32A-242 (3) BP-2021-2032
127 BRIDGE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-242-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2032 PERMISSION IS HEREBY GRANTED TO:
Project# INTERIOR RENOVATION Contractor: License:
Est. Cost: PIONEER CONTRACTORS 017890
Const.Class: Exp.Date:01/19/2022
Use Group: Owner: CAMPBELL. AMY
Lot Size (sq.ft.)
Zoning: SC/URC Applicant: PIONEER CONTRACTORS
Applicant Address Phone: Insurance:
PO Box 1145 4136267267 WCC5005957012021
NORTHAMPTON, MA 01061
ISSUED ON:10/15/2021
TO PERFORM THE FOLLOWING WORK:
INTERIOR RENOVATION, WINDOWS AND 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.
Signature: Iel ' if
O -
y,
I
Fees Paid: $1,950.00
212Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
s
The Commonwealth of Massachusetts
W Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-of`,Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: £j 0- Al. 20 3-1 Date Applied:
BuildingOfficial(Print Name) Signature ' I Da
;�
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
i 2Z af,6oe) 3 2 2-tz.
1.la Is this an accepted st et?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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 Sewag osal System:
Public Er'
Private❑ Zone: _ Outside Flood ? Municipal B On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.m(Prin f,eco1 (; n 7f 1 AAA' OID/
C�, re, 1V Cal/
Name(Pn City, State,ZIP 1
Z? '+ e S"�' L o 3 7 7 7- 1) Cavit �'e�11031 0..A6\'•Cc.1)(--
No.and Street Telephone Emlail Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply).
New Construction❑ Existing Building IV Owner-Occupied ❑ Repairs(s) 0 Alteration(s) ® Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: IL. A
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ ..?3 f Gf� 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $a q, O� 2. Other Fees: $
4.Mechanical (HVAC) $Ab i OWO List:
5.Mechanical (Fire $
Suppression) Total All F s� 60
Check No) Neck Amount: `1' Cash Amount:
6.Total Project Cost: $30-0j Op 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts r4 _ `' ,
DEPARTMENT OF BUILDING I S ONS :
212 Main Street • Municip
^� Northampton, MA 0 060 .P .. A>v
QED
OCT / 4 2021
npp
NORTH 0t08yr
PROCEDURE FOR OBTAINING A BUILDIN ;' '�a., `'S W
1 & 2 FAMILY DWELLING,ADDITIONS, POOLS,DECKS,ACCE STR CTURES,
FENCES, GROUND MOUNTED SOLAR,ETC.
1. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specification of proposed work(digital and hard copy).
3. Site Plan with location of proposed structure(s)and setbacks.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/replacement windows).
8. Home Owner's License Exemption Form filled out and signed by homeowner(if applicable).
9. Note any Conservation and/or Special Permit requirements (if applicable).
10. Driveway Permit(if applicable).
11. Proof of Water and Sewer entry fees paid(if applicable).
12. Trench Permit-public land by DPW/Private land by Building Dept.
13. Stretch Energy Code—all new construction will require a HERS Rater Affidavit to be submitted with
permit application before issuance of permit.
)14' poalsh fr73 64711/Q
e-S-Firna 6k C4 f�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C Gs — 011 10 I (1cl)L7.—
a 1 A License Number Expiration Date
Name o CSL Holder
'^/ List CSL Type(see below)
No.an�Street 1v� Description
\) k q A _ 0 `orl� l 1 U Unrestricted(Buildings up to 35,000 cu.ft.)
J`�` Restricted 1&2 Family Dwelling
City/Town,State,ZIPQ Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Register@d Homy Im ovement Contractor(HIC) 13`I D' ,/' qIr}(2.
D v� L//fib HIC Registration`( Number Expiration Date
HIC Co any Name orC Rea Name
No.and ()I a(lt�4-74/ ('(/�P�i K&L i&DIA
— '7 2 7 Emat address 1
4020
City/Town,State,ZIP Telephone V
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 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 v(.�
to act on my behalf,in all matters relative to work autho ze by this bui ding permit application.
(ivv y cpriiTheil g —Z7-2J
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
�v d accurate to the best of my knowledge and understanding.
� 66,L )1 1 ji 1z 1
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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. 142A.Other important information on the HIC Program can be found at
www.mass.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 half/baths
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
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
;c" r�
r
.r--
Massachusetts
_` r
A ' "s`q DEPARTMENT OF BUILDING INSPECTIONS °� i
.v. ' 212 Main Street • Municipal Building
---•*,, Northampton, MA 01060 w3
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: \ifiR Gk
The debris will be transported by:
Name of Hauler: tiS f
pp /
Sig nature of Applicant: 719 a /�7 Date: 2- (7-1>
The commonwealth 31assachusetts
Department of Industrial Accidents
;44 I Congress Street.Suite 100
- 71.
Boston..11A 02114-2017
www.mass.govidia
ui kers' Compensation Insurance.4tritiant it:Builders/ContractursiEkctricians/Plumbers.
Bk:FILED WITH PERMIITI.NG At11it)R1 I .
.‘itplicmit Please Print i.etzibi‘
Name 4 1.111SIIICSic()1 .1111lition.
Address:
CityiStateiZip: Phone#:
Ant yea an anplayell Cheek the appropriate but: Type of project(required):
La I am a employes*rib anp.11):!24: (flat raaviitte),.• 7. 0 New construction
21:I am a iole proprietor or lyartnerilup and have no employees working for an:ar 8. 0 Remodeling
any capacity [No x‘oricrx;comp.insurance required.]
9. Demolition
3.1::1 I am a lairra.xiwnel dtlinS all work myself.[No workers'edttli imurance extquired.r
10 ci Building addition
401 am a homeounn and will he hiring contractors to Lxinduct all W.vk on my property, I Will
ensure that all contractors either have wxnkeri"compensation insuranne or are iole 11E3 Electrical repairs or additions
proprretori ith xinployees.
12.0 Plumbing repairs or aiktitions
SCI I am a irentmal coati-avian and 1 have hired the istb-eurstr.scitsrs listed on the attached shox.L.
110 Roof repairs
Ther$e stlh-e0ratritetrItN hike employees and have voorkeri.comp.insuraitee.:
14. Other
6.E3 We are a corporation and n officers have exinciacd them right of ea:en:piton per
152,§141.and !use au employees.[Nu workers cump.inatItuntC
*Arty applicant that atzelo.box1 MAW Attu all out the section Nelus4%buss me their notitera'eranpriniatiun pulley informatosa.
*tionreuwriers who inhere thanatlitlavrt 41A:renting they are doing all work and then him outside contanctarri nun/itikanit a new;Aro/snit intinnting inch.
1"Contrainurs that check dux box must at melted an additional iheet showing the name of the sath-eontracior,and'tate whether or Out those
ainplo.....e.e. If die sch-conmactorx the!,mini irt or 1,1..ra, workeri'
lam an employer that is providing worAers'compensation insurance for nry employees. Below is the police anal job site
information.
Insurance Company Name:
Policy 4 or Self-Ms.Lie. 4: Expiration Date:
Job Site Address: City/StatelZip:__
Attach a cops of the roorker%' eolupensation policy declaration page(showing the policy number arid expiration date).
Failure to secure coverage as required under NICiL c. 152,§25A is a criminal violation punishable by a fine up to S1,500_00
aridior 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°trier of Investigations ot'the DIA for insurance
coverage verification.
I du hereby eertlfir under the pains and perialtie.+ ufPrjisrr that the information provider/above is true and correct.
Signature: Datc.
Pilonc 7::
Official use(Hill-. Do not write in this urco.tar hi'Completed hy city or town official
' tits or'Fawn: Permitil_icense A
Issuingauthority(circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. l'Iumbing Inspector
6.Other
('itritact Person: Phone 4;
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LEGEND
a Inn Pipe (Found)
• Inn Pipe(To Be Set)
♦ Drill Hole Sal In Cant.Driveway
TOW=Top el Watt
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}Jew errec.*
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how.Stereo() � !v Book lan6hPaea
Dave Dooms •'
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peek mu./So m.
Plan Of Land In
Northampton,Massachusetts
NO.
I) Thepeal.ee shown lerw.n dteeen.atsaveyd to AnnC.nrhdl by J.dad(oanlet a We Surveyed For
Hanpebla CounY Heptaer el Da.in Bwk 13073.Pegs IBS.
21 The Wm.J dilute•Nmisr3 and Oe vertical Uwe oNcvDlae. AMY CAMPBELL
1) Eitedaa•hew art a•I tam mew ueerval.
April S, 2021 Scots: 1" = 20'
I certify tat thapopettySen Atom hereon we Inc lraadioiAmp
"•ing ownoo*pe,Ina he Iona of ovate wed ways shown we
d im of Mkt.prin to woo or.,"dmdy emb lidol,.od Swim Bo:
shale('T.lip fa .m*rismof amine aenhyu fa s•.r oar RJCIUBO shale('ew LAaAIU:C a SON
m.o.,I feet..rtiy Act des pen tau lam papered in y.....
g overnance with the MondAepoi0oru of the Regime(of Dods. e,e.,,..e r.+.+.n tw n
Sala I.-Sit cps w.theroeat Reed
v Aft 1B 'It.mnrem Me Oleos
Prow 10W lard Surveyor
/..a-7 '�ciSe-S
The Commonwealth of Massachusetts
_. , � Department of Industrial Accidents
—.towel= 1 Congress Street, Suite 100
mi
_i_ Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual): caOsai).c ✓ V'( ((s
Address: 9 o. 1 I t-}j 1'1/�' r\vN1 N1P" of 7(
City/State/Zip: Phone#: L113- c<47` S
Are an employer?Check the appropriate ox:
Type of project(required):
I. I am a employer with employees(full and/or part-time).' 7. ❑ New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. fEl Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. El Demolition
10 0 Building addition
4.❑I 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.E Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.0 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.t
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#1 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: 56c k5W1],
Policy#or Self-ins.Lic.#: L cc, S?5957-ZpZ/A Expiration Date: (.91"5`Lz--
Job Site Address: (2-fi ✓ ' City/State/Zip: \c c r)i)
Attach a copy of the workers' compe sation policy declaration page(showing the policy number an e (71()xpiration 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 e pail's and penalties of perjury that the information provided above is true and correct.
Signature: Date: /(7/I t f/u
Phone#: 4.1(�
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#:
s�xc
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company •
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800)876-2765 NCCI NO 40959
POLICY NO. WCC-500-5005957-2021A
PRIOR NO. WCC-500-5005957-2020A
ITEM
1. The Insured: PI Con Inc
DBA: Pioneer Contractors
Mailing address: P O Box 1145 FEIN: "`1984
Northampton,MA 01061
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period is from 06/30/2021 to 06/30/2022 12:01 a.m.standard time at the insured's mailing address.
3. 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 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 000063757
INTER SEE,CLASS CODE SCHEDULE
Minimum Premium $393 Total Estimated Annual Premium
GOV GOV Deposit Premium
STATE CLASS
MA 5437 State Assessments/Surcharges
$1,642.00 x 3.5100%
This policy,including all endorsements,is hereby countersigned by 'r` 7 C_ 05/27/2021
Authorized Signature Date
Service Office: King&Cushman Inc
54 Third Avenue P 0 Box 447
Burlington MA 01803 Northampton,MA 01060
Wt 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with Its permission.