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23A-197 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: u��4za 20"., The debris will be transported by: The debris will be received by: 1 Building permit number: Blame of Permit Applicant 7 `2:- / r Date Signature of Permit Applicant • i _ CERTIFICATE OF LIABILITY INSU DANCE- 777 ,Y;) 6/30/1 (_IS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AIND CONFERS NO PLIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICfES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONISTITUTE A CONTRACT BETWEEN THE ISSUfNG INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IJAPORTANT: IT the cerfi;Icate holder is an ADDITIONAL INSURED, the pofic}fies) must be atdorsed. If SUBt OGATION IS WAIVED,subject to the tem-,s and ccndibons ctthe policy,certain porcies may require an endorsement A staternert on this certificate does not confer rights to tI-ie certmcate holder in lieu of Such endorse errt(s). PR CL'J CER CONTACT NAME: 3-esnahan Insurance Agency Inc PHONE (413) 536-05_5 FAX l ° 'O� ar - 3 rr. - (-13) 539-5__ 100 T,I-Hiting Farms Road E-1A)L ADCR>SS: Hoiyoke, 2a 01040 INSUP-`P4s AFFORDING C-OVERAGE � NAIC: IP-�JRERA:Essex Ynsur2mce ItiUU?F� 1N5URER e: I S=. ton, Roo;izg _ Siding InsuRERC: P.O. Box 6327 INSURER 0: IivSlJRER c: ?jC!VO)=e, i�.a 01041 I N'S UR;---R F: CO'/ERAGES CER T :FtCATc NU 11BER: REVISION NUMBER: Tr.IS IS TO CE R T 1FY THAT THE P-&ICLS OF INSURANCE:USTED BELOVV H.A'VE B'Eal ISSUED TO THE I,JSURED,,INAAiEEE)ABOVE FOR THE POLICY PERIOD INDiCATF.'. 07'1NITHSTAND'NG P:IY REQUiREME\F.,TEPJA OR CONDITION OF AIYYCOMFRAICT OR07HER DOCUMENT'AITH RESPECT TOVMiCH THIS CERTI'r=ICn,TE MAY BE !S-SUED OR MAY PERTAIN, THE INSUP.ANICE AFFORDED 8YTFL POLICIES. DESCRIBED HEREIN IS SUBJECT TO ALL THE TERNiS, Er.CL USONS P ND CONDi T IONS OF SUO-I POLICIES-LI=,975 SHOWiN MAY HAVE BEEN REDUCED BY P AJD CLAIMS. NSR AML SUER PODCY EFF j POLICY E.P --- .TR T•i P8 OF INSUP-AWOL: IN,SRi WVD POUF NuM3ER .(rliuilCvrYYYY).(rniNCDa,ih^(`i) Ut,"TS C-G�iCrt�L L;:.HILiT/ ;3DliSOb7 6/25 f! 6/23/151 D F., ,_ ( - E6 HOCCURRENCIE � '-' '0o0'000 LL;•31LITY I I I DAP RAGE TO RCHTED i ='L! r , FRF:;I F �;J,x�•re�-e - 50,O�JO C,.al',,,;daoE OCCUR i NIED-DP r ore p ss'. S 1,000 PEP,�-ONALEADVINJU=:Y 1'000 .000 GEI4ERAL A.GG FGATE r i i > 2,OOv, OJO j GEN TELI;T APP LIES PER PRODUCTS-COMR)OPAGG : S T OOO,OOO 7--1 rRC I }_ I P'-'L;CY AUTOMOBILE LIABILITY � COr,EINED SNGLELUMT (Ea acc.ra,ri) ANYAUT BOC'LY INJURY(Per,^ rsen) 15 ALL 0VVN£D SCTE7ULED :,UTOS AUTOS 6GDIL`!INJURY(?arm-.-.�encf s' NON-OV,MED PROPERTY DA1,1AGE . a HnEC:.0-JS _ AU-TGS (Peracderf) U9 aPLEI!A L A-B , OCCUR EACH CCCLIRRENCE 5 IXCESS L[Aa AGGREGATE 0 E RE]ENT 7ON I 5 WDRK6lf COMIP_.NSATION I t'C STATU- I GTH-I AND e41PLOYFRS'LIABILITY , T Y °.•T� FR YIP AN'PROPRIE-CR)P,RTN'EP,,EY_i:UTIVE � E-L.EACH ACCI E N OFF:CEF:niEr95ER ExCLLOE0 NIA CIA,ardanry in N'H,) E.L.CISFASE-EA 2%fPLCYEEI S Y, dzscr,� urda EL SA .CIS SE-POLICYLNiff ° D�SCFIPTION OF CPEPA,TiONS delorr , ! SASE I j ) 1 CCSCRIPTION OF OPERAT,ONS I LOCATIONS!VEHICLES (A2tach ADORE,1Ci,A.<drConat Rerro�s Schedule,if more spa ce is rmgiimd) ooiimcrand siding contractor CERTIFICATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DESCMIRED POUCIES BE CANCELLED BEFORE THE EAPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN Sexton Roofing Siding ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Pax 6327 , Holyoke, 2VL? 01041 Au t cD R PPS rlTa IVE Cc) 1QRA.D01n 3r'nan OGzu ,! Uff �r- A01 I'll 0CERTIFICATE OF LIABILITY INSURANCE 3!04/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIc 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 1NSURER(S), AUTHORIZEC REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les)must 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 tha certificate holder in lieu of such endorsement(s), PRCDUrER 04931-001 ,N0 ACT Universal Insurance Agency Inc I PA G. .9333 FAX, (508)752 o-_ (308)752-9303 37d Belmont Street EMAIL ---^ Worcester, MA 0160a aooRESS: V I�� SisL M E a'1 a-DI G CO'v RAGE uRER A ) I�I"rautuaf insurance Company I 20158` IM3LRED �INSURER 3: I ALG CorstrvcJon Inc — _ -- INyUgRP?� _.._- 116 Chapla siteet INS URER D: — --- Cherry Valley. ,TLA 01611 —------- — INSURER E: INaURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 TO ,CERTIFY THAT THE POLICIES OF INSURMI: r l he Commonwealth of Massachusetts Department of Industrial Accidents 3 Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 1 1 _ Name (Business/Organization4ndividual): !_ _()� �i l},1 1 n no C Address: I n h a Die p: �� hF'i��,� l[lJ 51 �C �� ().)lo l l (n I I q q-�-q,SE q City/State/Zip:/State/Zi � Phone#: Are you an employer?Checlk thenappropriate box: Type of project(required): ]. I am an employer with ` 4. C I am a general contractor and I 6. New construction employees(full and/or part time).* have hired the sub-contractors 7. Remodeling 1 C I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have & ±Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.insurance. I required] 5.'J We are a corporation and its 10. Electrical repau•s or additions 3. G I am a homeowner doing all work officers have exercised their 11. '--'Plumbing repairs or additions myself [No workers' comp. right of exemption perm MGL insurance required]i c. 152, § 1(4),and we have no 12. Roof repairs employees. [no workers' comp.insurance required.] 13. = Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contactors that check this box must attach as 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: l �} II '' f Policy#or Self-ins. Lic.#:����/��U0- (n U9 (0 �q_r9 l`T Expiration Date: 6,-:?) Job Site Address.- City/State/Zip: le(t-e t-��- Attach a copy of the workers' compensation policy declaration page(showing the policy number,and expiration(date). Failure to secure coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of 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 $250.00 a day against violator.Be advised that a copy of this statement maybe fonvarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under thepains andpenalties ofperjury that the information provided above is true and correct. Signature: fl Date. (o 9,z Print Name. J �CfLI Phone#: Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license#: Issuing Authority(circle one): 1.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact person: Phone#: The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers App_ licant Information Please Print LeZibly Na]ne (Business/Organization/Individual): Sexton Roofing Co. Address: P.O: Box 627 City/State/Zip: Holyoke, Ma. 01041 Phone#:413-534-1234 Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construption employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees . These sub-contractors have g. E]Demolition working or me in an capacity. employees and have workers' g Y P ty 9. ❑Building addition [No workers' comp. insurance comp:insurance.$ required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1.1.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance ire re q ud. t c. 152, §1(4),and we have no ] employees. [No workers' 13T] Other comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are 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 far my employees. Below is the policy and job site information. Insurance Company Name: — Policy#or Self-ins.Lic.#: Expiration Date: / Job Site Address: �C (5� City/State/Zip: �GGf��t' e ��� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ofthe DJX for Insurance coverage verification. I do hereby certify nder a pains and penalties of perjury that the information provided above is true and correct. �i Signature: Date ? S Phone#: 4135341234 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: / � �� PJ-� -le License Numb r Ad ress 14 Expiration Date / Signs ure Telephone 9. istered Home Im rovement Contractor Not Applicable £ Company Name Registration Number n © 1AIV2 _ �r- i-7 Address / Expiration Date TelephoneS3 t/•/Z 3 `y SECTION 10-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.4l£ No...... £ 11. - Home Owner.Exeiription The current exemption for"homeowners"was extended to include Owner-occupied Dwellines of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures._A_person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the buildint permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks (❑ Siding (0] Other(CI] Brief Description of Proposed Work: jf p d2o 6C4 44-410 � n 1 -z Cie t�l-T S� �� �Q-'/r`-�J Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a,"If New house and'or add tion ao exisfihO housing; complete the followingl: a. Use of building :One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? I. Method of.heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to on my behalf,in all matters relative to work authorized by this Ifuilding permit application. Signature of Owner Date l I as Owner/Authorized Agent hereby declare that the statements and inf rmation on the foregoing application are true and accurate,to the best of my knowledge and belief. Sign d under the ain and penalties of perjury. v Print Na e Signature of Owner/Agent Date ' ~ - ~ ' Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning 'Ibis column to be filled in by Building Department � Lot Size Setbacks Front r-- Bldg.Square Footage 0110 Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Hasa Special. Permit/Variance/Finding ever been issuedforhm the site? NO C) DONTKNOW 0 YES 0 IF YES, dateioued1 � IF YES: Was the permit recorded at the Registry of Deeds? NO DONlKNUY 0 'ES � IF YES: enter Book Page and/or Document# �� �� B. Does the site contain a brook' body of water orwetlands? NO �~��� DONT KNOW �~� YES ��, IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tnbeobtained ~�v~� Obtained �~x_�� Date� ' C. Do any d exist on the property? ��� YE� �=/ NO «=� IF YES, describe size' type and location: D. Are there any proposed changes toor additions of signs intended for the property? YES 0 NO 0 IF YES, describe size, type and location: ' ' [ ..._'__--_------- -_.............................___--............. _--__--� E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orisit part ofo common plan ' that will disturb over 1acre? YES NO D IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ^ '^ partment use onlx Q -- of Northampton tPi0%.P.E.Permtt' t s wilding Department �trrT�CuTlDnyeway Perrrttt 212 Main Street SewerlSeptcAva{rabtllty F � � S Room 100 Water/Vl�eirAyailabdlty ,g prthampton, MA 01060 Twa Sefs of S#ructural Flans s 1t Y Electric f phone'413-587-1240 Fax 413-587-1272 P[ot/Slte Plans Other 5pec�fy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE,INFORMATION This section to be'completed by office 1.1 Property Address: i_>'PQ Cam' rj S Map Lot Unit ::Zone Overlay District = Elm St District CB District _ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: n� y � � .` � � �t' !?r'c e�.1,,J `�;— ��Lisf'�✓.C' €'�6/�/1 Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Nam rint) Current Mailing Address: / Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number &r / h This Section For Official Use Only Date Building Permit Number: Issued: Signature: — Building Commissioner/Inspector of Buildings Date 45 BEACON ST BP-2016-0001 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A- 197 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2016-0001 Project# JS-2016-000002 Est. Cost: $7800.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sq. ft.): 10497.96 Owner: BITTEL RONALD D Zoning: URB(100)/ Applicant: SEXTON ROOFING CO AT. 45 BEACON ST Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON.•71112015 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department 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. Certificate of Occupancy Sienature: FeeType: Date Paid: Amount: Building 7/1/2015 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner