23A-005 (15) BP-2024-1189
36 MEADOW ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-005-001 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-2024-1189 PERMISSION IS HEREBY GRANTED TO:
Project# TEMP TRAILER Contractor: License:
Est.Cost: 24000 AMERICAN MOBILE HOMES INC 081119
Const.Class: Exp.Date: 06/18/2025
Use Group: Owner: PATRICIA KYLE,
Lot Size (sq.ft.)
Zoning: URB Applicant: AMERICAN MOBILE HOMES INC
Applicant Address Phone: Insurance:
51 MOORE RD (781)331-0333 WCC-500-5022645
EAST WEYMOUTH, MA 02189
ISSUED ON: 09/12/2024
TO PERFORM THE FOLLOWING WORK:
TEMP MOBILE HOME DUE TO FIRE
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: fffr,
Fees Paid: $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
�-'n1Gt i 1 sE�' 2
REc,
r------_„LL,:,---5-
The Commonwealth of Massachuset 2024
Board of Building Regulations and Stan rdsnF'?of nvi I IOPA ITY h�o tn�,i
Massachusetts State Building Code, 780 CMrNa.t�,,Torw�r"• �� FCTION SE
Building Permit Application To Construct, Repair, Renovate Or Demolish a a°1 b0' d Ma 2011
One-or Two-Family Dwelling
!� This S c ion For Official Use Only
Building Permit Number: 6�'�'7' it f Date Applied:
/Zvi.-)4 /l& 61'1Z-70zy
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1S4, tr1424PJ 5
1.1 a 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:
pa
-Ti t c a Ky l 4 d�I d r'eN. l4,4.,,`ro,.� vn n. 44136,&
me(Print) ity,State,ZIP
aCe P1 c.ocid,0 s r sos- q 7'1-Ca4-1
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. 0 Number of Units Other �Specify:_'r-e015 Alp jv14 t&
Brief Description of Proposed Work': +'a 4 t 4.. 1L(#V t — ' N+043Lt,4 likes-C. Li't NA'e
FQ4- ll!r) 4,1--CN 7 c 4t.!€ TJ ,Fk/t f. c A*' A.ICE-E t-ks."64--
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ ou. 660---- 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ i G GL ._ 0 Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ A — 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No.3t)�theck Amoun1:11/16 Cash Amount:
6.Total Project Cost: $
02`'1 060 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
gilil l�ak. G4(2 R ,/` License Number Expiration ate
Name of CSL Holder
List CSL Type(see below) R
A & ` Type Description
No.o.and Street Street
U Unrestricted(Buildings up to 35,000 cu.ft.)
LE iJki 0 of t-t wt/1 6 a ( R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7 " (. 53 i. 633 S I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I
4 /-l � ra6 .2� -I �1-1141.
C
M t'- - M d b i 6 p"e S HIC Registration Number Expiratio Date
Company Name or HIC Registrant Name ^
•
�t M n614- - Ae lc(...8/4r-t do(.4-1 I1OSE,14 t+)►n 5
No.and Street Email address
F , ,i-' .i v-l( �l 7Vl -,3c-4,353 - CO✓'A-
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 8"-- 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
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.
W LI `A^" C?�'t`ltk.l ,l TbliZY
Print 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
(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"
I HE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:Supplement Card Office of Consumer Affairs and Business Regulation
Registration Expiration 1000 Washington Street -Suite 710
106386 07/22/2026 Boston,MA 02118
AMERICAN MOBILE HOMES INC.
WILLIAM GARRITY
51 MOORE RD J ' 4/✓!//,,4'1- ��",�' �_
E.WEYMOUTH,MA 02189
Undersecretary Not acid without signature
U Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Regulations and Standards
Constructio i'ipenrh�gr..1 & 2 Family
CSFA-081119 i pires:06/18/2025
WILLIA25KIMMJ -BEACH
25 KIMBALL BEACH RD
HINGHAM MA:02043 ...; ri,,15111
Commissioner
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
wow mass.go4'/dia
11inkers' Compensation Insurance Affidavit:Builders]('ontractorsIElectriciansfPlumbers.
14)HE FILED WITH.[HE I'ERMIITINC A(THORI'1'f.
Applicant Information i Please Print Le�tibly
Name Il3usincsslthganizatiun''Individual):�/'t L,'t Y''7O •7l 4 / f
Address: 5 t ?v dam tl-Z
City/State/Zip: �LJvy P- GLt g, Phone#: 7 1 -3 3 t'-43 3 33 —
Are you au employer?('Peek the appropriate hay Type of project(required):
1.041n a emplawx with 1.L employees(full anikor part-time]_• 7_ 0 New construction
2.10 I am a sole propnetur or partnership and hav c no employees working for me in 8. Q Remodeling
any capacity.No workers'comp.insurance nxlurred.l
30 I am a homeowner doing all work myself.iNo workers'cony_insurance it -j'
9. ❑Demolition
ne
4.01 ant a hurntuuw ter and will be hiring contractors to conduct all work un my property. 1 will
10 0 Building addition
moon:that all cwntrteturs either hate workers'co mprasrtrun insurance or arc sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
51 I ant a emend contractor and I have hired the sub-contractors listed un the attached sheet. 13.0( '"i Roof repairs
These sub-contracture es have employe and have workers'comp.insurance.:
6.0 We are a commotion and its officers have exercised their nght of exemption per MUI..c. 14.a O[]ter
152.§t(41.and we have no employees.[No workers'cutup.insurance required.]
'Any applicant that checks box a I must also fill out the section below showing their workers'compensation policy information.
+Homeowners who submit this aft-tda%it indicating they arc doing all work and then hue outside contractors must subnut a new affidas it indicating such.
C'untruetors that check this box must attached an additional sheet show ing the mime of the sub-contractors and state w hotter or nut those entities lave
employees. lithe sub-contractors hate errgslu)Lccs.prey must pro%idc their workers'comp.pulley number.
i am an employer that i_s providing Workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: AS5O1/4. — ".11.)/oy<r /S �-' 0 Policy#or Self-ins.Lic.#:Vet. COO 5 b.1L Log��Z d.1� Expiration Date: (14 q.t.
Job Site Address: V(e P&(4c4 5 t City,State+Zip:NOr V-ist.n(� deg.2-
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 S1.500.00
andror 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 hereby eertif i' the the pains and penalties of perjurr that the information provided above is true and correct.
Sit:mature; ` K� /`� Date'_ q//2. /
Phone#: � ` 3 l'-0�3 3
Official use only. Do not write in this area.to he completed by city or town ofic-ial_
City or'I'oss n: Permit/License!f
Issuing Authuritr "circle cue):
I. Board of Health 2.Building Department 3.('its Town Clerk 4.Electrical Inspector g. Plumbing Inspector
b.Other
Contact Person: Phone#:
AMERICAN MOBILE HOMES INC.
51 Moore Road
Weymouth, MA 02189
(781)331-0333
1-800-232-9991
PROPOSAL f Fax(781)335-0707
Date lj/10� al y
Name PAT r 1 L l A Li Est.delivery date
Address 3 (o y✓LCA.SO'-u.) 11 57 p3cseclA Ikr4,4A1�'71ri ,' ✓- 6iOCa
American Mobile Homes,Inc.hereby propose to furnish the materials and perform the labor necessary for the
completion of installing ( l,'(,0, leased mobile home containing:
Refrigerator,stove,dining set,living room set,curtains,bedding 1st( ,;.t,2ndl(4.1 ,3rd FayPry ,washer
and dryer,air conditioning.
11;ymporary Plumbing installation to mobile home Lpplying for building permit for mobile home
0/temporary Electric installation to mobile home ❑ Remove necessary trees,tree limbs or shrubbery
❑ Remove any necessary fencing
0 Other:
Any resulting damage to said property as a result of the installation,removal and existence,of mobile home and its
its utility connections shall not be the responsibility of American Mobile Homes,Inc.,specifically driveway,fence,
stonewall,septic system,trees,lawn or any other type of landscape items and/or.
American Mobile Homes,Inc.,is not responsible for the re-installation of any of these items.
Costs:
—
The monthly rental of the mobile home at._S�3i mos. The delivery and pick up charge of
Air conditioning 5"Z - Pet fees 5Qt,'— other
There will be additional charges for utility connections,permits,fees,site preparation.
There will be a profit and overhead charge of 10& 10 for all sub contractors and fees paid out.
Any applicable sales tax.A 5%carrying cost will be billed and payable on all invoices not paid within 45days of billing.
A$1,000.00 security deposit is due on delivery of mobile home.Uwe agree to sign a lease for the mobile home rental at delivery.
Projected job cost:,1,1,n al)
--- Fkr g r /-7 d LA) C./el --Se ! kA
Payment Method : Idled directly to insurance company with a signed assignment of payment.
❑ Other:
Any alteration or deviation from above specifications involving extra costs,
will become an extra charge over and above the estimate. All agreements Respectfully submitted/(....//41,17
on contingent up strikes,accidents or delays beyond our control.
ACCEPTANCE OF PROPOSAL
The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as
specified. Payment will be made as outlined above.
If insurance company is not willing to honor assignment of payment,Uwe understand Uwe will be responsible for full payment of
all services.
NOTICE OF RIGHTS TO CANCELLATION
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the Seller,which may be his
main office or branch thereof provided you notify the Seller in writing at his main office or branch by ordinary mail posted,by telegram
sent or by delivery,not later than midnight of the third business day following the signing agreement.
See attached notice of cancellation form for an explanation of this right. ifK(-.4.--
SignatureDate '7/ill Signature
1
Client/:23090 AMEMO
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(M VDVTYY)
8/092024
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 pollcy(Ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the temhe and conditions of the policy,certain policies may require an endorsement.A statement on
this certificate does not confer any rights to the certificate holder In lieu of such endorsement(s).
PRODUCER NAMEeCT Matthew M.Bryan
Sullivan Insurance Group, Inc. PHOONr E,r,): (-508 791-2241 - ,tyC eI—
,508 797-3889
1 Mercantile Street E-MAIL
ADDAEss: mbryan®sulllvangroup.com
Suite 710
Worcester,MA 01608 IIS R(S)AFFORDINOCOVERAGE -- KIX _
INsuRER A:Westchester Surplus Lines Ins.Co. j10172
INSURED INSURER B:Associated Employers Insurance Company 11104
American Mobile Homes,Inc. -- —
51 Moore Road INSURER C:
East Weymouth, MA 02189 INSURERD:
INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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. OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
DDLUBR
TYPE OF INSURAtiCE BNB 8 POLICY RIMIER_ AM9PWilISw4% 17
0
8Di LIMITS
A '"�X CONHFACIALGtNCERALLIABILITY X X G74451482001 03/15/2024 O3/15/202S pEAAC�HpOECCUURRRENCE S1,000,000
I CHUMS-MADE X OCCUR PREM ES{Eno ner el S1001000
MED EXP(Any ate person) sExcluded
PERSONAL&ADVINJURY S1,000,000
GENL AGGREGATE LIMIT APPLIES PER_ GENERAL AGGREGATE S 2i000,000
PAO-
POLICY JECT I LOC PRODUCTS-COMP/OP AGO S2,000,000
OTHER
AUTOMOBILE LUU3IuTY I COMBINED SINGLE UNIT
(Ea accident)
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE S
AUTOS ONLY AUTOS ONLY (Per accident)
S
A _ UMBRELLA LIAB I X OCCUR X G74451524001 03/15/2024 03/15/2025 EACH OCCURRENCE s5,000,000
X D(CESS LAB CLAOAS-MADE AGGREGATE s5,000,000
DED RETENTIONS
B WORKERS COMPEMPLOYERS AUAaTIONILIT WCC50050226452023 D8/122023 08/12/2024 X s�rATurE °R
ANY PROPREETOR/PARTNER/EJ(ECUTNE Y/N WCC50 05022645 20 24 08/122024 08/122025 E.L EACH ACCIDENT S1,000,000
OFFICER/MEMBER EXCLUDED? ' N/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S1,000,000
II yes._DESCRIPTION OFFOOPERATIONS below _ E.L.DISEASE_POLICY LIMIT 511000LO00----_
DESCRIPTION OF OPE ATIONS/LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached II more space le required)
General Liability receives Additional Insured status If required by written contract.
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.
AUTHORIZED REPRESENTATIVE
l•ataAige
ID 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2018103) 1 of 1 The ACORD name and logo are registered marks of ACORD
#5534290/M528762 MBM
City of Northampton
/ O YMM. "4: `5 s••..S'.
"`` Massachusetts A. �'<<
al t
1��,. I ����C� �' DEPARTMENT OF BUILDING INSPECTIONS S;
.. i � 212 Main Street • Municipal Building ti. OD
r' Northampton, MA 01060 s'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: N b d r(
The debris will be transported by:
Name of Hauler:
Signature of Applicant:!'" ' lt4 t, Date: T/(h./z1
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SM.Plsn
Rds plen Amos romMn No copyrlohl cd destrof d NO noI No used other Nan for An MON sock Intended wOhovt woke Newly.No /Om PAW.
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Diselalmec Properly Details MAN SOON
This et rot en NNW documen*end may not seemly wiN current lews of Musky StellftedS.You Road TA*your own ermines one seek 36 M•o&n.St.Noltompten.MA 010132 USA Men: IAIT
Independett*OAP from Wessel MOustly poSesslonels Intone Nets o•'Mop NI to contents of tne doarnent
AMERICAN MOBILE HOMES INC. APN 23A-0054301
Deb Wed Sep II 2024 W-
AU_DIMENSIONS ARE IN FEET.00 NOT SCALE FROM PLANS. OS ION RE