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31A-106 (5) BP-2024-1489 22 FEDERAL ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31A-106-001 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-2024-1489 PERMISSION IS HEREBY GRANTED TO: Project# 2024 INTERIOR REBUILD Contractor: License: Est.Cost: 100000 VLADIMIR AGAPOV CS-060134 Const.Class: Exp.Date: 1 1/04/2026 Use Group: Owner: M MOLITORIS JOHN V& SUSAN Lot Size(sq.ft.) QUALITY CLEANING AND RESTORATION Zoning: URA Applicant: SERVICES Applicant Address Phone: Insurance: 72 MONTAGUE CITY RD (413)774-7737 7PJUB 0G09579-24 GREENFIELD, MA 01301 ISSUED ON: 11/07/2024 TO PERFORM THE FOLLOWING WORK: REPAIRS 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 Drivena!, 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. 7E- Fees Signature:Paid: $750.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner F- ----:—..c -___Ej___---VEL) C_Cti( 5-01).- £ 4 ,4 crm,�+ I T e Commonwealth of Massachusetts t il I' rat& r NOS - 5202* Board f Building Regulations and Standards MUNICIFOPALITY = �� ssaoousetts State Building Code, 780 CMR R USE . i ney p lil ation To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 ,'�'oN,wA One-or Two-Family Dwelling This Section For Official Use Only 2 BuildingWevi....) Permit Number: ,6 p-d-y.�e f 9 Date Applied: /255 C//� H-6-ZOZL Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 22 Federal Street 31A-106-001 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use i Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: John&Susan Molitoris Northampton MA 01060 Name(Print) City.State,ZIP 22 Federal Street 413-588-8352 Sarahannmolitoris@gmail.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other '8pecify: Brief Description of Proposed Work':Repair of fire damaged walls,floors,ceilings,cabinets,bathrooms SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building S 100,000.00 1. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:$n Check No.5 ).10t heck Amot :lab Cash Amount: 6.Total Project Cost: $ 100,000.00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS 060134 11/4/202ri, Toshi Kashima License Number Expiration Date Name of CSL Holder 15 Union Street List CSL Type(see below) u No.and Street Type Description Greenfield MA 01301 U Unrestricted Buildin up to 35.000 cu.II.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-522-1713 kashimabuilders@yahoo.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 188432 10/26/25 Vladimir Agapov,Quality Cleaning and Restoration HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 72 Montague city Road info@qualityrestoration.com No.and Street Email address Greenfield MA 01301 413-774-7737 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 0 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 Quality Cleaning&Restoration, Inc to act on my behalf,in all matters relative to work authorized by this building permit application. See attached authorization 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. Patrick Locklear 11/4/2024 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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. I42A. 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 �� S,S ; . j ej Massachusetts ' (4 terr° t1 .I DEPARTMENT OF BUILDING INSPECTIONS7i r 1 s�..•' 212 Main Street • Municipal Building J O\, , Northampton, MA 01060 ssI,h )`�0 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALI. 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: Valley Recycling.234 Easthampton Road, Northampton MA The debris will be transported by: Name of Hauler: USA Trucking LaZ112.Z42 3m Signature of Applicant: Date: 9/5/24 The Common wealth of Massachusetts Department of Industrial Accidents _:4)_ 1 Congress Street,Suite 100 Boston,MA 02114-2017 • www.mass.gov/dia Workers'('ontpensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITi'ING AUTHORITY. Atrplicant Information Please Print Lcuihls Name(Basiness)c>rganizatonflndiridual): Quality Cleaning & Restoration, Inc Address:72 Montague City Road City/State/'Zip:Greenfield MA 01301 Phone#: 413-774-7737 Are yea as employer!Cheek the appropriate box: Type of project(required): 1.®I am a employer with_18 _. .... employees(full and'e r part-time).* 7. New construction 20 I am a sole proprietor or partnership and have nu employees working for me in 8. O Remodeling any capacity.[No workers'comp.insurance required.) 0 I am a homeowner doing all work myself.[No workers'comp insurance required.)' 9. 0 Demolition 4.0 I am a humcow nor and will be hiring contractors to conduct all%rat on my property. I will 10 O Building addition ensure that all contractors either have workers'compensation insurance or are sole 1143 Electrical repairs or additions proprietors with nu employees. 12.0 Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed un the attached sheet. 13 Roof repairs Thesesub-contractors have employees and base workers'comp.insurance.: 14. Other interior demo 6.0 Wr area corporation and its officers have exercised their right of exemption per MGL e. © 152.11(41.and we have no anplowes.[Nu workers'comp.insurance required.] 'Any applicant that checks box al must also fill out the section below showing their workers'compensation policy irrfonnatiexi. r ltomeuwnerx who submit this allidrivit indicating they are doing all work and then hire outside contractors must submit a new affulao it indicating such. :Contractors that cheek this box must attached an additional sheet show ing the name of the subcontractor,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 pro►iding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Nattle: Travelers Insurance Company A_r mm 7PJUBOG9579-24 06/19/2025 Policy#or SLIP-ins.Lie.#: Expiration Date: Job Site Address: 22 Federal street City/State/Zip: Northampton MA 01060 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$1,500.00 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. I do hereby certify under the pains and penalties ofperjurr that the information pro►ided above is true and correct. it nature: �y Date: ('hone 4: 413-774-7737 Official use only. Do not write in this area. to be completed by city or town official Cit.. or Torso: fermi/license Issuing Authorit, (circle one): I. Board of Health 2. Building Department 3.( it:s[los►a Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other (contact Person: Phone#: AC R0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM DDIYYYY) 08/09/2024 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 statomont on this certificate doos not confer rights to the certificate holder in lieu of such endorsoment(s). PRODUCER CONTACT Jennifer Ellinger NAME: Aquadro&Associates PHONE (413)586-7373 FAX (413)584-0859 (A/C,No,Est): (A/C,No): 355 Bridge St..P.0 Box 357 E-MAIL Tenn@aquadroinsurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL a Northampton MA 01061 INSURERA: Quincy Mutual Insurance Co 15067 INSURED INSURERS: Travelers Insurance Company Quality Cleaning&Restoration Inc INSURER C: 134 South Shelburne Rd INSURER 0: INSURERE: _ Greenfield MA 01301 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1571006761 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMJDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Eaoccurrence) $ MED EXP(Any one person) S PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG S OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1.000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED Y AFV206793 12/30/2023 12/30/2024 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED NON-O''.NEi: PROPERTY DAMAGE $ AUTOS ONLY X AUTOS ONLY (Per accdent) UMBRELLA LIAB OCCUR EACH OCCURRENCE S _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY Y I N B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA 7PJUBOG09579-24 06/19/2024 06l19/2025 EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED 1.000.000 (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 1,000,000 If 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) DKI Ventures.LLC,its subsidiary companies,and its and their respective officers,employees and agents are added as Named Additional Insured to the Commercial General Liability, Commercial Automobile Liability,Follow Form Excess/Umbrella Liability and Contractors Pollution/Environmental Liability Insurance with respect to liability arising out of ongoing and completed operations performed by or on behalf of the Named Insured. 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 ' 1V IO 1.a�. -.0 . ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD