35-184 (5) 6 PINE VALLEY RD BP-2020-0828
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35- 184 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-2020-0828
Project# JS-2020-001428
Est.Cost: $6750.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MAJOR HOME IMPROVEMENTS 103054
Lot Size(sa. ft.): 34020.36 Owner: KRZANOWSKI KEVIN
Zonine: Applicant: MAJOR HOME IMPROVEMENTS
AT. 6 PINE VALLEY RD
Applicant Address: Phone: Insurance:
19 HUNTER SLOPE (781) 913-6405 WC
WESTFIELDMA01085 ISSUED ON.1/22/2020 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 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 1/22/2020 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 /i"
212 Main Street JAN SewerlSepticAvailability ��,
Room 100 WaterNVell Availability
Northampton, MA 01060 oFaT Two Sets of Structural Plans
o curt n, 2%/%��///
phone 413-587-1240 Fax 413-587_-'�2?�Ar.Rr, Plot/Ste Plans
Oth,er_Specify'
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Progertv Address:
This section to be completed by office
Val 1('�v`I' Q Map Lot Unit
ll� r 1 C �J �7 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1n
V I V) V
Name(Print) Curr tNtii ess*
Telephone
Signatur
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
lP QL-I W
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
complete by permit applicant
1. Building U (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 r
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Numb r: Date
Issued:
Signature: '/ J' Z-j-202t)
Building Comm issionerll nspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing SCJ
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [[I] Decks [Q Siding[0] Other[Q
Brief Wok St'Y � �riptign of rkpl t l' Irl�1 YLO h LCL 1311 1)2Y ` 11'Xt(� 111 r\Q1� O1 C t71' C t M YYJ s-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
'T (ha I f Of�
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, M& "y I n Y--�ZQ a Vy_f(—'1 as Owner of the subject
property
hereby authorize V .S I I ( Q ��[✓t i��rC'�V r
to act on my behalf, in all matters relative to work a rized by this ilding permit application.
j
Signature of r Date
I, �I�l j I IC I✓V 1(,�Y C I�I/ as Owner/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.
Vni I I IP VI-iVTAVC,h1)It-,'
Print Name
Sign wner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not Applicable ❑
Nameof License Holder: y—V ' C1VC' % /— CS / 2
o<�Q
License Number
�c� h�nfi� c f► o� e g1 Z(-A /Z o
Address Expiration Date
ll. —
Signature Telephon
9. Registered Home Improvement Contractor ,,,,,,_uti Not Applicable ❑
'1A a-vl0 T 2YI-1jo wi.e n t f I SM o I
CompAny Name Registration Number
10 ►-Iuyltlrs S'I�:�� Sl3-[40
Address Expiration Date
Telephone (O
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 build' g permit.
Signed Affidavit Attached Yes....... W No...... ❑
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONSi
c
212 Main Street •Municipal Buildingr�
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:
Q DiVW UclIIPl,j P-A
(Pleasbprint house number and street name)
Is to be disposed of at:
sadk of�Inco ver
(Please print narhe and location of fa ility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signat rmit 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
Boston,MA 02114-2017
www mass.gov/dia
lVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Analicant Information Please Print Legibly
Name(Business/Organization/Individual): Va I ; ; Q V_;vY-,hn r hu k
Address: g
S /
City/State/Zip:WUtfl ld oI Phone
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.R 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
10E]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 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑PI tubing repairs or additions
5.�am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. toOf repairs
These sub-contractors have employees and have workers'comp.insurance.: p
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#I 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 ofperjury that the information provided above is true and correct.
Simature. Date: —2-1
�y
Phone#: U 13) UZI C —(Q()u 10
Official use only. Do not write in this area,to be completed by city or town ofciaL
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
City of Northampton
y15 >
Massachusetts
.,cam
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building fd
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: P-0 0f u D 1 a a lyu n f Est.Cost: LP i 7 :D.00
Address of Work: Up u if V a I I-P 1 2
Date of Permit Application: 1 -2 1 — 2-0
I hereby certify that:
Registration is not required for the following reason(s):
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 PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
1 _ 71-7-C) V01.(i 11.P K.UU_nf('h uy__ I�;u
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
' Conw)onweatth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards 11
Constrr4o Mrvisor
CS-103054 g:`� �ires:08l24J2020
VASILIE M KI;K
19 HUNTERS'
WESTFIELD MAip 1.11,
Commissioner
1
Jrte F 1,11.11W 1� ;
QPfite((e�cb�yE.onsuafas; l/Y si-Won
Y �
t i
taA If7t t y�`
V4fEVMEIJ,M L Unrersecm4ay a
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AC"R" CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDO/YYYY)
-
lk. 3711512019
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 be endorsed. If SUBROGATION IS WAIVED,subject to the
berms 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).
CONTACTPRODUCER
E JESSICA BARRETO
POINT INSURANCE INC ?t+c"= _ 7- -- Fax
191 CONCORD ST E-MAIL 'QM
ADDRESS: fBARRET0,320INTINSURE
FRAMING.HAM,MA 01702 {NSU s AFFORDING COVERAGE NAIL#
INSURER A: EVANS TON INSURANCE COMPANY
INSURED
GA SIDING CONSTRUCTION INC INSURER s:
84 WATER ST INSURER C:
MILFORD,MA 01757 INSURER D:
INSURER E:
I NSURER-r:
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.
I�! TYPE OF INSURANCEWSRLI POLICY NUMBER f1UMtDD1YWYl i TA.�tLIMITS
GENERAL LIABILITY I EACH OCCURRENCE S 1 DOD 000
xi DAMAGE_Q RENT515—,
COMMERCIAL GENERAL LlABiLI Y PREMISES'ea ocwrrencel S 50.000
CLAIMS MADE } OCCUR f i i MED ECP(Anr one persm) 5 1,3!10
A 3EB7838 i 07117!2019 07!17!2020PERSONAL a ADV INJURY 1$ 1.000000
GENERAL AGGREGATE i 5 2,000,000
GEN LAGGREGATE UMITAPPUES PER: I { PRODUCTS-COMP/OP AGG 5 1,000000
X;POUCY�—,PZ- F7,LOC I
BIN=D NG' UMIT
AUTOVOEMELIAB11.17Y
1t1+1��. Ea BIKED
ANY ALTO BODILY INJURY(Per pecsart) S
ALL
TOS ED I AUTOSSCHEDULED BODILY INJURY(Per acciml S
PPR�OP=E uAMAGE S
HIRED AUTOS AUTOS �
i S
UMBRELLA UAB OCCUR EACH OCCURRENCE Is
EXCESS UAB CLAIpE ( AGGREGATE S
DED ! RETENTION 5 Is
WORD COMPENSATION { { WC STATU-
AND EMPLOYERT LIABILITY 'ORV
ANY PROPRIETOR.PARTNERtEXECLMvE YfJI F", E.L EACH ACCIDENT s
OFFICERWEMBEREXCLUDED? NIA l '
i(Mandatory in NH) E.L DISEASE-EA EMPLOYE 5
nom' m�-A ca- i E.L.DISEASE-POLICY LIMIT i S
I
DESCRIPTION OF OPERATIONS i LOCATIONS i VEHICLES IAltath ACORD i0i,AddE3ianal ftamaric Schetl k, t rare spate is regUSred;
CERTIFICATE HOLDER / CANCELLATION;
t
MII.EC INC i I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
DBA MAJOR HOME IMPROVEMENTS ' j ACCORDANCEMflTH THE POLICY PROVISIONS.
19 HUNTERS SLOPE R1ZEDPR_zSE.iT TIVE
WESTFIELD,-MA 01085 i
.CA BARRET^v
oc 1988-2010 ACORD CORPORATKM All rights reserved.
ACORD 25(2010105) The ACORD name aid toga are registered marks of ACORD
1
� DATE(MAL'OD/YYYY)
A
CC> CERTIFICATE OF LIABILITY INSURANCE 07/152019
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 be endorsed. If SUBROGATION IS WAIVEL, 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 rONTACT
NAME: JESSICA BARRE70
POINT INSURANCE INC PHONE (6�7)3$1-6240 CkX No
E-wArL JBARRETO�POINTINSURE.COM
1885 REVERE BEACH PARKWAY INSURER(S)AFFORDING COVERAGE MAIC#
EVERETT MA 02149 INSURER A: AIM MUTUAL INS CO 33758
INSURED
INSURER 8:
MARIA CHUQUI INSURER C:
G A SIDING CONSTRUCTION INSURER D:
61 WATER STREET INSURER E:
MILFORD MA 01757 INSURER F:
COVERAGES CERTIFICATE NUMBER: 425250 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSLRANCE 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 TYPEOFINSURANCE Li POLICY EFF POLICYEXP , L1AiIT'3
POLICYNUMBER MWDD/YYYY11 rMVMD,
COMMERCIAL GENERALLIA6ILITY �.. EACH OCCURRENCE $
CLFJMS MADE OCCUR AMA T'31NEA i t-
PREASSES�Ea occLm-,celS
MED ECP(Ary one person) $
INA PERSONAL&ADV INJURY 3
GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $
PruryF7 jEOT- 71 LOC % PRCDUCTS-COMPtOPAGG $
OTHER:
AUTOIAOBILE LIABILITY COMBINED SINGLE LIMIT
i Ea arxident)
ANY AUTO BCD-Y INJURY toer person) $
ALL OWNED ^� SCHEDULED
AUTOS AUTOS A BCDi'_Y INJURY(Per asddent),S
HIRED AUTOS AUTOS NED PROPERTYCAMAGE S
,^AUTOS : Per acadent',
;
j 5
UMBRELLA LIAB OCCUR EACH OCCURRENCE s
EXCESS LIAR CLAIMS-MADE NIA AGGREGATE S
DED RETENTIONS
WORKERS COMPENSATION I X STATUTE ER
AND EMPLOYERS'LIABILITY
ANYPROPRIET.DPJPARTNER/EXECUTIVE ; ; I-L.EACHACCIDENT 1,000,000
A 'OFF,CERIMEM6EREXCLJDED? NIA WA WA XWC40070302582019A 03,2612019 :i 0312&20201
iMandatory in NH) ' EL DISEASE-EAEMPLCYEE'$ 1,000,000
If yes4 describe under
DESCRIPTION,OF OPERATIONS oelc- I EL DISEASE-POUCYLIMIT S 1,000,000
NIA
i !
DESCRIPTION OF OPERATIONS i LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefrs to
employees in sates other tor Massachusetts if tTe inscred'nares,or has hired those empioyees outside of Massachusetts
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this
certificate of insurance}. The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at
www.mass.govAwd/workers-compensa:icnhnves6gatonsi.
Sole proprietor has not elected coverage.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
MILE INC DBA MAJOR HOME IMPROVEMENTS ACCORDANCE WITH THE POLICY PROVISIONS.
19 HUNTERS SLOPE AUTHORIZED REPRESENTATIVE
WESTFIELD MA 01085
Daniel M.Cr 'may, CPCU,Vice President—Residual Market—WCRIBMA
G 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(20141131) The ACORD name and logo are registered marks of ACORD