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31A-288 (8) BP-2022-0162 93 WASHINGTON AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31A-288-001 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-2022-0162 PERMISSION IS HEREBY GRANTED TO: Project# insulation Contractor: License: Est. Cost: 6000 BRETT SAHARCESKI 110761 Const.Class: Exp.Date:01/16/2023 Use Group: Owner: CHURCH,BENJAMIN &DEEPALI MAHESHWARI Lot Size (sq.ft.) Zoning: URB Applicant: FINE LINE BUILDERS LLC Applicant Address Phone: Insurance: 29 TAYLOR HEIGHTS (438)342-9831 PLA5026-PCCM374846 MONTAGUE, MA 01351 ISSUED ON:02/22/2022 TO PERFORM THE FOLLOWING WORK: BASEMENT INSULATION 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I cs:/6a, Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner , tiSI''' ' ,.., / `1. ----9 5 ., The Commonwealth of Massacht#�etts /1/ WI'''. Board of Building Regulations andSta /ds �.8 7, Massachusetts State Building Cod 78g R 8 2 ICS ALITY Building Permit Application To Construct,Repair,l olish`h evil Mar 2011 One-or Two-"Family Dwelling `9�i1`''tir, This Section For Official Use Only 4:"'�9 o ri,-, o Building Permit Number: bp' *4d,- io Z Date AI lied: / '1.6)4tAf,„ , \ I 0 dAaZiA Building Official(Print Name) Signature 0 Da SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbejs q Washes. -ktyn �/ (k� I.l a Is this an accepted street?yes )(; no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(tt) 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: Zone: Outside Flood Zone? Publics Private❑ Check if yes Municipal la On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ,r, 1cx r 1 Qy ccIN_ ./Uo h•Nvrpi M 44 0[0(00 Name(Pont) City,State,ZIP G3 Wayri4n� ? hP7 btit-3(p'13 Sus' 1 ben 0....erma►%1,C No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building El Owner-Occupied ❑ Repairs(s) 0 Alteration(s) f Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work': 13 on - - - AcieJ 4/0` o4 Tny,Lr 4 ork 1 Anm, 51.22-4ttx- -- )-a -Coundq'Eich Wal1S aond C r1(Oct Sub`CrlCI'r at`121S SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ (0,000 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) 7/Total All Fees:$ _ j n ,^ �`� Check No. i t Check Amount: LA, Cash Amount: 6.Total Project Cost: $Wr coo Cl Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Q CUhc c Gejk i License Number Expiration Date Name of CSL Holder 1 7 1 I Uy Ioc 9h-�s List CSL Type(see below) U No.and Street J Type Description ( f -t U Unrestricted(Buildings up to 35,000 Cu.ft.) / Q Tit /,I d f o's< R Restricted 1&2 Family Dwelling City/Town,%hie,ZIP M Masonry RC Roofing Covering WS Window and Siding �7 2 SF Solid Fuel Burning Appliances -9Z y-(�3y?) Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) FLing Zu`,Vde i LLC_ HIC Registration Number xp on Date HIC Company Name or HIC Registrant Name ,,, P No.and- OMeet� i VIAC JM-r t SF-`1ek%tNe 0 14.j<J LL' ory n*„q MA Email address Arkn, - Ot3s7 /�-s3y-Z3g8 City/TowN State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.$ 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 '14No 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 bQ.* Zglrat-c,esk, / Fi tte bill_ v 1 Id-WS ( to act on my behalf,in all matters relative to work authorized by this building permit application. e UPCiu ) Z /S ZDZD2yStrlerViiY\ s Name Electronic 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. Print Owner's or Authorized Agent's Name(E ectronic 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.) ZZO (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" it A O CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) O 1/24/2022 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 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 Customer Service Department NAME: Target Financial&Insurance Services,Inc. PHONE (800)450-8013 FAX (800)434-8053 (A:C,No.F-x0: (A/C,Noy 3250 Grey Hawk Ct EMAIL certificates@tgfis.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Carlsbad CA 92010 INSURER A: Preferred Contractors Ins Co. 12497 INSURED INSURER B Fine Line Builders,LLC INSURER C 29 Taylor Heights INSURER D: INSURER E Montague MA 01351 INSURER F: COVERAGES CERTIFICATE NUMBER: GL 21-22 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 ADDL UDR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD VIVO POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) LINTS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED CLAIMS-IMADE OCCUR PREMISES IEa occurrence) $ 50.000 MED EXP(Any one person) S 5," A PCA5026-PCCM413917 10/07/2021 10/07/2022 PERSONALBADV INJURY $ 1,000,000 OEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ,ECT LOC PRODUCTS-COMP/OPAGG S 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) S �r OWNED SCHEDULED _ AUTOS ONLY AUTOS BODILY INJURY(Per aAeM.. ) $ HIRED NON-OWNED PROPERTY DAMAGE - S _ AUTOS ONLY _ AUTOS ONLY (Per accdent) S UMBRELLA UAB OCCUR EACH OCCURRENCE S —, EXCESS LIAR CLAIMS-MADE AGGREGATE S DER RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTNE N/A E.L EACH ACCIDENT S OFFICERMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes.desade under DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICI PS(ACORD 101.Additional Remarks Schedule.may be attached if more specs is inquired) Verification of Coverage 'Subject to all policy terms,exclusions and conditions' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Verification of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton ,Iiiazi.14, G Massachusetts /"' / R .• ,. j DEPARTMENT OF BUILDING INSPECTIONS 212 !Bain Street • Municipal BuildingJ� P�� Northampton, MA 01060 �3'Nh, ,,.�� 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: UcLQy Q_GiL\i n,) The debris will be transported by: Name of Hauler: i�2 L ",\cLS S (.L-C__ Signature of Applicant: �� Date: 2Zl N,2Z .A __ The Commonwealth of Massachusetts ,' : ; :: Department of Industrial Accidents - � I Congress Street.Suite 100 a _ Boston.AIA 02114-201'' s'K'w.mtLcs.g(w/dia 11 vvi hers' ( ompcnsation Insurance.tffitla'it:Builders(-ontractorsiEkctricans1Plumbrr._ 10 131.11111)1A 1111 1 III. 11:K'II I II INC-tt 111(►KflV. -tiulieaut Information Please Print I.rtilds Name(Nu i- cle ..t►r_i'a lt 1,i/.allot , Awl): cp_ ti�.e...._ V t‘llX=1 L. .iC._... Address:_? ( .T-ck y l o-k c3yt-f-S CityIState1Zip:Fiore.- k Al,- 013s1 Phont: : fi - 6 3 y- Z3`l3 Aie Jr.....IY!Y er?(lud the 4ppnq►rlaic Inn.: l y,pe of project(required): am a employ is ash employee.(lull anal in part-Beni).• 7. New construction 1. t JUL a.ark proprietor or purtnat op and ti no employee.nonfinite lax me In R. 0 Netntconstg any:apacrty_[No aax(cr.'o.iq+.ua.uranat ngosrcdf �"i 30 loin a h mnrinmet tlouw all war(rows)).(%u nations'comp urwrance required.l 9. ❑ Iknioia ton .i.0 lam a lwmxwwner and%ell lir hu anod,m. omit:I or.to conduct all nod,on my propcats I a AI 100 Building addition muse that all:anitr.rtar,either lose Ro k. s orimpcmation nr+uranv.art ate*A: 110 Electrical repairs or additions proptkton.with no employees_ 12.0 Plunthtng repairs or additions s 3CI I am a general contractor and 1 ha.c hued the wb-contracivn lured on Ill:aitaaltad.IICJL 134:2 Root repairs Ille,e sub-canttaata+r+brae rinpl0y1:4:+and lune avrLta- comp.ucwraiw:e.' 6.0 We are a etttrrratlanl and it.officer.lune crietct.ed then Eight of exemplum per M(:L e. 14.0()diet 152.1114t.and nc Ita.c no airployec.-IN.,aaK(tn'comp.tnwranccn-quucd.l *An.applicant that chock.lrr. .l niu.t atw till out the seta+n Isla*sholA mu then warms,'rasnrpetisat ra,140,intOrmation- $lknneawners nh,.ulnutl Ili..altitltait aldleatun thess are daMnv all nork and then hue out.tak eaartraetvr must,Aiknint a nee attain it indicating.itch. 3Conttactor.that.he.i.ilir`I.,.a niUel attrw'Ikd.ni addliion.11 sheet shou mg the none a/I Its:cut-4:41nitactors and.late whether an llat Ilwisa'tiltltle:.ltaac employee. I' .i.ha.a:employee.,ttir_ti must ptalatde then -i orler.'coop.11,016,4 ntunbet. I am tin employer that is providing workers'compensation insurance for awns employees. Below is the polity and job site in/nrmation. Insurance t oinp it> Nairn:,___ Policy#or Self=iris.Lie.tit_ 1•:spuation()ate: Job Site Address: t its State lip.. Attach a copy of the workers'compensation pulic declaration page(showing the polio., number and expiration date). Failure to secure coverage as required under M(iL c. 152.§25A is a criminal viol:ltion punishable In a line up to SI.5O(LO0 and or one-sear imprisonment,as well as end penalties to the fixm of a STOP W(IRK()KUI:K and a tine of up to S250.00 a dais apamst the s iolator..A copy of this statement gray be forwarded to the(►like of Im e.tidratious of the 1)11 for insurance .a it 4.C.1'_.0 1 eriticatton. 1 del hereby certify under the pain and penalties of perjure'that the information presided abase is true and correct. Sivnaiure: (,''t 1)ate-: 2//S /2 7--- Phone : y/3 ''5�y Z 5,- (Ifficia1 use only. Do not write in this area.to be completed by city or town official City or Town: ___ Perniilll.icense Si Issuing.tuthurit:oi (circle one): I. Board of Ilealth 2. Building Department 3.('its "town Clerk .1.Electrical Inspector 5.Plumbing Inspector 6.Other (.untart Person: Phone#: City of Northampton i4; `5 s,. Massachusetts A. ' r �� DEPARTMENTOF BfJILD:NG INSPECTIONS �A. � � l" 212 Main Street •• Mucipal Building - f t Northampton, 01060 �°f'iv .t':i‘� HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, JCtm(Y\ C,41vtfc. (insert full legal name), born (insert month, day,year),hereby depose and state the following: 1. 1 am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. 1 am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a home owner. 4. 1 do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building C,do's requirements for the supervision of the project or work on my parcel, 1 am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this 17 day of / -- , 20 2 Z __ 0 ___,,___, (Si ture)��