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37-008 (6) BP-' 022-0780 770 FLORENCE RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 37-008-001 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-2022-0780 PERMISSIONIS HEREBY GRANTE' TO: Project# 2022 CHIMNEY Contractor: License: Est. Cost: 1 SHAMROCK C&C INC CS-110401 Const.Class: Exp.Date:09/22/2022 Use Group: Owner: HIJAB CABLE, LAYLA Lot Size (sq.ft.) Zoning: SR/WSP Applicant: SHAMROCK C&C INC Applicant Address Phone: Insurance: 246 WAVERLY AVE (631)206-4409 WC712256997 PATCHOGUE, NY 11772 ISSUED ON:06/30/2022 TO PERFORM THE FOLLOWING WORK: INSTALL SS PIPE & CONNECTIONS FOR 2 WOODSTOVES IN LIVING ROOM &DEN &DAMPER IN DEN 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL TION OF ANY OF ITS RULES AND REGULATIONS. Signature: I 0 ) • I� � r • 7- Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner c � 6har'rr✓ck'C /►srrn�• ' P. s - , - 'IV b 410 z c" FR The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR 1 o MUNICIPALITY , Massachusetts State Building Code, 780 CMR ', USE Bufi.ig Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling �______J This Section For Official Use Only Buildin Penult Number:SPjp2 .-b7 80__,Z Date Applied: (o Pot 2oz2_ t�r.�� Irons 6-30-20ZZ Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 11 p F\or2ncQ P-D,N ar n Qtcn 87 oo ' 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: SRAJSP 1.fobacres 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 Ow er'of Record: Lay�a C. a a\C— Nof--1,4larn 1 !''.1- O IU(pZ Name(Print) City,State,ZIP 110 F‘drencc X2 .0 Con-5't -0113 LcAck\i(flak.@Coma:%.(ovn No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(checkpll that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) PO' Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: I n $411 4 5- n\cs 5 9e-c-1 5,4 k'5 vn1 ( P i re I� Con n cc ;dn S) -far 4 V.)GO d s-k .'t (rs 1 V i nC rdvvr) I pc..-e.- 4— 5 a rn e c n 5-l.41 14 4-Can i n 1 en 2 r w��4v�t_. n 5-�c 1 k e.rn Qc r n 02-6.-N 41/*/69 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: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ WO 0Q.. v J List: 5.Mechanical (Fire f Suppression) $ Total All Fees: $ Lob ' Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: S I a" e C,k, 2ySo $32'-'= mo 1-31oq 13o q 4 33°t ' DocuSign Envelope ID:DEB64825-06CB-40AC-9FD0-43C6018C80DD • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) (.5"‘,0y r 91 Z., 5 art.jt \ „�U'i,n o License Number Expiration Date Name of CSL Holder List CSL Type(see below) 9 fl , C n"4 w 4- A'v No.and Street Type Description �` h U Unrestricted(Buildings up to 35.000 cu.ft.). 5 t 0 1 0 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Bunning Appliances 4 13 5 ff1-(g15-0 s}1atntp4L'CorP3f�gYY1A.1 •f'^'t I Insulation Telephone Email address D Demolition • ` 5.2 Registered Home Improvement Contractor(HIC) i t q aaUS I l,p, '1 S 1``atn roc L C ' G i tV C- HIC Registration Number Expiration Date HIC Company Name or HIC Regist�rraarntt�Name and rc t zoo-440 9 Email address 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 lssuan 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 L QM` o. C.q'\� to act on my behalf,in all matters relative to wor eitlde3t this building permit application. Layla Cable 6/24/2022 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 m knowl ge and understanding. Cont\t.) t t'4n(c)—s/tmtot k C C HNC ( Zs \ zL Prmt 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 i (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,rnass.gov/task Information on the Construction Supervisor License can be found at w yy.n>ass,fmv,4p, 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 systcm Number of decks/porches Type of cooling system Enclosed Open '3. "Total Project Square Footage"may be substituted for"Total Project Cost" Cityof Northampton �a� :A.' 5.5 s, fMassachusetts ,f i:_ f<e w dek t' i' DEPARTMENT OF BUILDING INSPECTIONS �`. m =` 212 Main Street • Municipal Building 9;H 4�` ' 47:: -. Northampton, MA 01060 ssy .._30° 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: 5\\c,c0(D(--k (-$k C., kiNL C D\LAC;C,\ C.caitICi (1 The debris will be transported by: Name of Hauler: d \U<< t C. ar Vt, 1 �, 61zcl ) .2- z- Signature of Applicant: _ Date: ILI) `• The Commonwealth ofMassac1iaseas i'�=-r Department of Industrial Accidents iiiiiie._. _.,�►= 1 Congress Street Suite 100 :=_" Boston.ill.4 02114 017 tvww mass.got(eta 11u,ker.'('untpe vation insuranceAAl4asit:llolltktai('ontrstturvtEiretrkiar ePhrmhert. to lit, t ILLU WITH THt PltMIMI 1'1'I%G At I HON1 f 1. Antillean(Information Please Print Leeibh Name IBusiness tkr.ir.juurt indrviduaiI _ Sh pp t - G G�Qm C. (- In — Address: a L1(Q VJ es q eta t, ( ,v t City/State/Zip: li Olt_ U ‘1112- Phone#: 6131 —ZOQ 'yy09 kre seal as rnetaio lr('heck the appropriate hunt: Type a project(requiredl: 1�am a employer writ 3 •employees rfui)and or part•Irrwi• 7• 0 New construction :.fl I am a sok proprietor or partnership and have no employees workers; for nu in S. O Remodeling arty apaeay iNo workers'comp.i'a crane minims J 30 I am a ha.rneowner don all work rtyyell.!No%token'coup naaaatwe rc.ivary L)• 9. CI Demolition 1 b 0 Building addition 1 0 I am a honatrwtaT and wrll be tame contraeto s to conduct all work on nn rnaperty. 1 will .naure awl all,,rneraw-turs tuh:r have workers'ctnrgxna ttnn insurance of an yule I I.0 Electrical ical repairs or additions pruprw Iois...ail OD mnpluveta. 12.0 Plumbing repairs or&labi a .. 50 I am a general umuaeku and I hoe hired the solo-c.aruacturs Irat.:d ern,Ix atwcircd a&it Tb.se sub•cuntrxkan have employees acramd have workers'cramutsurance. 13 Roof repairs 4 e,.Q We are a curprrraaion and its ul•fiters have et.uv red their right of exemption per M(iL e I�.t-=-1'" J M `"7- 152.t 1(41.and we have Ix, sir employees INo vow/kers'comp rnanvc mourned.)ed.) 1 1 9L ON:Mil 4-1• •Any apptrcaaat that hooks bus,al saran into fill out the setidun below show mg their w.nkers vi•mrwraaii..ti pa•lr.v rntarna sera. ' ikanraownvn v<hu.uirmrt this aftidao rt in.iwatin5 flees an.Ja.ng all work and their tort taat>i.Se.i.ntrackr.rnia.t vuhnut a nee affrlav iI,odii..afreie sack 1l'amrn.kns that cheek tbs.loos must attn.:a l an additional sheet slarwmg the name of ilrc subcantravton and state whether'or not those entitles have employees It the hilt-,untracta,s lane etc aloyera.they moo provide their workers'comp.pnla.v number. l am an employer that is proiidiaq workers'compensation insstra,ce for my employees. Below is the polity and job.iite information. Insurance Company Name: C OC\A'; n e n \-0-r\ —• C 4,SQ.e\ (-C rr Q f11 Policy a or Sell-ins. Lic.n: W C.-11 a alSep'1 1-1 Expiration Date. \k\ z\a '.- Job Site Address110 1 \Ofenxe ( -O t00 cIty''Stutitlap: NOt'-vhame IIJI4 Attach a copy of the worken'compensation policy declaration page(showlag the policy number and expiration date). Failure to secure coverage as rewired under MCiL c. 152.§25A is a criminal violation punishable by a fine up to S I.SW1li) and'or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S2 50 00 a my against the violator.A copy of this statement may be lorwiarded to the Office of Ins estigatiuna,of the DIA for insurance coverage verification. I do hereby cerdfj•wader the pains and penalties of perjrry•that the information provided is true and correct. 9 Sigmawte'� G' Date: (.2 —2.Li' 2.Z Phone#: le"; 1 —2-v Ce M 4 C °7 Official use only. Do not'wise in this area,to be completed by city or town official ('Its or Town: Pernik/License as Issuing Authority(circle one): I.Board of health 2. Building Department 3.('ity''f nun Clerk 4.E lectdrieal Inspector S. Plamblog Inspector ' 6.Other Contact Person: Phone#: 1 • 110 - THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affaig4� '�t - Suite 710r and Business Regulation 1000 Washin t 9 Boston, Massachusetts 02118 Home Improvement Contractor Fie istration INSIIIIIM id: :In Out of State Corporation .....r.a,�,._.,.. YP SHAMROCK C&C INC $ �. .N...d:e. ation: 192205 "" .- ,.. f 246 WAVERLY AVE - , ation: 06/18/2024 PATCHOGUE. NY 11772 _ _ yilki � -* - -- N _.__...._..� .v_tee. ._-_.�,__ Update Address and Return Card. • 6/24/22, 11:25 AM Details Licensee Details Kull Name: Samuel Jusino Owner Name: License Address Information amity: Springfield State: MA Zipcode: 01104 ,Dountrv: United States License Information License No: CS-110401 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 3/29/2021 Issue Date: 12/8/2016 Expiration Date: 9/22/2022 License Status: Active Today's Date: 6/24/2022 Secondary License Type: Doing Business As: Status Change Reason: License Renewal PrereltiNfte Infnrmat ion No Prerequisite Information No Available Documents https://madpl.mylicense.comNerification/Details.aspx?result=e6308a67-9c5a-4f8c-b98b-3f45c48c77cc 1/1 ACG CERTIFICATE OF LIABILITY INSURANCE DATE (MM6!O 0 2 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 NAME: SPECIALIZED INSURANCE&SERVICES PHONE 631-7btRi180 FAX 6�3, 1-758-6/81 204 RTE.112 (A/C.No.Ertl: MAIL.Not: E-MAIL SRU SPECIALIZEDINSURANCE.COM PATCHOGUE,NY 11772 ADDRESS; Auto-Home-Business-cycle-etc. INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:ATLANTIC CASUALTY INSURANCE CO 1 42846 INSURED INSURER B;Entinental Casualty Company 1 524126 SHAMROCK C&C INC INSURER C: 246 WAVERLY AVE INSURER D: • PATCHOGUE NY, 11772 INSURER S: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE AWL SUER POLICY EFF POLICY EXP LTR kVSD WV() POLICY NUMBER .2dhilDOPITYTUMMIDOMCM LIMITS A X- COMMERCIAL GENERAL LIABILITY Y N L268000803 8/30/2021 8/30/2022 EACH OCCURRENCE $ 1,000,000 • • DAMAGE TO RENTED CLAIMS-MADE OCCUR I PREMISES Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ' 2,000,000 X POLICY I I JEC LOC PRODUCTS-COMP/OP AGG $ 2.000.000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Me accident) ANY AUTO BODILY INJURY(Per person) S — OWNED —SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) , $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DEO RETENTION$ $ WORKERS COMPENSATION - PER OTH- AND EMPLOYERS'LIABILITYWC712256997 X STATUTE ER Y/N 1/12/2022 1/12/2023 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDEXCLUDE FriN/AD? (Mandatory In NH) N E.L DISEASE-EA EMPLOYEE $ 1,000.000 II yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT;$ 19nn(Inn 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CARPENTRY-INTERIOR;DRYWALL OR WALLBOARD INSTALLATION;REMODELING INCLUDING ONLY THOSE CLASES SHOWN ON REQUIRED FORM AGL-REM CHIMNEY CLEANING CERTIFICATE HOLDER BELOW IS LISTED AS ADDITIONAL INSURED AS PER WRITTEN CONTRACT OR AGREEMENT CERTIFICATE HOLDER CANCELLATION SUFFOLK COUNTY DEPARTMENT OF LABOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LICENSING AND CONSUMER AFFAIRS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O BOX 6100 ACCORDANCE WITH THE POLICY PROVISIONS, HAUPPAUGE,NY 11788 AUTHORIZED REPRESENTATIVE 'I ©1988-2015 ACORD CORPORATION.I All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD . 6/24/22,.2:26 PM Details Licensee Details Demographic Information Full Name: Samuel Jusino owner Name: license Address Information City: Springfield State: MA Zpcode: 01104 ,:ountry: United States License Information License No: CS-110401 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 3/29/2021 Issue Date: 12/8/2016 Expiration Date: 9/22/2022 License Status: Active Today's Date: 6/24/2022 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prrrerpfelte Information No Prerequisite Information No Available Documents ail https://madpl.mylicense.comNerification/Details.aspx?result=433e0bec-79f4-4ab9-af8d-5834339d87ae 1/1 Shamrock C& C Inc. PROUDLY SERVING MASSACHUSETTS EmmaCORPORATE OFFICE 192205 1. --fx• a� � mo 246 Waverly Ave. ,�: ��� Patchogue, NY 11772 it j 0 mom= CALL! "`��m'�. Service * Repairs * Ins011ations 1 SHAMROCK CNIMHC 1 -888-737-0903 Licensed*Bonded*Insured Customer /Yl(s ab/c. Telephone !�`'-�f 'O�g3 Address 7 7O ( D eh ce- Email Town A0(441 sAIP4ron ,4 Date a-a,),. Time It 7)Crown llr. 11 -�a.L1 ev 'S�avoo � ss 5:e-ei 1)Cap 't r tf.,"4, w Jaye > �' j ' i Rep1O l-* ©IiwT 2)Flue ` 8)Flashing . /19 514 lir,:0 ev 4 less S4-e--t,k .,.., at , i 1/VI ><1 TtVr �/000j�5-ro✓t (riA kueet aacG I= == —NM._. /� �/ a: �2 9)Throat it !ICU/ Clam 4v 71. 0�� 7 6 3)Brick -- 1u �/'/ . M 1 kktoSea I --Va L1 n • 4a it, M�� �",�1} rtar .-. r t _ 1 :* 10)Damper i i 0 -- - rn I/Lk-444? tiotaavt 41 5 44 5 5)StovePipe a l �'_>.' W, 11)Firebox a I Mr: \ w_ _- \ WM u. _ V/SA i!,I Cash-Check# SUB r_- Card# { A = I TAX Codef U. Security There is a$30.00 [ ■ it, CC Billing Zip fee for any check .? ? ` r' J returned for any reas J TOTAL 6)Soot Pocket 12)Ashpit / SPECIAL ORDER //PROPOSAL Start Date: Complete Description of Work to be Performed Completion Date: Si° Total Cos . i -rDeposit on Work: 1100 4 Balance Due Upon Comple ioi tioac We propose hereby to furnish material and labor-complete in the accordance with the above specifications YOU THE BUYER, MAY CANCEL THIS TRANSACTION AT ANYTIME PRIOR TO THE MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE REVERSE NOTICE OF•CANCELLATION FOR AN EXPLANATION OF THIS RIGHT Contractor or Authorized Representative Shamrock C&C,Inc. (1/We) have read the terms stated herein, they h e been ex fined t (me/us), an (I e) find them to be satisfactory and hereby accept the ��� _� Signature of Homeowner or Authorized Pa — Date d