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23A-107 (6)
137 SOUTH MAIN ST BP-2022-0111 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A- 107 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Bath reno BUILDING PERMIT Permit# BP-2022-0111 Project# JS-2022-000129 Est.Cost:$15000.00 Fee: $105.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ALVIN HALL 042574 Lot Size(sq.ft.): 12371.04 Owner: ROSENBLUM JEFFREY M Zoning: URB(100)/ Applicant: ALVIN HALL AT: 137 SOUTH MAIN ST Applicant Address: Phone: Insurance: 109 WEST ST (413) 586-4633 0 HADLEYMA01035 ISSUED ON:7/30/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:1 ST FLOOR 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. Q • • r s4 ' Certificate of Occupancy Signature I ' FeeType: Date Paid: Amount: Building 7/30/2021 0:00:00 $105.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner ✓(// 2 O The Commonwealth of Mass 1 Office of Public Safety and Inspections '"`'ON ini n Massachusetts State Building Code(780 CMR) • 44'-6-orio Building Permit Application for any Building other than a One-or Two-Fanu �0' Nellin (This Section For Official Use Only) Building Permit NumberGD A 3"-III Date Applied: Building Official: SECTION 1:LOCATION 131 S. Mout Sr Fbrehc� 01042,,, No.and Street City/Town_ t��-co Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New onstruction check here 0 or check all that apply in the two rows below Existing Building Repair 0 Alteration 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 0 No iiir." Is an Independent Structural Engineerin. Peer Review lred? L ` ye ❑ No IllY Brief Description of Proposed Work: iee ha✓wt 4 J17 0 ?ter i- c/0 or Dom ro o m 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) Cl 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 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 -5❑ I: Institutional I-1 0 I-2 0 I-3 0 I-4 0 M: Mercantile 0 R: Residential R-ID R-2 0 R-3 R-4 0 S: Storage S-1 ❑ 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 ❑ IIIA ❑ IIIB ❑ IV VA 0 VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 1 .3 for details on each item) Trench Pe t Debris Removal: Water Su pl . Flood Zone Information: Sewage Disposal Licensed sal Site 0 Public Check if outside Flood Zone 0 Indicate municipal A trench w' not be Dispo required or trench or specify: Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 Railroad right-of-wa Hazards to Air Navigatio • MA Historic Commission Review Process: Not Applicable Is Structure within airport a ach area? • Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 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 Ip and Ad ess of VQ P eJe Chn t �o1 �h ti \ \-\,) nP,- Q\O Le? Name(Print No.and Street Ki Town Zip p Property Owner Contact Information: / _31kA_ Tr PI )A k'C'°1 Title Telephone No.(business) Telephone No. (cell) e-mail addrds If applicable,the property owner hereby authorizes: 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 CI. 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 /1-1f'ii 44 /I1/ Compan ame Hid/ �i✓> �, Al Cs o `-iZS1 c$9: /67696( e-) Name Person R spe fokC truction drti License No. an ype rf ApplicabloO3�Street Address `` Ciiitty/ wn � Zip., fL34i7 77k • a 111)'AY11hci1I out, f. cOn _ Telephone No.(business) Telephone No.(cell) e-mail a less SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Ott ance of the building permit. Is a signed Affidavit submitted with this application? Yes Q' No SECTION 1Z CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item 5, DO 0 and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ Q/ 000 Building Permit Fee=Total Construction Cost x ' (Insert here 2.Electrical $ I 5-0 0 appropriate municipal factor)=$40.r. 3.Plumbing $ 3aj 0 O 4.Mechanical (HVAC) $ I Note:Minimum fee-$ (contact municipality) 5.Mechanical (Other) $ N{/ �I f orj p pp. 1IV/�, Enclose check payable to e'Cic 6.Total Cost $ I S 000 (contact municipality)and write ch number here ')3 SECTION'3: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 thebest of y knowledge and understanding. • / ti \'\'(V\'%i)1..r. )\'')n (\z - 'ill_a_3)0 t/A Pl ase print and sign na e Telepone N to \ j�� 0% S\ V\tcr)cL �1�.0�i- yvr \VO.) e Street Ad City/Town State Zip Email Ad. Municipal Inspector to fill out this section upon application approval: �� / ''"Z/ZI Name Date City of Northampton oaSHAMPT� S.. S 4. Q �'' Massachusetts �? '<< : It- A 4 :: K .- DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building y0ti � Northampton, MA 01060 �SNiy 5‘. 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:G / ee' Location of Facility: Alf/1✓ewA The debris will be transported by: Name of Hauler: (5.4 - " 'C isiieL yG �n 77 tile, f- s�-�t- a W clf 4-61-6'4Jd ✓4,t o/okt Signature of Applicant: �� Date: lAvtiA =. They Commonwealth of Massachusetts Dt purfinetll of Industrial Accidents —; � I CongressStreet,Suite 100 „ toter sz, Boston,MA 02114-2017 ‘,,,,.. r ,,..: www.mass.Rovtdia 11ofkers'Compensation Insurance Afitlitsit:Builders'('ontractors!Electricians Plumbrrs. 'ID BE F1L1:1)N tin 111E PE111111111t;AI i i t►tiii, applicant Information Please Print Leitibh Name ilium:lino.Orpant,att.m indlvidual):j3c\� \\W.-A �` A _____ _ Address: VjeNik . \ City/State/Zip: \Or\t1\Q\ ' ©\Q c Phone#: t..;'‘ e' b r A_ Am yes tar empinyee?Cheri'the appropriate 1tp: Ty pr of project(required): I.711 I nit a employer with -_,.--..__entpk.}ecs[full arxt'ur part-tined•' 7. 0 Ne ' nstructinn _.trJ a sok proprietor orpmtnetiship and have no crupitayevs working fix air in g_ emodt:ling e�•any capacity.'Nu workers'comp.unurrttcr rcquenxt.] 9. Demolition i trtereeawtxr editing all work m}�if(No worker'comp.insurance required.] 10 0 Building addition am a homeowner and will lie hint*auntractun to conduct all work on my property. I will e71M4:that all contraetun.idwt Lac workers-cuap►nsatiun unutan-e or are sole 1 1.a Ekctri- repairs or additions prupncten with no einjaloyees. 12. tubing repairs or additions S0 I am a general contractor and I have hued the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and Mac workers'wont,.msuranke.; 60 w...an:a corporation and his utfrcis have exercised their right of exenlq.atual tier!ti(L c_ 14.0 011/er IS'_QI14).and we have no et ploynes.[No workers'e+wnp.iasleratr::remain-all 'Airy applicant that cheaka box Is must also till out lite MA:n.141 below%haulm then workers'cutnp.nsation policy attoci ration. t lain uwin:sa who submit this affidavit mdseathng the-[ate doting all walk and than hire outside e.xltra:to s:mat submit a new aflidacit uaivatmg such. '('untra:Wrs that,hcek this box must attached an addstionall sheet show mg[lac mutt,:of the sub-iunttae'turs anti,sole s he1ha ex not thorn*minim have employers if the sub-contractors kart ettrl�'�..xs.they mina pros idc that worker,'comp.puiiiy ntunivr. I oar an employer that is providing workers'compensation insurance for,a employees. Below is the policy and job►ite information. Insurance Company Name: �.._ _ — Policy#air Self-inns.Lie.#: _-----._.__ Expiration Date: Job Site Address: . City(slateiZip: Attach a copy of the workers'compensation policy declaration page(showing the policy member and expiration date). Failure to secure coverage as required under MGL c. 152.{25A is a criminal violation punishable by a tine up to SI.500.00 and=or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 co%grape(eritication. I do hereby c iJi'and he pains and penalties of perjury that the information provided abase -.s true and correct. Signature: 1)al:_ �� phones: ‘'\O�� 1� —� Q c%�t Official use only. Do nut write in this area.to be completed by city or town ofcial ('it♦ or'Iowa: PerntitiLicense 4 Issuing Authority(circle one): I. Hoard of Health,2.Building Department 3.('ity,"1'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ('ontact Person: Phone#: i ACORID® CERTIFICATE OF LIABILITY INSURANCE DATE""'"°°'"""YY' `+r--- 06►29r2921 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 CONSTCTUTE 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 Susan Fleury CIC CISR CPIA NAME: King&Cushman Inc. PHONE (413)584-5610 FAx (413)584-9322 P.O.Box 447 "/' (A/C�NoI: ADDRESS: sfleury@kingcushman.com 176 King Street INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURER A: Main Street America Assurance Co. 29939 INSURED INSURER B: AMn Hall INSURER C: 109 West St INSURER D t INSURER E: Hadley MA 01035 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2162904289 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 IN R TYPE OF INSURANCE INSSDD MD POLICY NUMBER 131.1 POLICY EFF POLICY EXP(NUvVDDlYYYY) (MNVDD/YYYY) LINTS Xl COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE I X OCCUR DAMAGE 10 RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A _ MPP6994G 04/24/2021 04/2412022 PERSONAL BADVINJURY $ 1•0•°°° _Galt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑ E LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: GDAL $ 25,000 AUTOMOBILE UABLITY COMBINED SINGLE LIMIT $ -- (Ea accident) ANY AUTO BODILY INJURY(Per person) $— _ — OWNED SCHEDULED • BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA I.IAB OCCUR EACH OCCURRENCE $ .— EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANY PROPRIETOR/PARTNERJE7(ECUTIVE ElN/A E.L EACH ACCIDENT $ OFFICER/MEMBER OCCLUDED? ( YInNH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) 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. AUTHORIZED REPRESENTATIVE _,4A0�C(,L_ rt..-J. .:-1 i-.JJ 6 iff88-40-15 AtOM CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 629 2021 irng0jpg Commonwealth ot Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construithi;141)pervisor CS-042574 pires: 06/26/2022 ALVIN M HA4. 109 WEST SY, HADLEY MA 01035 • Commissioner c/cr ,QA Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 167646 1 0/1 2/2420- 2 0 ALVIN M. HALL g71 ALVIN M. HALL , 109 WEST ST HADLEY, MA 01035 Undersecretary haps-//mail googl e.com/mail/u/1/#inbox/FMfcgzGlawNbqT v RgmGrnKZJfgCsV nv zh?proj ector=1 1 1 d /h' 3)N3? -1 -� t 0,.,z ><: v r A 4 Z 91 q