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23A-087 BP-2022-1060 14 PLYMOUTH AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23A-087-001 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-2022-1060 PERMISSIONISHEREBYGRANT TO: Project# 2022 PORCH REPAIR Contractor: License: STEPHEN D ROSS GENERAL Est. Cost: 15000 CONTRACTOR 079160 Const.Class: . Exp.Date:04/28/2023 Use Group: Owner: GARTLAND AGNES E Lot Size(sq.ft.) Zoning: URB Applicant: STEPHEN D ROSS GENERAL CONT CTOR Applicant Address Phone: Insurance: 36 SERVICE CENTER RD (413)584-1224 WMZ-800-8006546-202 A NORTHAMPTON, MA 01060 ISSUED ON:08/26/2022 TO PERFORM THE FOLLOWING WORK: REPAIR FRONT PORCH IN SAME FOOTPRINT 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 VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: _52 11. ' • III Fees Paid: $98.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR r` Massachusetts State Building Code, 780 CMR MUNICIPALITY USE Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011 i" One- or Two-Family Dwelling This Section For Official Use Only Building Permit Number: I3P ZCZZ-/O&tt Date Applied: 40...) /1Lvs //' 2 g.ZG, ZOZZ Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address; 1.2 Assessors Map& Parcel Numbers /q Plv]�te.µ-1... 11 2 ft _'©6- 7 — OO / 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: U/03 ;/ ' aeme_. 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 caner'of Recor n-► G �I..,d %'C- ,-- 144 Dll 6 Z_ ame(Print) City,State,ZIP L /y �4,3io.p.- e✓,e- 73Z-5`-/)--"V7 f. " Q -c CO,*ewij. hA- No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check allthat apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) I Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units p Other 0 Specify: Brief Description of Proposed Work': Tat ✓ .,*/•' fpp('Q-1/\ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ mde'o . r✓ I. Building Permit Fee: $ Indicate how fee is determined: i ❑ Standard City/Town Application Fee 1 2. Electrical $ � 0 / ❑Total Project Cost3 (Item 6)x multiplier/6 "` x 6,, .- ' 3. Plumbing $ C' — 2. Other Fees: $ 4. Mechanical (HVAC) $ e, List: 5. Mechanical (Fire l�j Suppression) $ Total All Fees: $ / t- �� r✓ �' Check No.r� 6. Total Project Cost: $ /c� 7 b� Check Amount: q�— Cash Amount: ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 a Constructionte� ct Supervisor License(CSL) e 79/G 0 q!ir ,a$ L<" ""9"n " (D," `0 5 License Number Expiration Date Name of CSL Holder 34 c3erv/'e.C'�enize I30ti List CSL Type(see below) U No.and Street Type Description j /O k rn n . 616 4 6 U Unrestricted(Buildings up to 35,000 cu.it.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling �' M Masonry RC Roofing Covering WS _Window and Siding q,7/ dra55 2 h/ob`Ca SF Solid Fuel Burning Appliances ���61/+/a •` s�°p Yw! I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /6. D�L frJ 5. 1 (3 _ hen 2U' D 55 gen+C/Gt..t' ravic HIC Registration Number Expiration Date HIC 6 y Name or rtiled ,I IIC R sir�}t,Name, c L 7' ` o Pya-4 No.and tt1a,6'h�h0i . Emaiddress 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 Issuan of the building permit. Signed Affidavit Attached? Yes i 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 '.' p_ ,'7 to act on my behalf,in all matters relative to work authorizldby this building permit application. .-11"------ 0_ nt Owner's Name Electronic Si / Signature)gn ) 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. 11;. h-w. o. g. 81g.Z5 . 2 ei xl�r Print Ow '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 1 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/dns 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 }z- l Sys.....s! f a Massachusetts DEPARTMENT OF BUILDING INSPECTIONS tri • ,,o/a 212 Main Street • Municipal Building � .w„» ���' Northampton, MA 01060 ssy� 10 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: 1/�d/ v`--\ The debris will be transported by: Name of Hauler: e. Signature of Applicant: Date: O t Z The Commonwealth of:ifassachusetts 1";_• f� Department of Industrial Accidents -_r I=�', 1 Congress Street,Suite 100 • i'�= �, Boston, MA 02114-01? -y www.mass.gov/ilia II in kers'Compensation Insurance Amdavit:Builders/Contractors/Electricians/Plumbers. t•o iw FILED WITH THE PERMITIJN(.AUTHORITY. Applicant information Please Print Legibly Name(1Jusittres Chgantrattun Ind lvtdustl: p ve_. *-5- ) Address: 3 51c-✓I/.�--- C 4 - /721_ City/State/Zip:/VA,•l 7/1,1 o/'6'G o Phone #: `f13 `( ' (Z L-` ' Are you an employer?Check the appropriate box: Type of project(required): I 1 a employer with employees(lull ana'orpart-time).• i he' construction 2 arn a aide prupnrtur or partnership and hove no employees wooing fur me in g, emodeling lay capat:try. [No workers'comp.usurance required.] 30 i am a homo>wner doing all work myself.[':u*Orkin,'comp insurance required]" 9. ❑ Demolition 10❑ Building addition lui.4.0 i am n mcuwner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either hake workers'compensation insurance or are sole 110 Electrical repairs or additions pruprivton with no employees. 12.0 Plumbing repairs or additions 5C:j I am a se-tiered contractor and I lake hued the cab-contractors listed on the attached sheet_ 131:1 Roof repairs These cab-contracture hook employees and lake workers'comp.msunincc.: 14.n Other tipwe an u corporation and its officers have exercised them right ofexemption per WA.c. 152. Itil.and we hake no employees.[No workers'comp.insurancercyuutid_l 'Any applicant that clucks bus al mail atw flit Out the wctum Lilo*showing then workers'compensation policy information i Homeowners who submit dig atl`ed:1k it uxtrrtting they tie durng all work and then hie outside contractors triad sabers a nc'w afftday it rrxN:Stang such. :Contractors that check thu boy must attached or additional sheet slowing the name of the sub-contactors anal state w heiher or not those entities hake c-rnpluyecs If the sub-contractors love employees.they must provide their workers'cony.policy number_ I am en employer that is providing workers'compensation insurance for my employers Below is the policy and Job site information. Insurance Company Name: Policy#or Self ins. Lie.#: Expiration Date: Job Site Address: City/State.-Zip:__ 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 tine up to Sl.500.00 anti or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 coverage verification. I do hereb eertlf i s and penalties of perjury that the information provided re is true and correct Signature: Date:�J (7Z✓� Phone: �l S`d'1/,-/2r�. // Official use only. Do not write in this area,to be completed by city or town official 5 ('its or Town: PermitfLicense# : issuing Authority (circle one): - I I. Board of Health 2.Building Department 3.Cityl'Tosn Clerk .4.Electrical inspector 5. Plumbingiorector 6.Other Contact Person: lime#: • "..wiliN CONSTRAS01 CPOROWSKI '4�R� CERTIFICATE OF LIABILITY INSURANCE °A�`'"M'°°'""Y' 6/20/2022 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 NAME: AXiA Insurance Services PHONE F X y (413) (ac,No):(413)886-0190 84 Myron Street (A/C,No,Ext): 788-9000 Suite A E-MAIL _ West Springfield,MA 01089 INSURER(S)AFFORDING COVERAGE NAIL a INSURER A:Arbella Mutual Insurance Company 17000 INSURED INSURER B:A.I.M.Mutual Insurance Co. Stephen Ross INSURER C: _ 36 Service Center Road INSURER D: Northampton,MA 01060 INSURER E: 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. LTR TYPE OF INSURANCE ADDL SUER I POLICY NID Y YT P• EXP LIMITS INSD WVD POLICY NUMBER ° � � , A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500071119 7/1/2022 7/1/2023 pRArm SES(Ea NTED 6 _ 100,000 MED EXP(Any one person) 6 5,000 l PERSONAL&ADV INJURY 6 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: • •• GENERAL AGGREGATE i 2,000,000 POLICY Pi(FJ 6 1 LOC PRODUCTS-COMP/OP AGG ,j 2,000,000 OTHER: EPLI 6 25,000 A AUTOMOBILE LIABILITY IEOMBIDa t SINGLE LIMIT $ 1,000,000 _ ANY AUTO i 11020098280 7/1/2022 7/1/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) 6 AUTOS���� ONLY , X—�AUTOSpp E ! ! R p _X A1RTOS ONLY X AUTOS ONL� (PerOa Ecc Cent)AMAGE 6 6 A X UMBRELLA LIAB X i OCCUR 2,000,000 EACH OCCURRENCE 1 EXCESS LIAB CLAIMS-MADE 4620098565 03 7/1/2022 7/1/2023 AGGREGATE DED X RETENTION S 10,000 6 2,000,000 B WORKERS COMPENSATION PER I OTH- AND EMPLOYERS'LIABILITY l_.— STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ WMZ-800-8006546-2021A 7/1/2022 7/1/2023 E.L.EACH ACCIDENT 500,000 MFFICER/MEMBER EXCLUDED? N/A 6 andatory in NH) E.L.DISEASE-EA EMPLOYEE 6 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT 6 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE .y.,,,,<,,r-^, ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD VI Division of Professional Licensure Board of Building Regulations and Standards . • Construction Supervisor CS-079160 int Wires:04/28/2023 STEPHEN D ROSS 36 SERVICE CTR RD NORTHAMPTON MA 01060 C IP Commissioner • ,S'. DfnLiz& I . THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer AffaiFs and Business Regulation 1000 Washingr4t - Suite 710 Bosto •ii�� .Y•rr\JY 2-.118 Home Im.ro - - ---- ---- --•- ----.istration '..11.r: : `111111111111.11111111111, 1111 y*gloomy Type: Individual STEPHEN D. ROSS ___ e• i ation: 150847 36 SERVICE CENTER RD. _ _- E .tion: 05/03/2024 NORTHAMPTON, MA 01060 Air# `= 1 ♦ ii 1 MOW 4 — Sit �f4 i IN Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aff &Business Regulation Registration valid for individual use only before the HOME IMPROVEMENtCONTRACTOR expiration date. If found return to: :e`Cdual-. Office of Consumer Affairs and Business Regulation Resist-ti. =s-- k4ration 1000 Washington Street -Suite 710 ~ 15ergia 4;Ati 101124 Boston,MA 02118 wS z =E ;TEPHEN D. ROSS .. .L s =` ii. _- ). ;TEPHEN D. ROSS 17 e ' ;6 SERVICE CENTER - ', ,,,.� ,2;/,/. NORTHAMPTON, MA 01 cl.e = fi' • �,t'` Undersecretary Not valid without signature