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35-057 (7) BP-2024-0752 955 RYAN RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-057-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERFI) CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2024-0752 PERMISSION IS HEREBY GRANTED TO: Project# CHIMNEY REPAIRS 2024 Contractor: License: Est.Cost: 8575 FIRESAFE CHIMNEY SERVICES INC 105507 Const.Class: Exp.Date:06/04/2026 Use Group: Owner: ETO MARTIN MICHAEL A&ELISETH M Lot Size(sq.ft.) Zoning. WSP Applicant: FIRESAFE CHIMNEY SERVICES INC Applicant Address Phone: Insurance: 277 PALMER RD (413)436-7946 7pjub06033546 WARE, MA 01082 ISSUED ON: 06/11/2024 TO PERFORM THE FOLLOWING WORK: INSTALL CHIMNEY LINER POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: 1.ootings: 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: 172_ Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner REC1= `. 1 sZ. The Commonwealth of Massachus tts - 'Qt Board of Building Regulations and S dar s FOR 1 Massachusetts State Building Code, 7 C R J�N MUNICIPALITY _ USE Building Permit Application To Construct, Repair, R nov e Or Demolish a Revised Mar 2011 One-or Two-Family Dwellin nrPr of ri;u This Section For Official U Only.. "oR?f-:• Building Permit Number:f n'a Ar-b•2%7. Date Applied: / eu f5'> /2 L-ll&zy Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1. P o rty Address: % 1.2 Assessors Map& Parcel Numbers 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: . 1 rIty rinrh tvtplon t NiFt. c1r(4a Name(Print) City,State,ZIP Q 55 {_ rl YZ-d- 6413)63i -190)5 sku-too 191 -I- No.and Street Telephone —r 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. 0 Number of Units Other g Specify: C LIVIYUA L if, r 3 Brief Description of Proposed Work': 6 Lr .k,_ck.N1 Stcorthss steel t t_r -e-or M. k C+,Ncl rebU..Lk -rap ob cam,uvkAs_,/ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ O J1 S.co 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ 0 Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier x 3. Plumbing $ e5 2. Other Fees: $ 4. Mechanical (HVAC) $ 0 List: 5. Mechanical (Fire $ Suppression) e5 Total All Fees: $ r,� Check No. alit Check Arnold* Cash Amount: 6.Total Project Cost: $Ss 1 S.( 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) vwc �� 1 l % 1 Q s s m—� License Number Expiration ate Name of CSL Holder 1 Street `,, List CSL Type(sec below) p No.and S �l� " v` Type Description SOu�eA CAl\tr C ,M O C) NJ Unrestricted(Buildings up to 35,000 cu.ft.) 1 R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry Cif „ r_ _`_wA �r Oa S. �� RC WiRondow aCnd Siding g � �ct.tCs-Y` y WS Window and Siding fiD Solid Fuel Burning Appliances (Li 13)(4310 -7 19`t COI Insulation Telephone Email address D Demolition 5.2 Registered� Home Improvement Contractor(HIC) 1 6?[,{[{G1 [o p s'�{ 'ZCc � , c `L � 'J La-s HIC Registration Number Expiration Date HIC Company Name or HIC Registr Name .277 Th. pwrYL Casscrrdm6)Ct resoLil ti V tv\ ser/to s, No.and Street Email address CO".-' 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 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 fe Sclie LV t L V.CSox J LU2 S to act on my behalf,in all matters relative to work authorized by this building permit application. rr\,tk_k_ I-��Y, UIL L1 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 my knowledge and understanding. `-56v e.m t,t)a it c4Ll) LI Print Owner's or Authorized Agent's NameNamV(1Zronic 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 o;„mr;J S ...- s (:/. Olt Massachusetts � lo �?' �. 4�G A y: � 1 '`! DEPARTMENT OF BUILDING INSPECTIONS �: . 212 Main Str••t • Municipal Building yJ`1 cam -�.- Northampton, NA 01060 44.--- 5��a 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: Q2-71 Vairov 6 l OEGR The debris will be transported by: Name of Hauler: kv c C_V\WA .i Sep J tcSLID Signature of Applicant: Date: 2 Commonwealth of Massachusetts Division of Occupational Licensure Construction Supervise specialty • Board'of Building Regull nIations and Standards Constructs _peor' rc.:s:Specialty • Restricted to: CSSL-SF-Solid Fuel Burning Device �G�7ire8•01/191202i CSSL-105507 .JAMES J WALLING y - 40 HIGH STREET P.O. BOX 40 91k- SOUTH BARRE-MA 01074 Failure topossess a current edition of the Massachusetts o �^ Commissioner jtw�� f;. State Building Code is cause for revocation of this license. For information about this license • Call (617)727-3200 or visit www.mass.gov/dpl 7, cof-iwimweoealff et/./Ra..);' / • /7' Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation FIRESAFE CHIMNEY SERVICES INC Registration: 182449 Expiration: 06/25/202S 277 PALMER RD UNIT 2D WARE, MA 01082 • Update Address and Return Card. WA 1 Li 201.1.0.i77 •7'6fTei'df Cdifsif10trrlktfa0i b'Su61nass'Re9uldtion HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 182449 06/25/2023 1000 Washington Street -Suite 710 FIRESAFE CHIMNEY SERVICES INC Boston,MA 02118 JAMES WALLING JR 277 PALMER RD WARE,MA 01082 Undersecretary Not valid without signature _ '\ The Commonwealth of Massachusetts -*, fl, Department of Industrial Accidents ?11►= 1 Congress Street,Suite 100 ;.=1.`tt ..4 Boston, MA 02114-2017 \MOM/ 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):Firesafe Chimney Services Inc Address:277 Palmer Rd City/State/Zip:ware, MA 01082 Phone#:(413)36-7946 Are you an employer?Check the appropriate box: Type of project(required): 1.12 I am a employer with 1 0 employees(full and/or part-time).* 7. ❑New construction 20 I am a sole proprietor or partnership and have no employees working forme in 8. 0 Remodeling any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]I 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑ Building addition ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 50 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.[pother chimney repairs 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 arc 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:Travelers Policy#or Self-ins.Lic.#:7PJUBOG033546 Expiration Date:5/12/2025 Job Site Address:955 Ryan Rd City/State/Zip:Northampton, MA 01062 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$1,500.40 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 d penalties of perjury that the information provided above is true and correct. Signature: Date: [t f i-(1 Ic/ 1 Phone#:(413)436-7946 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#: ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYVY) 06/04/2024 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 Rachel Dauphinee NAME: p BRABO INSURANCE PHONEA/ o Eal: (508)356-8266 NC,Not EMAIL ADDRE_SS: rdauphlnee@braboinsurance.com 65 Cordage Park Circle INSURER(S)AFFORDING COVERAGE NAIL Plymouth MA 02360 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED ------ --- ------ INSURER B: FIRESAFE CHIMNEY SERVICES INC INSURER C: INSURER D: 277 PALMER RD INSURER E: WARE MA 01082 INSURERF: COVERAGES CERTIFICATE NUMBER: 1014697 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. !NWT-. ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE /SSD wvn POLICY NUMBER (MM/OD/VYVY) (AM)DO/YYYY) LJI IT$ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO S ]CLAIMS-MADE L OCCUR PREMISES(EaENTED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL E ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY JECT LOC PRODUCTS-COMP/OP AGG S OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Es accident) ANY AUTO BODILY INJURY(Per person) S OWNED -SCHEDULED N/A BODILY INJURY(Pet accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB `~ CLAIMS-MADE N/A AGGREGATE DED RETENTIONS $ WORKERS COMPENSATIONPER AND EMPLOYERS'LIABILITY - "I AME ER - X A o ICER/MEMB AXRCLUDEDXECUTNE Yj/j NIA N/A 7PJUB0G03354624 05/12/2024 05/12/2025 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 M yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ N/A DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached It more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN City of Northhampton ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main St AU THORIZED REPRESENTATIVE Northhampton MA 01060 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DATE(MM/OD/YYYY) ACORE, CERTIFICATE OF LIABILITY INSURANCE 6/4/2024 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 Brabo Insurance Agency NAME: Ne — FAX 65 Cordage Park Circle mic.No,EzO:508-830-3800 uuc wo):508 746 1540 Plymouth MA 02360 EADDDDI IL info@braboinsurence.Com INSURER(S)AFFORDING COVERAGE NAIC I Licensez:1933420 INSURER A:Northfield Insurance Company INSURED FIRECHI-0' INSURER B: Firesafe Chimney Services Inc. - -- 277 Palmer Rd, Unit 2C INSURER C: Ware MA 01082 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1100610548 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 ADDL SUBR POLICY EFF POLICY EXPM/ UNITS LTR INSD,WVD POUCYNUMBER IMDDA'YYYI (MMIDD/YYYYt A X COMMERCIAL GENERAL LIABILITY WS551038 7/15,2023 7/15/2024 EACH OCCURRENCE S 1.000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaE NTED occurrence) $100,000 MED EXP(Any one person) $5,000 `— PERSONAL&ADV INJURY S 1,000,000 GEM.AGGREGATE UNIT APPUES PER: GENERAL AGGREGATE S 2,000,000 X POLK;Y n JJECTT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: S AUTOMOBILE LIABILITY 'COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 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 S EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY Y/N STATUTE I ER I ANYPROPRIETOR,PARTNERIDECUTIVE E.L.EACH ACCIDENT $ OFFICER/ME MBEREXCLUDED? n N/A - -- - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes.descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UNIT S • DESCRIPTION OF OPERATIONS/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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Northhampton 210 Main St Northhampton MA 01060 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD