature: 5 I4 2019
Building Com issonentrapecmr of Bu mP Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Sachet 4. ZONING All Information Must Be Completed,Permit Can Be Denied Due To Incomplete IMormat ion
Existing Proposed Required by Zoning
This column to Ix ruled in by
Building Deyartment
Lot Size
Fronto e
Setbacks Front
Side L�R: I,=R:=
Rear
Building Height
Bldg.Square Footage
Open Space Foot age %
(lotarea minus bldg&posed
parking)
N of Parki ng Spaces tJ
Fill:
(volume&Weatiun)
A. Has a Special Permit/Variance/Findi�ng ever been issued for/on the site?
NO O DONT KNOW G) YES O
IF YES, date issued:[=
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW a YES O
IF YES: enter Book �� Page= and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued: Iu�
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 awe or is it part of a common plan
that will disturb over 1 acre? YES O NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(ChWk all a0011mil
New Nouse ❑ Addition ❑ Replacement Windows Atteretion(s) Q Rooting
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [M Siding[0] Other[0)
Brief Des r�ption of Prtl
opo5e
Work -Frinkx Siinc. yt 5lurTCQ.Pn Iv114aQ,Cyl.2(-l1w
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes I/ No
Plans Attached Roll -Sheet
nJCL
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?
I. 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 It of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No
I. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? _Yes No.
I. Septic Tank_ Chy Sewer_ Private well_ City water Supply_
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR11CIIONTRACTOR APPLIES FOR BUILDING PERMIT
I l a s f�^�A " as Owner of the subject
property 1/ '/I- � J/
hereby authorize \/GSl if C Ku kkarc�uat
to act n my ehalf,in all matters relative to work authorized by this building permit appticetion.
s�g � ig
Sigma 1 of Owner V
Date
as OwnerlAuthorized
Agent hereby declare that the statemen5 antl information on the foregarg appliceLon are true and accurele, to the best of my knowledge
and belief.
Signetl under the pains and penalties of perjury.
\�Asi Ll E KU KHAPcHUt�
Print Name
S G h
Signa mof gent Date
SECTION 6-CONSTRUCTION SERVICES
6.1 Licensee Construction Suoervlsor: ' NotApplicable ❑
der
Name of License Hol : TSI IIQ K�(-i�CA'1lLR JILJ`-/- C5— I0 -1�02J
License Number
IP H (An"s SloFae ( IA)eS� eld ,nnno�ox� 0aWIa,o
Address Eviration Date
tme Tallepliomi
Not Applicable ❑
11 l0 �2 f l afk e �rx o cave nca rc�s l 5y a Lt I
C me r Registration Number
�a 14 cn 5 S �3I �-o
MAddress Expiration Date
;5 ' d MIL oho DLJ TelePhon I�7636-
SECTION W WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.15%§25C(6))
Wodaers 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....... qk, No...... ❑
City of Northampton
Massachusetts
DWARDEaPF OF BNILr)ING INSPECTIONS
212 Main Btxaet • Mnioipsl BoiUUng
Noitbe ton, MP 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registratio of contractors and
subcontractors performing improvements or renovations on detached one to four family ho s. Prior to
performing work on such homes, a contractor most be registered as a Home Improvement ontractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, in mization, conversion,
improvement removal, demolition, or construction of an addition to any pre-exubng owner- pied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to uch residence or building"be
done by registered contractors.
Note:/f the homeowner has contracted with a corporation or LLC,that emit must be registered.
rr
Type of Work: (� n E .Cost:
Address of Work:
Date of Permit Application: rb J q
I hereby certify that:
Registration is not required for the following reason
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PE OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTO FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE A ESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH NERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILD G PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of per y:
I hereby apply for a buildin ermit as the agent of the owner.
S 9 I 5iwC- fizULuK ISUB�I
Date Contractor Name HIC Registration No.
OR:
Notwiths mg/the above notice,I hereby apply for a building permit as the owner of the above property:
Dat Owner Name and Signature
City of Northampton
Massachusetts
e
ZaPARTMSBT OF BUILDING 171? L TIONS
212 Nein , Municipal Building
NOrthrtM1eVton, Md 01060
Massachusetts Residential Building Code
Section 1 IO.R5.1.2
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 I IO.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 110.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 forst 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 Commonwealth ofMassachusefts
Department of IndialitrialAccidents
1 Congress Street,Suite 100
Boston, MA 01114-2017
www.mass.gouldia
Wwricks,irs'Commication Insurance Affidavit'Builders/Contractors/Electricians/Pluenbem
TO BE FILED WITH THE PERMITTING AUTHORITY.
Apolicam,Information Please Print Leeibly
Name (easiness/organiiedon/Indiv+aaal): Yl'1 t'3 n-012, P.Ay,xk lIM.IJ�L,0k&Pt=—C",S
Address: ( tel - -ur1+C-pK1S S1
/
City/State/Zjp:(A)e S+ i� ¢tet ,c L)1C)1;1 Phone#: l'I
Are yaw an empluyerT Check dminlmpriate boa: Type of project(required):
L❑Iamaemployer ovate_ _employces(full and/orpazt-time3^ 7. ❑New construction
z❑I am awar,rana ,or partnership and Fine no employees wmking for nein g. ❑Remodeling
any capaarty.Mo workers'comp.interstate required.l
9.
3❑l am a homeowner doing all work myself flit womos,comp.insumncewconad l' 10 Demolition
4.❑I am a M1omeownerand will be hiring commtlors m wndu<t all work on my pmperry. 1 will 10 Building addition
encore that an wmrecter,either have workerseamisnsation insurance or are sole 11.❑Electrical repairs or additions
p rpratu rs with no employees. 12.❑Plumbing repairs or additions
5 l am agcoand comracter and l have hired the sub<omracters listed on the anached sheet 13. Oofrepairs
These sub-conimctom lave employees and have workers comp.insurance:
6.❑Weareacos MionandidsoRcershaveemmis theirngh[ofexemptionper MGLc. 14.O0thsr
"2,41(a),and we have no employees.INo workers wmp.inamance tequima.l
^ony applicant that chrom box al must also fill aur the section below showingthnr workers'compensation Polity lamination.
f Homeowners who submit this of dervit indicating they are doing all work end then hire outside contractors must submit a new affidavit iMicating such.
occonactors that check on,me men anacM1ad an additmou shell showing the tame of*,suave rots and,(ate whether or not thou entities have
employees. If[M1e sub-commeters neve employees,they mug provide their workers omp.polity number.
I mn an employer Nor isproviding workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/state/zip:—
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
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 forth 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 Ne pains and penalties ofperjury,that the information provided above is true and correct
Si atur : Date: q
Phone#: t 3 b-J — 6t''
Official use only. Do not write in this area,to be completed by city or town oJrciast
City or Town: Permit/License q
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cdtylfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone h:
City of Northampton
Massachusetts
DEPAa1 r OF BD'xwO ZESPECTIONs
212 M+in St—t •Municipal Buildi�
.0.N t.' M 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c40, 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:
_(1J ood PCvzd "-'"e trtO14-0 .0 f Mk
(Please print house number and street name)
Is to be disposed of at
U SAW aAA-b-ns N rd w cz
(Please print name d location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
c-Permit Applicant 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.
ConsnonMith of Massachusetts
DNison of Professional Licensure
Boar,of Bu„ing Regulations aW 3tanN r,s f
Constrvisor
If
CS-103054y'S 4pims:03/2412020
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18IIIBJ'fERS
VIE57FIELD 8C
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Commissioner � !tom
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CERTIFICATE OF LIABILITY INSgRANCE oa/oezols
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS N RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTE THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT B TWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. '
IMPORTANT: NMe certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
She terms and conditions of the policy,certain policies may require an endorsement A State ant on this certificate does not confer rights to the
certificate holder in Its.of such endorsements.
AOouwR P.IAMEAO JESSICA ARRETO _
POINT INSURANCE INC Z", En. (617ZaBl 24o_ _
EawL s. JBARRET POINTINSURE.COM__
1885 REVERE BEACH PARKWAY INSU ERS)AFFD0.DING COVERAGE _NMC.
EVERETT - _ MA 02149 INSURER A; AIM MUT 33758
INSURED INSURERS: —
MARIA CHUQUI INauRE0.m _
G A SIDING CONSTRUCTION INSURERS: _y
61 WATER STREET IxsuREa E____._t—___
MILFORD MA 01757I INSURER F:
COVERAGES CERTIFICATE NUMBER: 387299 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT O OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY Pi THE INSURANCE AFFORDED BY THE POLICIES ESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXC WSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PA D CLAIMS.
1N8p TYPE OF INSURANCE ,,a 8R POLICY EFF LY SUP
POLICY NUMBER N Np LIMITS
COMMEMC GENE LUA&IRY EACH OCWz9a 5
CLAIM&MADE OCCUR
PR MISE9 Eaoccens x S
! MEO E%P IPnYMeppraon) 9
_ N/A ! PERSONAL a ADV INJURY IS
GENT AGGREGATE LIMIT APPLIES PER: ! GEnERALMiCREGATE .$
POLICY C PRC- ElL,.
JECT LW I FROOULTS-COMPpP AEG 9
OTHER'. S
P.TOMORILELIAe1LIrY Merl' IN LIRA S
NYNLCM BODILY INJURY,Pev' uU I$
ALLoh AutosSCHIDLEO N/A BODUYINJURYIPernco"t) 9
HIRED AVT09
NOKOWNEO pRWERTY DAMAGE
HIRED AUTOS AVT08 I II Per arrears)
S
S
U..ELLALMB OOLUR FgCX OCCVRRENCE S
"am OAS CLAM -ki I N/A AGORIEni s _
DED I I RETENTIONS a
WORNERB CCMPENSATON E ER
.DMPLOYERS'OA UW YIN'
ANYRNRREFCRNAN`mME%ECUTvE E.L EPGry ACCIDENT 5 1,000,000
A OFFCEWMEMBERE%CLVDEO? XIA'N/A 1 NIA AWC400]0302M2O19A 03/26/2019 03126/2MO IDENT
IMaOYEE 5 1,000,000
nBIIary In NN) LEL DISEASE
a.
HDel-6a=0W,OFF POLICY LIMIT s 1,000,000
PTION OF OPERATIONS EYmr E L.D19EA9E-
NIA II.
DBCM"OXOFWERARONSILOC nl 81VEHICLE4 IACORD LD1,AtleMbnvl RamaM SNaEula,Tsy O[albrAae NlnenaI[rtyullW)
Workers'Compensation beneff s waI be paid to Ma a chusetb employees only.Pulsuareto Endorsement WC 20 O OB B,no authorization Is given to pay claims for benefits to
employees In stalest other then Massachusetts if the Insured hires,Or has hired Mose employees outside of Mean uusNI
This certficateW insurance shows the policy in force on the data diet this certificate Mans issued(unless the exiIn data on the above polity precedes the asue date Of this
cedffok.ofinsumnce). The staWsofthis coveregecan be mpnaved daily by accessing the PmorofCoverage-Coverage Verification Search tool at
www.mass.govllwtlAvwkera-compenestiominvea6gationsl.
So.P oorieNr has not Elected..,ads
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION D1yTE THEREOF, NOTICE WALL BE DELIVERED IN
MAJOR HOME IMPROVEMENTS ACCORDANCE WRHT E POLICY PROVISIONS.
19 HUNTERS SLOPE
PUTNIXUEED0.EPRESENTATME
WESTFIELD MA 01085 """tomk
Daniel M.Clgwey,CPCU,Vice President–Residual Market–WCRIBMA
®1888-7014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD