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37-065
125 BLACK BIRCH TRAIL BP-2021-1211 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37-065 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ALTERATION BUILDING PERMIT Permit# BP-2021-1211 Project# JS-2021-002023 Est.Cost: $5000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CHESTER D MITCHELL 67026 Lot Size(sq. ft.): Owner: Bambi Rattner Zoning: Applicant: CHESTER D MITCHELL AT: 125 BLACK BIRCH TRAIL Applicant Address: Phone: Insurance: 2 PATTEN HILL RD (413) 625-2167 COLRAINMA01340 ISSUED ON:5/5/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:EXTEND ROOF AND SCREEN IN PORTION OF EXISTING DECK 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 UP N VIOLATION OF ANY OF ITS RULES AND REGULATIONS. ei • • y2 - Aly Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 5/5/2021 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Ar121-6 (e- . APR 22 -----7 2p�1 , The Commonwealth of Massachusetts * y_...s?si7{Y.A' 9 --A-- 0Y (// a, wkeit ) r.---------i'-''''-I---ivE-- 4 K , .. If) )t Office of Public Safety and Inspections ktt,0 T or r[;i��`" —• Massachusetts State Building Code(780 CMR) "�RT� J Buii41ngPe) it Application for any Building other than a One-or Two-Family Dwelling - (This Section For Official Use Only) Building Permit Number. bia..' f 211 Date Applied: Building Official: SECTION 1:LOCATION RS- g\c44- K S c-i-‘. Zc`„1 Florc - L, MR oto6L. / koc.k.1 Hill Cr.oinovsr^J No.and Street City/Town Zip Code Name of Building(if applicable) 037 06S- -025' Assessors Map# Block#and/or Lot # SECTION 2 PROPOSED WORK Edition of MA State Code used a QCO`e-If New Construction check here❑or check all that apply in the two rows below Existing Building 0 Repair 0 Alteration p Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No 151) Brief Descri•tion of P oposed Wor.: II Ilk. ' 1. ill !il i • i r • ., ' ► • iffril "Ita- vr poQC's . SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4 BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational ❑ F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2❑ I-3 0 I-4 0 M: Mercantile 0 R: Residential R-ID R-2 0 R-3yt' R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB ❑ IIA ❑ IIB 0 IIIA ❑ IIIB ❑ IV CI VA 0 VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information Sewage Disposal: Trench Permit Debris Removal: A trench will not be Licensed Disposal Site❑ Public 0 Check if outside Flood Zone 0 Indicate municipal 0 required 0 or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation MA t listoric Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 6arr,b; R et ' r r \25 Fi\c.Ll4. Qi,!r`%., Tr"\\ F\uR.,cu F�1P 010G2 Name(Print) No.and Street City/Town r Zip Property Owner Contact Information: • - - 611 - `12n )12.1 bgrnbi. coiT4-1« le.„9r,4 ,\.Cc;r, Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: C Mc '( VA t CAN C.\\ 2 PaiteN 4.41 (,Irat n ill 0►3YZ) Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor CKO-T ill itdl it P414ova1io►15 Company Name Chad ill i"010 1 067a26 CS Name of Person Responsible for Construction License No. and Type if Applicable A RT't(eA .11 Ccf(aLLA IMF 0139 v Street Address City/Town State Zip 140-535- 71457 to -537'_ 7'157 _ cliteT'Ad take iI 11Z‘? 14Ov .C.LW'► Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKFRS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? YeZ No Cl SECTION 12:CONSTRUCTION COSTS AND PERMIT Item Estimated Costs:(Labor — � and Materials) Total Construction Cost(from Item 6)_$ DI�D — 1.Building $ 5 COO•°p Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ . 3.Plumbing $ / � 4.Mechanical (HVAC) $ Note:Minimum fee= V (contact municipality) 5.Mechanical (Other) $ 6.Total Cost $ 00 Enclose check payable to 3 ,`j�`Do-" (contact municipality)and write check number here / SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. g Atrrlb i t 1",c,'..L. g. }fi ntr' p` a p C r 1-y c►w,us- <01. ,_ ti- Z`k- -i q Z9 CIa--J_ �if=.4 Q � Please print and sign name Title Telephone No. Dateat i � 13' 2.1 "`'.'lam Street Address City/Town ' State Zip Email Address �� '4 r"t Municipal Inspector to fill out this section upon application approval: ____S ) !1 'i Name tie 1 zNiti,12-P,frI 921 ya-NAAA7J f.rivg .yorno LJ - yaoge., rd,,d0Je Z%,-Q 'e3.( .Fli � I 1 1 1 12(h 2 p,.. , _ . 1 _ , "204 9c;) 411C) , 1 % Tiod :nab.)0 ' .t ..'>>> I 1:viifilri0 .5"e I ._,,_- ../avuivx I u ,„__-------------- ---. I , -e . .„,.....-----. ,r-:-. ___--) _____________i< -. . ------ I -----, , , \ -- ,. -,....„,„_ 1-^- _ ,,,--------- -:>1 ,___ ______:--,,,i,„.„_ ------ 1 , ---.--„,„,„ City of Northampton zoo 5 Massachusetts PC DEPARTMENT OF BUILDING INSPECTIONS 8 , p 212 Main Street • Municipal Building 0 Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: (.It CAC-a(-c( ( Gt:�� C ,�4ac ty. �a / � U�u'l�` The debris will be transported by: Name of Hauler: C Signature of Applicant: Date: ..,.;,...i&..4** The Commonwealth of Massachusetts 1 1.44r- i N:==f., Department of Industrial Accidents T::T, ,-.-5 1 Congress Street,Suite 100 t!!inttit'c Boston, MA 021142017 www.mass.govldia Workers'Compensation Insurance Affidas it:Builders/ContractorsfElettriciansiPlu milers. 10 RE FILED WITH THE PERMITTING AUTHOR.ITT. Applicant Information Please Print 1.reibis Na.mc t liu.stness'()%antitatiory Individual): (2,he5te C D • iYi,'-f-eAke-1 I .. .....,„ , - Address: 2 PecitetA ii.: ik M - Cot C ' 1 1 „ -- City/State/Zip- a-t vI i/l)0 0134 b Phone#: (p i D 2(2 - - ' Are you an rertploy ell Cheek the appropriate box: Ty pe of project(required): IC31 81111 a employer with _ employees(full anchor patra-tirtiel... 7, 3 New construction 2 1 am a sole prmwietur or pannership and have no employees working for me in li. 0 Remodeling any capacity (No workers'eterip.,insurance re-qui/WI 9_ 0 D,,,nolition .3C:1 i ant a homeowner doing all went myself.[No workers'comp,insurance required.] 4,0 I am a hOMEN0101901 and will be taring curtiratiors to cOttdOet ad work on ray property_ I will It)[3 Building addition ensure that all 0.1414taidni either have workers'compensation instarance or arc sole il 0 Electrical repairs or additions proprietors with no innployees. I 2,0 Plumbing repairs or additions 5C]I am a general connartor and I have hired the sub,contraesors list**1 un the attached sheet 13.0Roof repairs These sub-contraeturs have employee*and base workers emnp.insurance,'; .4,--NOther P Oire•t- es(t5flito 6.C.3 we are a corporation and its officers have exercised then nght of etenspuon per hfCrl.c root-0 I$2, 11 41.and we have no employees.[No workers'cornp insurance required.] as2C.t( Ct-thULA iv perax .,.. . .A1.111'applicant that cheeks boa 91 Ulna also fill out the section below show in their workers'compensation policy trdonnatstat t lieincusiners who subertit this affidavit narficating they are doing all work and then hue outside eontractors mint submit a new affidavit tadanialirg such. Contractors that cheek du*box must attached an ohlummil sheet show trig the name of the sub-vocanictors and state whether or nut those entinini have employees It the ntractors hive envloyec*,die inthi provide then woricm",..tono,is.111.,:lv nufavt I ant an employer that is providing worAers'compensation insamitce far toy employees. Below is the policy and Job site information. Insurance Company Noinc: Policy ff or Self-ins.Lic.ti: Expiration Date: Job Site Address.: City/StateZip: Attach a copy of the workers'compenxation 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 tine up to S1,500-00 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 u er enettle, of perjury that the in[ormrttlonpnnIdvtiabote ix true and correct, Signature: , 1, K. 1)atc Phone 4: 11.3 —5 3:, -7q 5 7 . ........ , . . _ . _ Official use only. Do not write in this area, to be coinpletecl tit.city or town offkial (its or Town: l'ertiiiill.icettse 4 Y.,. Issuing Authority (circle one): 1 Board of I lealth 2. Building Department 3.City/Triwn Clerk 4.Electrical Inspector 5.Plumbing Inspector t.: 6.Other ('ontact Person: Photo:o: _. . .... _ 1.------ A ® CERTIFICATE OF LIABILITY INSURANCE DATE T (M /202 Y) 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 CONTACT Michelle Bettencourt NAME: FAX A.H. Rist Insurance Agency, Inc. INC No (413)863-4373 {A/C,No): (413)863-9658 159 Avenue A AD1AIL ADDRESS: P.O. Box 391 INSURER(S)AFFORDING COVERAGE NAIC# Turners Falls MA 01376 INSURER A:NGM Insurance Company INSURED INSURER B: Chester D. Mitchell INSURERC: 2 Patten Hill Road INSURERD: INSURER E: Colrain MA 01340 INSURERF: COVERAGES CERTIFICATE NUMBER:2020 Certificate 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 SUER POLICY EFF POLICY EXP w LIMBS LTR INS° VD POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYY7 x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 DAMAGE A CLAIMS-MADE n OCCUR PREMISESO(Ea Eoccurrrrence) $ 100,000 MPT0042Y 9/4/2020 9/4/2021 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 300,000 GGEE'N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 POLICY JEa LOC PRODUCTS-COMP/OP AGG $ 500,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per UMBRELLA LIAB _ OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Classification: Carpentry - residential CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Northampton THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 212 Main St ACCORDANCE WITH THE POLICY PROVISIONS. Northampton, MA 01060 AUTHORIZED REPRESENTATIVE Tracey Kuklewicz/MB (..^.-n y ; ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards • Construction Supervisor CS-067026 Expires:03/2312022 CHESTER D. MITCHELL 2 PATTEN HILL RD. i • COLRAIN MA 01340 y lr)/tiVI:10A \`-‘ /A Commissioner c, 0, A ` /6,,, ,A • . ire Winrri�iva2.%s-"dddo 'a�kia�ud� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 184189 12/17/2021 CHESTER D.MITCHELL CHESTER D.MIT s, :/ 2 PATTEN HILL RD%— COLRAIN,MA 01340 Undersecretary