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18C-141 680 BRIDGE RD-46 FIRETHORN BP-2020-0843 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C- 141 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2020-0843 Proiect# JS-2020-001452 Est.Cost: $12000.00 Fee: $78.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MARK JODOIN 49918 Lot Size(sa.ft.): 1497897.72 Owner., LATHROP COMMUNITY INC zoning: Applicant. MARK JODOIN AT. 680 BRIDGE RD - 46 FIRETHORN Applicant Address: Phone: Insurance: 15 JONES DR X413 885-7361 EASTHAMPTONMA01027 ISSUED ON:1/24/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-PORCH, KITCHEN AND BATH RENO 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 sip-nature: FeeType: Date Paid: Amount: Building 1/24/2020 0:00:00 $78.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only �rrrr1 City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availabilit Room 100 Water/Well Availability r Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 PropertAddress: Thi section to be completed by office Lot l C41 Unit /l/ l�pv� �tfr D/66d J _Overlay District DEPT.OF BUILDING r.n A NORTHAMPT istrict CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ame(Print) u n M i in Aess © lW7 Telephone - ignature 2.2 Authorized Agent: Name(Print) Currentailing Address: � 95S--7%/ gnature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee { fig 4. Mechanical (HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number !� This Section For Official Use Only Building Permit Number: �/ Date Issued: Signature: ju Building Commissioner/Inspector of Buildings Date -J6-2�L 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: Rear Building Height Bldg. Square Footage _7 Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Sp tial Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW /--X- YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO ®/ IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, exc ion, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 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 ❑ Or Doo Tfrdows Alteration(s) EJ Roofing E]Or Doorss Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other[0] Brief Description of Proposed &c L�l /r I pod / l���4w! (3,47,vWork: /�/Q � ��oo�� �N�TW, !� Alteration of existing bedroom Yes J No Adding new bedroom Yes f 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? q--n— el- d. d. Proposed Square footage of new construction. Dimensions 6�o- e. Number of stories? f. Method of heating? Fireplaces or Woodstovesyd 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, AG (f Sl 12y�,l A-4,Z- as Owner of the subject property ` hereby authorize / -11444 �tlDo� to act on my behalf ' all matters relative to work authorized by this building permit application. < x '�)Lo Signature of Owner Date 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. Print Name 3Z ature of Owner gent Date t SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable /❑ Name of License Holder: 610 License Number - 010,P7 0 Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number <S -J-60Ole- � � �>, � 01,6,2 Address Expiration Date Telephone/,�i�/ 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.......^Ef— No...... ❑ City of Northampton 3 r� Massachusetts >, Jir DEPARTMENT OF BUILDING INSPECTIONS i r e;r•' 212 Main Street • Municipal Building 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 buildings'be done by registered contractors. Note:If the homeowner has d o°1>s contracted with a corporation or LLC,that entity must be registered. Type of Work: /PP-1'Ia&1 4 d Est.Cost: 12,600 Address of Work: � - Date of Permit Application: 1/a 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: / ,� o 7-77,4R,k 7cD6 AJ /3 Date Contractor Name HIC Registration No. OR: Notwithstandin e aboveKe,I hereby apply for a building permit as the owner of the above property: v Date / wner Name and gignature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS rye 212 Main Street •Municipal Building r+�- �\ 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: �� ���r �ho� GA-�✓G. (Please print house number and street name) Is to be disposed of at: (Please print name an( lease print name an locati�acility) Or will be disposed of in a dumpster onsite rented or leased from: ,-5f4e /V 1+418�, (Company Name and Address) Signature of Permit Ap 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 IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 w www mass.gov/dia NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /� / Please Print LeRibiv Name(Business/Organization/Individual): 77 /40l`- Address: / eft City/State/Zip: �!�}� � /'J6yl�'�Wftone#: l-7� Are you an employer?Check the appropriate box: Type of project(required): 1.0 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. [Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑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? 6.❑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 till 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. Zff Insurance CompanyName:9 p� ,,S/C�-7SJ/Q ��/ 4, Policy#or Self-ins.Lic.#: W� A j018 0 377 Expiration Date: 1111,911 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 ce ' undertains and penalties of perjury that the information provided above is true and correct Si ature: 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#: DATE(MMIDD/YYYY) o® CERTIFICATE OF LIABILITY INSURANCE 01/23/2020 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 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 NAME: RICK KOUVO __ A1C No HUB INTERNATIONAL NEW ENGLAND LLC MA�PHONE e (413)750-7106 E A-MAULDDRE : rich.kouvo@hubintemational.com 600 LONGWATER DRIVE INSURER(S)AFFORDING COVERAGE NAIC# NORWELL MA 02061 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURERS: MARK JODOIN INSURERC: JODOIN HOME IMPROVEMENT INSURER D: 15 JONES DRIVE INSURER E: EASTHAMPTON MA 01027 INSURER F: COVERAGES CERTIFICATE NUMBER: 496956 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. POU-Cyr." POLICY EXP LIMITS LR TYPE OF INSU jNqn WVD POLICY NUMBER MMIDD MM/DTRD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ GE TO RENI E—D CLAIMS-MADE FIOCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E POLICY ElECTT D LOC PRODUCTS-COMP/OP AGG $ E OTHER: IN LIMIT $ AUTOMOBILE LIABILITY Esacci t BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED WA BODILY INJURY(Per accident) $ AUTOS NON-OWNSED PRO ERTY DAMAGE $ Per accident HIRED AUTOS AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ $DED RETENTION$ PER OTH- WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY Y 1 N EL.EACH ACCIDENT S 500,000 ANYPROPR I ETOR/PARTNE RIEXECUTIVE A OFFICER/MEMBEREXCLUDED? NIA NIA WA AWC40070296132019A 08/31/2019 08/31/2020 E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory in NH) It s,descfihe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached ti 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 benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees 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.gov/lwdtworkers-compensaton/investgations/. 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 ACCORDANCE WITH THE POLICY PROVISIONS. Lathrop Retirement Community 100 Bassett Brook Drive AUTHORIZED REPRESENTATIVE Easthampton MA 01027 Daniel M.C y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD JODOHOM-01 KOUR11 A�OR� CERTIFICATE OF LIABILITY INSURANCE DATE 1/23/1202(M 202YYY) 0 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 HUB International NE formerly ICNE,Inc. PHONE, Ext):(800)243-8134 jac,No:(413)731-9539 1070 Suffield Street MAIL Agawam,MA 01001 11RESS: INSURERS AFFORDING COVERAGE NAIC K INSURER A:Nautilus Insurance CO 17370 INSURED INSURER B:COmmerce Insurance Company 34754 Jodoin Home Improvement c/o Mark S Jodoin INSURERC: 15 Jones Drive INSURER D: Easthampton,MA 01027 INSURER E, 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 rypE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR O MMIDD/YY (MM/DDffYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 CLAIMS-MADEaX OCCUR NC863543 6/26/2019 6/26/2020 PAMAGETSESOR(EaENTEDo=rrence $ 100'000 MED EXP(Any oneperson) $ 5'000 PERSONAL&ADV INJURY $ 1'000'660 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000 POLICY❑PEET F]LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COME. BINED.ntjSINGLE LIMIT $ 1,660,000 ANY AUTO RPJ989 3/26/2019 3/26/2020 BODILY INJURY Perperson) $ OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per.acGtlent $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ _ DED I I RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY Y/N TUTE _ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? F—] NIA E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lathrop Retirement Community THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY ACCORDANCE WITH THE POLICY PROVISIONS. 100 Bassett Brook Drive Easthampton,MA 01027 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD