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38B-033 (6) 4 FORT HILL TER BP-2021-1491 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:38B-033 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Porch Repair BUILDING PERMIT Permit# BP-2021-1491 Project# JS-2021-002476 Est.Cost: $22480.00 Fee: $149.50 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BENJAMIN JOHN 112410 Lot Size(sq.ft.): 4007.52 Owner: COTE KEVIN Zoning: URC(100)/ Applicant: BENJAMIN JOHN AT: 4 FORT HILL TER Applicant Address: Phone: Insurance: PO BOX 505 (413) 800-4253 WC BERNARDSTONMA01337 ISSUED ON:6/15/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:REBUILD EXISTING PORCH LEAVING ROOF INTACT, REDO CEMENT STAIRS LEADING TO PROPERTY 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. ICpi i 'I • Certificate of Occupancy signature: FeeType: Date Paid: Amount: Building 6/15/2021 0:00:00 $149.50 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner L5 The Commonwealth of Massachusetts I , C-- a Board of Building Regulations and Standards FORig, z ;11 E -• Massachusetts State Building Code, 780 CMR M IUS CITY "u cn Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised M N 711 One-or Two-Family Dwelling rw This Section For Official Use Only Jul Building ermit Number:BRZO21-- 44 1 ____IZ/ Date Applied: plot IS/Zoz( j _--� kallk) &>s ____zzert-: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers L ,Fo- Re'1( Tun.cc- 3?E3 b33 1.1 a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zonin Information: 1.4 Property Dimensions: ugt Xi 00) Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Kt.van Coo--e. Nor4-ha-rr%p4 .m, 14/4 o10ctc Name(Print) City,State,ZIP f 41 1( 're - r, . *3-S84- 90 R a K c of c. . 0-t @.%)^la;l . co w No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 11 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: grief_/ L_., 1 . 4 . 'or.C- 14ct)"' , redo cr-.r.ir.k a,s-S (ca..d t..y ff-o Pr ores +7 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building r$ zz, L{ 0 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire ,Sd Suppression) $ Total All Fees:$ I 1}af r— yp - Check No243µ Check Amount: 141 -- Cash Amount: 6. Total Project Cost: $ Z2_,H T-0 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 112 41 r O 1 /9 I L Z c�r►t to 41. • J©h n License Number Expiration Date Name of CSL Holder List CSL Type(see below) P O e0 K. 5-0 No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) 13-e— t'1 QSa ` 0C 1 M CI 337 R Restricted I&2 Family Dwelling City/Town, State,ZIP M Masonry RC Roofing Covering WS Window and Siding rf SF Solid Fuel Burning Appliances 1413-$Ca0 -fZ..s3 een 6 gri bck L � �a - I Insulation Telephone Emai address D Demolition 5.2 Registered Home Improvement Contractor(H IC) 79 Ct d ai I l I 2-Z.�S l � V.LtI`S 1-1-C.. HIC Registration Number Expiration Date III Company Name or IIIC Registrant Name No.and Street 'Entail address MA 01337 L-113-800-(-1253 City/Town, State, ZIP Telephone SECTION 6: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 ii No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize eue-n3&I\i r1 Q• 3-din to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION 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. 13.e4 .Mir C12.. dohs 5 fr/ oz Print Owners or Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be found at www.ntass.gov oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton ea,"AMP SsS... °', s,C Massachusetts + i y 1 DEPARTMENT OF BUILDING INSPECTIONS y ,� .,. "• 212 Main Street • Municipal Building ud•.,_ Northampton, MA 01060 s/'1 ,1a0 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 eP zoz l- r4ei 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: Q n^� Sf • 0 ci / $-f A- 6J63 8 The debris will be transported by: Name of Hauler: A-PA ko cSf �� 'n SAC • 'Signature of Applicant: Date: 5 kS"/Zoz The Commonwealth of Massachusetts ►k •! Department of Industrial Accidents I Congress Street,Suite 100 =,?!1=�y Boston,MA 02114-2017 4.z.7 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMrFI'ING AUTHORITY. Applicant Information Please Print Lesibly Name (Business/Organization/Individual): 13Q li,,t_t t Address: F. D . eDo) S C2S- City/State/Zip: B-e- Q- 4-00 1 N A- ot337 Phone#: q/ 3- So — 2 S Are you an employer?Check the appropriate box: Type of project(required): 1.011 am a employer with_ .5_ employees(full and/or part-time).* 7. ❑New construction 20 I em a sole proprietor or partnership and have no employees working for me in 8. ErRemodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will l0[]Building addition ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 50 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 end have workers'comp.insurance.: p 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),end we have no employees.[No workers'comp.insurance required] 'Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy information. 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: • G_ Policy#or Self-ins.Lic.#:__W CV O j $ 1 pQ _ _ Expiration Date: �— 1 c{ ( 2.0 2 _. Job Site Address: Li +r 1-1( (( (1 Zt Q City/State/Zip: /Jo / tA.A 1' OICO( 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 51,500.00 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. s�— $ianuhue: ��--� Date: /2 S/ 2 0 Z Phone#: L.4 13 — 'zoo Li 2.5 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#: ti�}�,�. ,k f Cv Atlantic Charter Insurance Company VDAC NCCI Co. No. 29211 Policy Number WCV01484001 1. INSURED: Prior Policy Number WCV01484000 BRJ BUILDERS LLC Producer: Bearingstar Insurance, Inc. 199 BALD MOUNTAIN RD 375 Airport Road BERNARDSTON, MA 01337 Fall River, MA 02720 Federal ID Number 001421546 Business Type: Limited Liability Risk Id Number: SIC 1521 -236118 Residential Remodelers Other Named insured: Other Work Places 2. POLICY PERIOD: The Policy Period Is From: 02/14/2021 To 02/14/2022 12:01 A.M. Standard Time at The Insured Mailing Address 3. COVERAGES: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here:MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 068 D. This policy includes these endorsements and schedules: See WCE105 4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates & Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Total Rate Per Estimated Code Classifications Co Estimated Annual $100 of Annual Remuneration Remuneration Premium See WC 00 00 01 Minimum Premium: Deposit Premium: $500 $5,290 Total Estimated Premium $6,718 Interim Adjustment: Annually Surcharge(s) 223 Servicing Office: Total Premium and Surcharge(s) $6,941 25 New Chardon Street Boston, MA 02114-4721 Issue Date 01/26/2021 Countersigned By: ( GO; rf ei-4- Date Copyright 1987 National Council on Compensation Insurance Form: 100mvnf4