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18C-083 (6)
B P-2021-2070 242 JACKSON ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 18C-083-001 CITY OF NORTHAMPTON Permit: Acc Structure PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-2070 PERMISSIONIS HEREBY GRANTED TO: Project# ACC STRUCTURE Contractor: License: Est. Cost: 14670 BRJ BUILDERS LLC 112410197960 Const.Class: Exp.Date:01/09/202202/11/2022 Use Group: Owner: KATZ-BRANDOLI JENNIFER & ERIC M BRANDOLI Lot Size (sq.ft.) Zoning: URB Applicant: BRJ BUILDERS LLC Applicant Address Phone: Insurance: PO BOX 505 (413)800-4253 WCV0148400 BERNARDSTON, MA 01337 ISSUED ON:10/25/2021 TO PERFORM THE FOLLOWING WORK: ADD ELECTRIC SERVICE, INSULATION &DRYWALL TO ACCESSORY STRUCTURE 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: Fees Paid: $97.50 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner z -o�z REC Co onwealth of Massachusetts OCT 2 n�}�and f B ilding Regulations and Standards FOR 261'assa hus s State Building Code, 780 CMR MUNICIPALITY USE ermit App 'cati n To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 DENT NOOFR BTHgMP nN UILDING INSPECTIONS On -or Two-Family Dwelling MA 01000 This Section For Official Use Only Building Permit Number: 6P-a i -A0 7 o Date Applied: f(5)\f)hAth'-1 11-1147 1 l Building Official(Print Name) Signatures SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Asses rs Map& Parcel Numb s zyiSac..�s.en-, 1.1a Is this an accepted street?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 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: 3enn�4er I(& - ilranaoli NoHAncu 1p#bn ) M11' OiO(QO Name(Print) City,State,ZIP g41,11 Ju. r' S+. y13-S4g-(.,3b jennta1 -tbrandoil ; C18 Mai l .coN 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) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. Bi' Number,of Units Other 0 Specify: Brief Description of P oposed Work2: P,(� Co ri C SeJV Cl1 I Ins t.td 1k, �t.t,) M 4-.0a shed 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: 2.Electrical $ CIStandard City/Town Application Fee Cl Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ Li4t: 5.Mechanical (Fire $ Suppression Total All Fees:/, *co Check No. 2 ll(neck Amount: . Cash Amount: 6. Total Project Cost: $ (L l —10 .CO 0 Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL.) ' C Z 44'4 1 / at.m l'r1qt. . John License Number Expiration Date Name O CSL Holder O 5 List CSL Type(see below) aK 'nS No. and Street Type Description M 6. ©� 3�j..] Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town, State,ZIP M Masonry • RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances-6°0-1(Z,,c'3 eel BCiballeux..t:.m,rh I Insulation Telephone Ema address D Demolition 5.2 Registered Home improvement Contractor(HIC)663- ,et 79 4 �/i, t �� +�`�' ( �''�'C- HIC Registration Number Expiration Date IIIc Company Name or I1IC Registrant Name P.b. C oe St/S- Gen a� c ' bpi I owe fs. N .and Street Mail address n �113�8'DD-�/2S� City/Town. State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152.a 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 . 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 l�.e^;ot,.i% ; r1 g• -abhni to act on my behalf,in all matters relative to work authorized by this building permit application. enn; .r 16a4-z— Qr-zun do( i i o / 1 c /2oz I rint Owners ame(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. Q, n to 1 Je /2021 Print Owner s 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 CHIC) Program),will ne(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.mass.govioca 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" The Commonwealth of Massachusetts t•--l` '�� Department of Industrial Accidents - �_= 1 Congress Street,Suite 100 i311 Boston,MA 02114-2017 y www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTIIORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ef 3 (ems i t ck-ef-S Address: P. D . BOX 577S- City/State/Zip: 13-e-M a-r+on j N A- oI 337 Phone#: If/ 3- Soo (I s Are you in employer?Check the appropriate box: Type of project(required): em a employer with _ employees(full and/or part-time).* 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working forme in 8. ❑Remodeling any capacity.[No workers'comp,insurance required.) 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.)t 9. ❑Demolition ur 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will ]0[]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.0 I em a general contractor and I have hired the sub-contractors listed on the attached sheet 13.ORoof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[Other CV-LC `—" 5,001 4466• Jkt4 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 wink 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 fob site information. Insurance Company Name:__441. _�__Cj- ► t-t r:... . e Policy#or Self-ins.Lic.#: W 01_9 ' `'(00 Expiration Date: Ps/ 114 ( zo 22 Job Site Address: a y 2 Tat, n ,s�' City/State/Zip: 'NC yam p+an / / Pr OIO(tI 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 certify under the pains and penalties of perjury that the information provided above is true and correct i a Dat : 10 /9 20Z1 Phone#: q i ZOO- 42,S3 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#: 45 t �.-ys i'r ° � ' " ru t 49A° ).` 0A { r Yip it }w -'' : S • Y S� 7 c�•� 5'',T � 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 06B 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. Code Premium Basis Total Rate Per Estimated Estimated Annual $100 of Annual Classifications Co 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) $6,941 25 New Chardon Street Boston, MA 02114-4721 Cc tQ•'o, A ; (I Issue Date 01/26/2021 Countersigned By: ` ( Date Copyright 1987 National Council on Compensation Insurance Form: 100mvnt4 City of Northampton s$..r.. sic • �a✓ ' Massachusetts A.- ,.. '<e ryi i' ; x' DEPARTMENT OS BUILDING INSPECTIONS S. ;� �y 212 Main Strut • Municipal Building % ^' Northampton, MA 01060 ao f . ,1 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: Q flay S+ • 4-fet-4- act , 0-4 FF- 6163 The debris will be transported by: Name of Hauler: A �a 1S+ Tt.��.,kc�ngnC Signature of Applicant: Date: 10 I /q / 20 Zt