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29-603 (6) 82 STONE RIDGE DR BP-2020-0155 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-603 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-2020-0155 Proiect# JS-2020-000259 Est.Cost: $16226.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WORTHINGTON CONSTRUCTION 069649 Lot Size(sq. ft.): 84070.80 Owner: KAPLAN RANDY Zonin : Applicant: WORTHINGTON CONSTRUCTION AT. 82 STONE RIDGE DR Applicant Address: Phone: Insurance: 254 WORTHINGTON ST (413) 883-6171 WC SPRINGFIELDMA01103 ISSUED ON:8/6/2019 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# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Deuartment 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 8/6/2019 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 Northarrlptor+[��r`E� tU f Pe it: Building Departiinent 1 V Curb C;Drivdway Permit 212 Main Stregt Sewer/S�ptic Availability ,I Room 100 A�� _ 4', Water/Well Availability Northampton, MA 106 Two Sets f Str4ctural Plans phone 413-587-1240 Fax 413-5 7-127 F Ot r�U�t n�r:r ;o DEPT O SHA'• APPLICATION TO CONSTRUCT,ALTER, REPAt ENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 47 P'-" 'R 0— 1 6�5- 1.1 Property Address: This section to be completed by office ,� - �r� (Zi,�,p_ e � Map Lot Unit Lir �c-Q r V Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: as l�c�- �n �? � :� �J ores cQ Name(Print) 1j Current Mail' Address: g(h()- �1 Telephone Signature 2.2 Authorized Agent., CW qyu�-d�� Name(Print) Current Mailing Address: Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building I DID(0 '1� (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 = (1 +2 + 3 +4 +5) 1 `1(0t� Check Number This Section For Official Use Only Building Permit Number: Date Issued: p 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 Frontage Setbacks Front Side L: R: L: R:r---] Rear 0 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 O DON'T KNOW Q YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW C) YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DON'T 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 0 Date Issued: C. Do any signs exist on the property? YESO 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 © 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? YESO 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 0 ff Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [0] Other[p] Brief Description of Proposed Work: (_'ZN J 1�S` ��r LEW CLr\-,'\ s[ 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, (Lo as Owner of the subject property C _ hereby authorize to a my behalf, in all matters relati a�tc work authorized by this building permit applilbation. Sign ture of Owner Dafe as Owner/Authorized Agent hereby dec are that thO statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. 1 Si d;4detlhe pains and penalties of perjury. Prin ame \\ !J I eJ 1 Signature of Owner/Agent Date —� SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supe isor: Not Applicable ❑ j( Name of License Holder: t0%..c License Number �4 (o C\ (,:;I � ss Expiration Date lure Telephone 9.i Registered Home Improvement Contractor: Not Applicable ❑ 11�tX- yy� �smS�w•c,�u� L"o �h L \ 6CN ILD- Company Name Registration Number r 1\�ci Addr s Expiration ate 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 , DEPARTMENT OF BUILDING INSPECTIONS ;ter x 212 Main Street •Municipal Building 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: i�a 't�*W UU " ��ep U " (Please print house number an treet name) Is to be disposed o`f at: ��\G (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: �S ULC (Company Name and Address) Q4k- &L1,A S' ature f 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 = I Congress Street, Suite 100 a Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Avylicant Information Please Print Les ibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[J I am a employer with employees(full and/or part-time).' 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 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.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 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#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: 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 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: 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#: 4"A) WORK AUTHORIZATION AND WORTHINGTON DIRECT PAYMENT REQUEST CONSTRUCTION GROUP www Wordtington(:onstructionGroupinc.com 413.279.9144 MA 1 860.270.0409 CT 800.386.0179 Toll Free 254 WORTHINGTON STREET FEIN#82-1034609 CS#069649 HIC# 189575 SPRINGFIELD, MA 01103 INSURED NAME&BILLING ADDRESS PROPERTY ADDRESS t c= )De,F INSURANCE OMPA INSURANCE/1! V/ SAL AGENT: f 12 The general scope of work and the Contract Price is set forth in the estimate of Worthington Construction Group Inc,which is incorporated into this agree- ment.Work will commence on and the estimated completion date is which may be extended for delays beyond the control of Worthington Construction Group Inc. In consideration of the agreement of Worthington Construction Group Inc to provide services required to preserve and protect the personal and/or real property,which I own,control,or lease: 1. 1/We hereby assign to Worthington Construction Group Inc all my right,title,and interest in and to a portion of all insurance benefits or proceeds to which 1/We may be entitled,and assign any and all claims which I/We may have against my insurer,to the extent of the amount of the bill for professional services rendered to me and/or my property referenced above;and[/we hereby grant a lien to Worthington Construction Group Inc on any insurance benefits or proceeds that may be due me.I/we further acknowledge and agree that said assignment may not be revoked retroactively,and may only be revoked by giving a written notice by certified mail or hand delivered to Worthington Construction Group Inc ef- fective Pfective after the date of receipt of said written notice by Worthington Construction Group Inc. 2. 1/We hereby authorize and direct the payment of such insurance benefits or proceeds directly to Worthington Construction Group Inc and direct the above referenced insurance company to pay to Worthington Construction Group Inc such sums as may be due upon receipt of statement for ser vices rendered. e s related to rofessional servi LEEndered by Worthington Construc- o way releases me rom pe 4. 1/We hereby request and authorize my insurance company to furnish Worthington Construction Group Inc with any and all information,including without limitation,payment information and estimates with regard to work required to preserve and protect the personal and/or real property which I/we own,control,or lease. 5. Any individual or entity shall be entitled to rely on the original and/or photocopy of this document as if it were an original. 6. It is understood that the estimate is subject to the approval of the adjuster or representative of the insurance carrier. 7. 1/We acknowledge that all moveable items of significant value have been removed from the premises or destroyed except as follows: 8. I/We further understand that any and all deductibles and/or betterment from our insurance carrier shall be due and payable by us at the completion of services rendered.If payment is not received within 30 days of invoice,a delinquent payment penalty will be charged at 18%annual rate. • ti I we a re mgton Construe to p, 1 . 10. Aff contractors and subcontractors must be registered by the state and any inquiries relating to a registration should be directed to the state.Owners rights are set forth in M.G.L.c.142A. Do not sign this agreement if there are any blank spaces.You may cancel this Agreement provided you notify Worthington Construction Group Inc in writing at its office or by mail posted not later than midnight of the third business day following the signing of this Agreement.See Notice of Cancellation. Intending to be legally bound,l/we sign this day of 1�) OWNER'S SIGNATURE DATE OWNER'S SIGNATURE DATE Worthington Construction Group Inc Representative DATE Licensee Details Demographic Information Full Name: PAUL M DEGRAY Owner Name: License Address Information City: Southwick State: MA ipcode: 01077 Country: United States License Information License No: CS-069649 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 5/23/2019 Issue Date: 5/11/2011 Expiration Date: 5/11/2021 License Status: Active Today's Date: 5/24/2019 Secondary License Type: Doing Business As: ,Status Change Reason: License Renewal Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation L ' W Registration: 189575 WORTHINGTON CONSTRUCTION GROUP INC.!: Expiration: 11/05/2019 254 WORTHINGTON STREET - SPRINGFIELD, MA 01103 "" c G,l,y Svc Update Address and Return Card. SCA 1 8 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 189575 11/05/2019 1000 Washington Street -Suite 710 WORTHINGTON CONSTRUCTION GROUP INC. Boston,MA 02118 ANTHONY R.MATOS 254 WORTHINGTON STREETC '��� SPRINGFIELD,MA 01103 Undersecretary Not valid without signature 0 F Amo CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 04/18/2019 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: James ASSelin CHI Insurance Agency, Inc. PHONE wo _( )413 536-2685 FAX (413)532-0889 No.EXt):- AIC No 416 Main Street E-MAIL wassen Chia en ADDRESS: ) liC 9 cYcom INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01040 INSURER A: PENN AMERICA INSURANCE CO. 32859 INSURED INSURER B: NORGUARD INS CO 31470 Worthington Construction Group Inc INSURERC: 254 Worthington St INSURER D: INSURER E: Springfield MA 01103 INSURER F: 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. INSR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP , LTR POLICY NUMBER MWDD MWD LIMITS X COMMERCIAL GENERALUABILITY EACH OCCURRENCE E 1,000,000 CLAIMS-MADE ❑X OCCURA MAGE TO RENTED PREMISES LEa ocrurrence $ 100,000 MED EXP(Any one person) E 5,000 A PAV0168779 05/18/2018 05/18/2019 PERSONAL BADV INJURY E 1,000,000 GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑X JE� D LOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT Ea Edent $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY Perecdtlent $ AUTOS ONLY AUTOS ( ) HIRED NON-OWNED PROPERTY DAMAGE y AUTOS ONLY AUTOS ONLY Peracaa S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I RETENTIONS �/ y WORKERS COMPENSATION /� STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE y�/OWC995254 08/05/2018 08/05/2019 E.L.EACH ACCIDENT b 500,000 B OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE E 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Addltlonal Remarks Schedule,may be attached If more space Is required) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MA 01103 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department oflndustrialAccidents e I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNUTTING AUTHORITY. Aimlicant Information Please Print Le ibl Name (Business/Organization/Individual): c, Address: ] City/State/Zip CM 03 Phone#: I-{i 3"ftV3—(0 k Are you nn employer?Checle the appropriate box: Type of project(required): am a employer with employees(full and/or part-time).' 7. New construction 2.Q 1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.) 9. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.Q 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 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 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. tContractors 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 providitrg workers'compensation insurance for my employees. Below is the policy and job site information. r `� , Insurance Company Name:_ Nor`1 or Ctl air-A 11 S, . co Policy#or Self-ins.Lie.#: � I V �►V n�5 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 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 thepains and penalties ofperjury that the information provided above is true and correct Signature: Date: Phone M 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#: