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18-030 (5)
BP-2024-1452 14EMILYLN COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 18-030-001 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-2024-1452 PERMISSION IS HEREBY GRANTED TO: Project# MOLD REMEDIATION 2024 Contractor: License: Est.Cost: 7500 SERVPRO OF HAMPSHIRE COUNTY 107843 Const.Class: Exp.Date:08/21/2025 Use Group: Owner: SMITH RONALD R &DARA M ADAMS-SMITH Lot Size (sq.ft.) Zoning: RI/RR Applicant: SERVPRO OF HAMPSHIRE COUNTY Applicant Address phone: Insurance: 50 DEPOT ST (413)324-1300 TWC4386665 BELCHERTOWN, MA 01007 ISSUED ON:10/31/2024 TO PERFORM THE FOLLOWING WORK: MOLD REMEDIATION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Sere ice: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: ii/2_ Fees Paid: $75.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner • OcT 3020 The Commonwealth of Mass4bhusetts 24W FOR Board of Building Regulati'ns -Standards r Massachusetts State Buildi ode;,,$, `CM ~----� MUNICIPALITY ,'.� ;._.-Jr 141sPFcrioyys USE Building Permit Application To Construct, Repair,Renova t lish a evised Mar 2011 One-or Two-Family Dwelling !J/ This Section For Official Use Only Building Permit Numbei$v'a " J� 5-4,2. Date Applied: 57 �iti 5'g.. /,' to-„�,•ey Building Official(Print Name) Sign re Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1y E.n:i\.- Lane 1.la 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 II) 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 AL Private❑ Zone: _ Outside Flood Zone? Municipal, On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owne 'of Record: "tiara gRonald Srn kin Nor'HnaM 00, MR, O%o(o0 Name(Print) City,State,ZIP li Er :t1y littne (413)2:o4-6S43 DAdannS&A +e9ma t.Com 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) ffi Alteration(s) 0 Addition 0 Demolition 4 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2:CY10%a ?Iernedt a-H evn— RemoM a dn3i &t% Insula-Vion 1 Replace &&+er rnoka ren+edhakon Is done . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: •Official Use Only• *(Labor and Materials)+ 1. Building $ 1500 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) $ List: 5. Mechanical (Fire ( $ Total All Fe-.. 15�r Suppression) f; � n Check N`' � heck Amot ." Cash Amount: G 6.Total Project Cost: $ - l J00 0 Paid in F 0 Outstanding Balance Due: II s SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-101$y3 ON 2%1202.5 Ke vin Fa II License Number Expiration Date Name of CSL Holder U ,t ^—)t 1 ree List CSL Type(see below) .and Street►`et` l Type Description �` l.•Cher1 �-1 Ot 001 U Unrestricted(Buildings up to 35,000 cu.ft.) � 1:��n ► ` ,M+� Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 1?CQ Me efta eSCr VPrO'nCsq.Cortn SF Solid Fuel Burning Appliances ` 24- Kv1n sC'ry f'o!l c si•corn I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) k4 L Fa�� Services,Inc. IgOOtofo ►Ol05loa{o HIC Registration Number Expirationn Date HIC Corn any Name or HIC Registrant Name 50 t- Street Kevin@Servprohcsoc.com 1NNro.and Strec Email address 16e l c her town/M A 101001 04324-1'300 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 SEt2V912O oYU arcipsK C'e loud}."keel A roll 4' to act on my behalf,in all matters relative to work authorized by this building permit application. mealy)Fall 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. Print 0 '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.tnass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) 39 to (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" • The Commonwealth of Massachusetts 4 �>• Department of Industrial Accidents , Ry J. b I Congress Street,Suite 100 3a.�= . Boston,MA 02114-2017 - www.mass.got'/die - %1 iakers'Compensation Insurance Affidavit:Builder JContractorslElectriciattsiPiuiuhtrs. 10 BE FILED WITH i Hk PERMI t'I'l\G AUTNOWTi'. Applicant Information n Please Print Leeibh Name tRusinsc'OrpanizationIndividual): SE ZVQQQ of IAQmpsh'sre Coufcn � (K}�.Fa11Serv�tes,�t1C) Address: 5C) De ice, City/State/Zip: \cher-I-ownt"t Ape ut Phone r;: (913.)3Z - Ate you as canployest Check the appropriate bon: Type of project(required): I�I am a employer with. 1 b employees(full and'er pasttimc)• 7. 0 New construction 20 I am a sole proprietor ur pudnenhip and have nu ctliploycva working forme in S. ''ri Remodeling any capacity-(Nat wantcri'comp.insurance mooed.1 4. [�Demolition 30 I am a hsin7lvwMY dome(all k.iOtt n1yself.[iso warkG s corm.insurance reounYY1.J AIDI ant a Itctaxcfwncr and will he hiring contractors to conduct all work on my pnsp.'ny.1 will lt1 Building addition ensure that all txruuac1un etcher hose Wnrken'compensation insurance ur are solos I I.]Electrical repairs or additions proprietors with no employees 12.0 Plumbing repairs or additions I am a general coeuractur and I hoe hared the soh-contractors listed on the attaches)sheet. 131"'1 Roof repairs These sub-co ntractors have ctttploytaa and have works.'comp.itnttrnttee.• LJ hp We are u cerpurttion and its officers have exncised their right of exemplum pet Mtit. 14.0Other 152.41(4).and we have no empluyi es.(No winters'comp.inwnance requin:d.) 'Any applicant that chucks box al mutst also till out the section below showing their workers'compensation policy information. Hanteuwttcrs who submit dos aflidasit indicating they aie doing all work and then hire outside contractors matt submit a new affidavit Milk:ding such. tContr actors that check this host must el ts1sed an additional sheet showing the name of the sulrctmtrac tun and state whether or tint tltetsc cniitk,.lave emplayec+ lithe stab-contractors Iva e employees.Ike) mu>t pia,ide their workers'ss trip.p.h .numb., ---. -- -----t I am an employer that is providing workers'compensation insurunce fir ml'employees. Below is the policy and job site Information. Insurance Company Name: I Th?eC1nnOkO( anCeC •,n C Policy#or Self-ins.Lie.#:TWC 4 3S (D J Expiration Date: 31 B(25 Job Site Address: 7a44 E 0(.1\ Lo.c- e City/Stat&7_ip:tOrk'harn /MA)0 I OloO Attach a copy of the workers'cotupdtt;ation policy declaration page(showing the policy,number and ex iration date). Failure to secure coverage as required under MM.c. 152,§25A is a criminal violation punishable by a fine up to S 1,500.00 and/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. 1 du hereby certify under the pains and peennalties of perjury that the information provided above is true and correct Signature: dan al Date_ i013012 4 Phone#: (.4 2 y" 1300• Official use only. Do not write in this area,to be completed by city or town official City or'fuss a: Pernlilll.icrnse# 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#: I' SERVOFH-01 DALDRICH ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM DDIYYYY) `.� 10/30/2024 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 NAME: Marsh l McLennan Agency, LLC PHONE FAX 95 Ashley Ave (A/C,No,Ext):(413)781-7000 I(A/c,No):(413)733-9545 West Springfield,MA 01089 ADDRtbSS:info@habermaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC e INSURER A:Technology Insurance Company 42376 INSURED INSURER B: Servpro of Hampshire County INSURERC: 50 Depot Street INSURER D: Belchertown,MA 01007 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMMIDDIYYYYI (MM/DD/YYYYI COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ CLAIMS-MADE I OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL.&ADV INJURY $ GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY n jref n LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY lEa accident) $ ANY AUTO BODILY INJURY(Per person) $ — OWNED ^SCHEDULED _ AUTOSRE� ONLY _AUTOS BODILY BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY I PPr a ec n1DAMAGE 1I $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION STATUTEPER _X AND EMPLOYERS'LIABILITY 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N TWC4386665 3/8/2024 3/8/2025 E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? Y N/A (Mandatory In NH) 1,000,000 E.L.DISEASE-EA EMPLOYEE $ 11 yes.describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Corporate Officers are excluded from workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Dara&Ronald Smith THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 14 Emily Lane Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD City of Northampton /';k ts..-,,o'..sick Massachusetts . _ e�. it.,t.,..A:.4, 1.... ,4 l ;r DEPARTMENT OF BUILDING INSPECTIONS ys k 212 Main Street • Municipal Building J1 \a f Northampton, MA 01060 jjt- `.O 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:D....Vrilce r 00 Sc\--C. Location of Facility: EMI EI ik. � r)ne , NJO(*harn n, Mk The debris will be transported by: • Name of Hauler: US 4C LLU n GI l(1 W eSi-T\e\ a+ f"I k • Signature of Applicant: 0 0 6 Date: i DI alay I Corinionwealtti of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards (��orrst ia.1!��►b' �'�. �.I�'M: J"V'isUt" 1' CS-107843 E piros: 08/21/2025 KEVIN FALL; •: 50 DEPOT STREET �" 1', i " BELCH E RTOIN MA 01007 it ' f lf,f,\ A ii' 4 ,t Commissioner Construction Supervisor Unrestricted - Buildings of any use group which contain less than 35,000 cubic feet (991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts state Building Code is cause for revocation of this license. For information about this license C a I I (Eli) /27. 3200 or visit www.mass.gov/cipl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor.Registration r. max ' _ • Type: Corporation €4o: s t -70egistration: 180066 K&L FALL SERVICES, INC. toel I;.:', PO BOX 821 t~ Expiration: 10/05/2026 ;. PALMER,MA 01069 ,�- 77' Update Address and Return Card. THE 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:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 180066 10/05/2026 Boston,MA 02118 K&L FALL SERVICES,INC. KEVIN GALL 50 DEOT STREET P �— Ca_,tC BELCHERTOWN,VA C1007 (Undersec•etary Not v id without signature