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38B-082
165 SOUTH ST BP-2020-0066 cls#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-082 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2020-0066 Proiect# JS-2020-000103 Est. Cost: $12000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: JASON ALVAREZ 105846 Lot Size(sa.ft.): 8015.04 Owner: COLBY CHRISTOPHER&BEVERLY zoning:URB(100)/ Applicant. JASON ALVAREZ AT. 165 SOUTH ST Applicant Address: Phone: Insurance: 30 LOWELL AVE (413) 495-2861 WC WEST SPRINGFIELDMA01089 ISSUED ON.7/16/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF WITH METAL 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# 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 Si(nature: FeeTvpe: Date Paid: Amount: Building 7/16/2019 0:00:00 $40.00 212 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 CONST UC ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION -:I L 1 6 2019 41-:2. Zp-667 This section to be comp J�ted by office 1.1 Property Address: DEPT OF BUILDING INSPECTIONS � � n I�IJl1!_ NORTHAMPTON,MA 01060 /� � � Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: X NamePrint) Current Mailing Addr ss; Telephone Sig ature 2.2 Authorized Agent: pp pp / Jgso� i4hl 'AceZ 7Gv� Res�c+4+ion. 3o 4oweU Awe, Cr/ S �Falq rhA �Iyd�j Name(Print) Current Mailing Address: Sig re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building JV Ua� (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC)/I 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 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 Department Lot Size Fronta e 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 ® DONT KNOW (C) YES i IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO IF YES, describe size, type and location: E. 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 ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 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 [p] Decks [0 Siding[p] Other(� Brief Description of Proposed n Work: 5444 toe- AIA V(nS I /Iew P,e,4.41 R0 Alteration of existing bedroom Yes 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 I, as Owner of the subject property hereby authorize AIuA,,,_ ,� -SCA ReIJWAA o^. to act on my behalf, in all mtters relative to work authorized by this building permit application. i gt" nerr ate I, tel �_Zl as Owner/Authorized Agent hereby declare t at the statements nd 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. 02:e4)--PA—� )/ 'h f Print Na e Signa pre of Owner/Agent ate SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Superview:: Not Applicable ❑ Name of License Holder: 7A So,\ At u A z M5 5y6 License Number 3o Lv�,e� Au ly, so,. no FkJ f1, 01OS5 to -3 -.2020 Address Expiration Date nature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ /6 9775 Company Name Registration Number Nuse--L 8-! - 2015 Address Expiration Date 3o 0)08--r Telephone 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....... $ No...... ❑ City of Northampton Massachusetts �:.A A DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building s� Northampton, MA 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: (Please print house number and street name) Is to be disposed of at.- (Please t:(Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: l74[on s 2 �// /� U �/U Y!S Lyu� }L�1� --J e,44A-,,A, MA OI-0-27 (Company Name and Address) -"� Sign re of 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. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbem TO BE FILED WITH THE PERNUTTING AUTHORITY. Anulicant Information 1 Please Print Legibly Name(Business/Organization/Individual): 'TC_it R ¢srr.k ,,.. Address: 30 /,, -Q A,-O _ City/State/Zip: filA vlo89 Phone#: Are you an employer?Check the appropriate box: Type of project(required): La am a employer with 1 employees(full and/or part-time).* 7. []New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required] 9. El Demolition 3.rl I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 10 Q Building addition 4.❑1 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 I I.Q Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I 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 6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'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 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 thepolicy andjob site information. Insurance Company Name: M AVAI JY1 S. (�c), _ Policy#or Self-ins.Lic.#: 5 3 1 S 21 SY 9 a 1 g Expiration Date: `/-,2N-,1o Job Site Address: Ill s - ooA A City/State/Zip: M)q. 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 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 andpenalties ofperjury that the information provided above is true and correct. Si tore: 4z,- — Date: 7 1 b 19 Phone#: Official use only. Do not write in this area,to be completed by city or town offwiat 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#: i•� JCAREST-01 GMARSZA ,acoRL7 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) � 1 4/25/2019 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 have ADDITIONAL INSURED provisions or 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- First American Insurance Agency PHONE ;(413)592$118 FAx No: 413 592-0995 PO Box 147 E-MAIL Chicopee,MA 01021 ADDRESS: INSURE AFFORDING COVERAGE NAIL# _ INSURER A:Atlantic Casualty Insurance INSURED INSURER B:Preferred Mutual Insurance Co. 15024 JCA Restoration LLC INSURER c:Li Mutual Ins.Co. 30 Lowell Avenue INSURER West Springfield,MA 01089 INSURER E: INSURER F COVERAGES CERTIFICATE NUREVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POL EXP LIMITS LTR INSD WVQ A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 9 1,000,000 CLAIMS-MADE X I OCCUR M261000387 4/24/2018 4/24/2019 DAMAGE TO RENTED 100,000 MED EXP IlAny onePerson) 5,000 PERSONAL&ADV INJURY 1'000'0 N'LAGGREGATE LIMIT APPLIES PER: GENE AGGREGA 2,000,000 X POLICY F]JECL-J T LOC PRODUCTS-COMP/OP AM 1,000,000 OTHER B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ANYAUTO PCA0100300003 14/24/2018 4/24/2019 BODILY INJURY(Per on OWNEDSCHEDULED AUTOS ONLY X AUTOS W Ep BOIN YINJURY eraccident) AUTOS ONLY AUTOS O"NLY R�d n AMAGE UMBRELLA LIAS OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION$ C WORKERS COMPENSATION X PERUTE OTH- AND EMPLOYERS'LIABILITY Y/N C531 S621589019 4/24/2019 4/24/2020 100,000 ANY PRO PRI ETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ N/A OFFICER/MEMBER EXCLUDED? /M (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 100,N0 If yes,describe under 5W,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT I I ,Efs-5�hi'. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached I mora space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD