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29-499 (10) 68 GILRAIN TER BP-2020-0275 GIS - - GIS#: COMMONWEALTH OF MASSACHUSETTS MV.-Block:29-499 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:Siding BUILDING PERMIT Permit# BP-2020-0275 Project# JS-2020-000467 Est.Cost:$18000.00 Fee:$60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK ST LAURENT 100341 Lot Size(sg.ft.): 47219.04 Owner: BOUDO KENNETH G&DONNALEE A zonin¢. Applicant. MARK ST LAURENT AT. 68 GILRAIN TER Applicant Address: Phone: Insurance: 77 FISHER DICK RD (413) 531-4924 WC WAREMA01082 ISSUED ON:9/3/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-SIDING HOUSE POST THIS CARD SO IT 1S 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 9/3/2019 0:00:00 $60.00 212 Main Street,Phone(413)5874240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 5 /)�) // (r Department use only W-r,7a/,'_- City of Northa prt Status of Permit: r�,� Building Dep rtme �C�f urb Cut/Driveway Permit t _ ` 212 Main tree `I ' 0rer/Se ticAvailabili Room '�00 er/W II Availability Northampton,,UA 10 p T o Se of Structural Plans phone 413-587-1240/Fax 13-587- 22f2 4t9 P ot/Sit Plans I nFaT of ther pecify Sp APPLICATION TO CONSTRUCT,ALTER, REPAI ,44,ate Alfa MO ISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 610_ 0?19_d Z_ 1.1 Property Address. ,, I This section to be completed by office Cr/k/Z/�l/�-' / �� Map ` — Lot— Zone ot 7 % Unit Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Curren Mailing Address:�li9r Q�/ CL I�CL��J Telephone Signature 2.2 Authorized A ent: ame(P(nt) Current Mailing Address: 6 Signature Tele one SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dol►ars)to be Official Use Only completed by permit applicant 1. Building `' T1L<!�1 (a) Building Permit Fee i�ls. 41 �U. 6e) 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) bz 5. Fire Protection 6. Total =0 +2+3+4 +5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: / 42 Signature: Building Commissioner/inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) _7 New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[ Other[U 1/ Brief Description of Proposed Work: 4 Q (Jsz-E 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 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, bCA//114 L Z= ZZ6 11, as Authorized Agent hereby declare that the statements and 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. D /moi �=i= / - ,U6 Print Name Signature of Owner/Agent Dat6 I qW SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Reallstered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date 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...... ❑ SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number 2 ? rel aZoE2- &Z9 //q Address Expirefion Dafe Signature Telephone 9.Realstered Home Imorovement CoMractor: Not Applicable ❑ Seos, /2,?O , L 9 Company Name Registration Number 22 ✓t?64 / / Address Ex ration Vate �A O .Z 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....... k No...... ❑ City of Northampton Massachusetts f ! N DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building �`•., Northampton, MA 01060 rst"�y. 41)%� 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 print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Nar fe and Address) Signature of Permit Applicant or Owner Date i 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. DATE IMM/DD/YYYY) ,CARD CERTIFICATE OF LIABILITY INSURANCE 1 08130/2019 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 endorsoment(s). PRODUCER NAME:TACTT Chnslina Barrett PAX PHONEn 13)586-7373 (413)584-0859 Aquadro&Associates355 Bridge St,P.0 Box 357 ADDRESstina@aquadrolnsurance,com INSURER(SI AFFORDING COVERAGE NAICMA 01061 velers Indemnity Co of Conn25682 Northampton INSURE INSURED INSURERS: Quincy Mutual insurance Co 15067 Mark St Laurent INSURER c: The Hartford DBA St Laurent Brothers WSURER D: 77 Fisherdkck Road INSURER 9: Ware MA 01082 INSURER F COVERAGES CERTIFICATE NUMBER: CL1912209802 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS AFFORDEDCERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTSR RrCOMMERCIALGENEFtALUABUTY RANCE POLICY NUMBER MMIDD/YYYV MWID POLICY EF uwTa EACH OCCURRENCE S 500.000 PREMISESS 300,000 ©OCCUR 5,000 MED EXP An ate ) 68056382077 10/27/2016 10/2712019 PERSONALSADVINJURY i 500.000 A 1,000,000 GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: 1,000.000 POLICY PRO- LOC PRODUCTS•COMP/OP AGG S HirednxxTowed s 500,000 OTHER COMBINED SINGLE LIMIT f 500,000 AUTOMOBILE LIABILITY iftscciolm� ANY AUTO awn BODILY INJURY(Per p ) S B OVMEp SCHEDULED AFV206530 04/01/2019 04/01/2020 BODILY INJURY(Pa soddsnt) S AUTOS ONLY AUTOS "Fffa HIRED r;ZoJ NON-OWNED iper TY A S X AUTOS ONLY AUTOS ONLY UIM/UNI f 100,000/300,000 UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S f DED RETENTION SM• WORKERS COMPENSATION PSfTATUTE £R AND EMPLOYERS'I LIABILITY YIN E.L EACH ACCIDENT S 100,000 ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ NIA 6S60UB•9522L76-9-18 10/2712018 10/27/2019 100,000 (- OFFICER/MEMBER EXCLUDED? E L DISEASE-EA EMPLOYEE S (Mandatory In NH) 500,000 It C•e deacnbe LwIda E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS W- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedula,may be suschad I more space Is replAred) PROJECT-FLORENCE 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. CITY OF NORTHAMPTON 210 MAIN STREET AUTHORIZED REPRESENTATIVE NORTHAMPTON MA 01060 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvemontractor Registration 17Wi Type: Individual MARK J.ST.LAURENT I l Registration: 123029 � 't ° Iz DBlA THE ST.LAURENT EROS Expiration: 11/21/2020 '"` ate',91 �.. 77 FISHERDICK RD -� WARE,MA 01082 4" tE ' I SCA 1 p 20M-OW17 Update Address and Return Card. Office of consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TY09:Individual before the expiration date. If found return to: Regiltea EXphysm Office of Consumer Affairs and Business Regulation UI=9 11/212020 1000 Washington Street-Suite 710 MARK J.ST.LRlftV`f' Boston,MA 02118 D/B/A THE ST.LAUFIEN7 BRoS MARK J.ST_LAURENT Q 77 FISHERDICK RD WARE,MA 01082 Undersecreta tvali 'without signature ry Commonwealth of Massachusetts ®. Division of Professional Licensure Board of Building Regulations and Standards Construction-Supervisor Specialty CSSL-100341 Expires: 10/09/2019 41.?; MARK J ST LAURENT 77 FISHERDICK ROAD WARE MA 01082 Commissioner C The Commonwealth of Massachusetts Department of Industrial Accidents Y 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 PERMITTING AUTHORITY. Applicant Information Please Print Letdbly Name(Business/Organization/Individual):/J7/�& ,<T,' ,41g evp/-;,z::�-� Address: ,2,,7 City/State/Zip: /7 (3/p E2 Phone#: Are you an employer?Check the appropriate box: Type of project(required): l.gl am a employer with �f 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. ❑Dem011tion 3.M I am a homeowner doing all work myself.[No workers'comp.insurance required.]I 10 I 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. These sub-contractors have employees and have workers'comp.insurance.$ 13.[:]ROOF IEpatIS 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. lContractors 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 at employer tarot is providing workers'compensation insurance for my employees. Below is the policy and job site inform adm 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 eeerrtyify under thew' paatidpena/ties of perjury that the information provided above is true and correct. Signature: /P&,i 13.1c: Dater Phone#: Official use only. Do not*rite in dlis 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#: