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24A-042 (5) 120 JACKSON ST BP-2016-0373 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 24A-042 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2016-0373 Project# JS-2016-000607 Est.Cost: $50000.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GALVIN & SONS MASONRY 013977 Lot Size(sq.ft.): 274428.00 Owner: NORTHAMPTON CITY OF JACKSON STREET SCHOOL Zoning: URB(100)/ Applicant: GALVIN & SONS MASONRY AT: 120 JACKSON ST Applicant Address: Phone: Insurance: 95 NORTH MAPLE ST (413) 253-6585 WC H A D L E Y M A 010 3 5 ISSUED ON:6/24/2016 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT NEW CONCRETE LANDINGS & RAMP AMENDED 1/12/16, 6/21/16 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/4 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 Signature: FeeType: Date Paid: Amount: Building 6/24/2016 0:00:00 $0.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 W ater/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATETEOR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION L jE47(X/C , <4 NS• 1.1 Property Address: This section to be completed by office C53CCI.0 Map Lot Unit Zone Overlay District p 5 r. Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 r, ner of Record: ,Atli. CE7v'Za4 l (, Neme(7s 1� 1��e1ry S� �r uiw til 47 if G(�- (YF p J 5 e�Zbo C�1� .�^ I Telephone Sign. u- VQ N�Its 2.2 Au hor-ed .ent: Name P �•,.,1',lJ';R fir" r; fl •t Lh t� • Trott- 6-VbC n l7 Current Mailing Address. Signature- Telephone - SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars)to be Official Use Only completed by permit 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) VMu Check Number — O '— This Section For Official Use Only Building Permit Number: Date ///%/////���/////�//�Jf/JJ/�qJ Issued Signature:��aa-'F2 ��WW�i/�'� 0/-6. (..?"5"1/4/ Building Commissioner/Inspector of Buildings Dale Ok ro .3742 rdefr,o 1-a/-/6e • RFC .. -I") anent use only City of Northampton Status t ' '(�" �f, . JUN 2 i Building Department riliiiiilesPmmtl a 212 Main Street S wertSeptic.Ayajebihty pemc —�"„s Room 100 Water/WebA%mdabiHty - Northampton, MA 01060 Two b SWGoml Plans {;phone 413-587-1240 Fax 413-587-1272 Plot/Site Pians Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATEENOR DEMOLISH A/O ONE OR TWO FAMILY DWELLING NO SECTION 1 -SITE INFORMATION /e&iebtl/rG f 4,AC-C 1.1 PProperty Address. / This section to be completed by office goka ntJ�csfra t 54.0 e( Map Lot Unit N ""Ortino (1-� \\ Zone Overlay District all St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /,,,,, Cid- ' k�c M11k�.1/SPA yk ce,lugg NV.* S ke�4�rkaAr -1 i "1 Name(PO) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: fitn (ki)JIN _ t vI/rl ,. l A-- a Al Name Pnp Current Mailing Address: Signator Telephone SECTION$-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2 S (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) SS-wro Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size _.. .. Frontage __ .. . Setbacks Front Side L: R:.. L: R:. Rear Building Height Bldg. Square Footage Open Space Footage ,a (Let area minus bldg&paved parking) M of Parking Spaces Fill: (volume d location) _.. __... _.... __. A. Has a Special Permit/Variance/Fin ing ever been issued for/on the site? NO O DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW 0 YES 0 IF YES: enter Book Page. and/or Document # 1/4 B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW (3 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES IJ NO 0 IF YES, describe size, type and location: eX\16.104 5 t1...,a D. Are there any proposed changes to or additions of signs intended for the property? YES O NO its IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 6-DESCRIPTION OF PROPOSED WORK(check all applicable) New House in Addition ❑ Replacement Windows Alteration(s) .F�1 Roofing n er Doors E _,` Accessory Bldg. ❑ Demolition I❑ New Signs [Dl Decks [i Siding[D] Other[0j Brief Description f Proposed p��_ p�t e2'` p«p �� 11�� 11 f Work: t .notliQW kiv9 `Vrtv'4 ( C ad Alteration of existing bedroom 1 Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing,complete the following: 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? f. 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. I. 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 act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner �/�/ L.. �\, )-7)64) `' ` Dale I. Pei e I lL ))64)t'V as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the°wins and penalties of perjury. Print Name {////���'J'//'/����''/��/�" 1/ Signature/Jf OwnerlAgent Date (264101- Signature SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ! 1 Name of License Holder'. f7UV"1,1C (1. C"`6„t1.11A Cy—C\ License Number QC A1. ver S Ikcfllen(silk mc C0141 7008 Address r Expiration Date t"ature Telephone 9.Realstered Hope Improvement Contractor Not Applicable p,u)t. firsn Soul /Dire ALKAAt k) 1--)-Li(21 Company Name Registration Number err Pink t(' S - (dtd[u) m - 6163 r 17<11.-t1oU,. Address — I(l� (—V7-3153 I1 Expiration Date ( i- Telephone(-W .) i Gbl/ 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. N Signed Affidavit Attached Yes✓s- I No 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 building 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 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 150k Address of the work: I� rm� c nr{ The debris will be transpo ed by: -Th- k s.Lc / ( t. 49 44 S 9 The debris will be received by: 1A)\VI \) )(YcCM7tt (00640l{. Building permit number: (n� �� Name of Permit Applicant G iC.�Z ,Ca.`�IC t' (AA Dat /)2Xáfl/fr ' Date SignatureomitApplicant ice GALVIN&S01 SFRIBERG ACERTIFICATE OF LIABILITY INSURANCE DATE,MMNDT `,-� 1/2712016 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(tes)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 the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME. AMA Insurance Services PHONE 933 East Columbus Ave INNa-Ee):(413)788-8000 (Arg{NC ,No:(413)886-0190 Springfield,ri eldMA 01105 nooaEss InFo@axtagroup.net. INSURER(S)AFFORDING COVERAGE NIJCO INSURER A:Travelers INSURED INSURER e. Galvin 8 Sons Masonry INSURER C: Jason Galvin -- - - - 107 Blue Hills Road INSURER D: Amherst,MA 01002 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 POLICES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. RSR; —_. __._. -.. . J{OOL-SUSR POLICY EFF • OuCYEXP _. _..._ LTR TYPE OF INSURANCE ROD VIED POLICY NUMBER (MWDDNYYY) (M14CDM9Y) LIMITS A X COMMERCIAL GENERAL LIABILITY . EACH OCCURRENCE $ I,000,00m CLAIMS-MADE X OCCUR 68020537793-15.42 08/10/2015 08110120161 °pREMISEe EaEm eED nom) $ - 500,00„1 _ . D I I MEEXP(Any one Person) $... 10,00`0' • I PERSONAL S ADV INJURY S 1,000,00011 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ 2,000,0001 _ POLICY X • PED LOC PRCWCTS-COMP/OPAGO $ 2,000,000 OTHER HIRED NONOWNED a 1,000,000 •AUTOMOBILE LIABILITY • COMBINED SINGLE LIMIT $ 1,000,000[ • (Ea aruden9__. ANY AUTO 680-20537793-15-42 08/10/2015'.08/10/2016. sassy INJURY parson) $ l AI ALL OWNED SCHEDULED BODILY INJURY(Per aAadent) $ 1 AUTOS AUTOS XI HIRED AUTOS X accident) I PROPERTY DAMAGE -$ AUTOS (Per adent) _ _ UMBRELLA LIAR OCCUR I EACH OCCURRENCE $ 1 RECESS LIAB • CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION I v PER LIABILITY0TH 'AND EMPLOYERSBILITY YI NI STATUTE _ ER A ANY PROPRIETORPARTNERECUTIVE 7PJUB-2E67193-0-16 01/20/2016 01/20/2017 EL.EACH ACCIDENT $ 500.0001 FX - OFFICERRAEMSEREXCLUDED? :NIA (Mandatory In NH) EL DISEASE-EA EMPLOYEE$ 500,0001 If yedescribe under I DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S 500,0 DESCRIPRON OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached II more apace is required) 2016 EMR: .95 CERTIFICATE HOLDER CANCELLATION I 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts . Department of Industrial Accidents n,,dir�c --t— Office of Investigations 1az +l 1 Congress Street,Suite 100 Boston, MA 02114-2017 . www.mass.gol/dna Workers Compensation InsurancsAffidavit: Builders/Contractors'Electridans'Plumbers Applicant Information ^ MM Please Print Legibly Name (a cincssiOrganixatiorvtodiyiduaq: (.Ail- iU r S .g+S Address: lc �i Jr e.. City/State/Cip: Vi (.. 4 _.. C1Glj _ Phone ff: 4f_R '_ ..) Are you an employer?Check t e appropriate box: Type of project(required): I.❑ 1 am a employer with 4. ❑ lam a general contractor and! 6. ❑New construction employees(full and/orpart-time). have hired the sub-contractors 2.�I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 3. ❑ Demolition workin for me in any employees3-M have workers gn capacity. 9. ❑Building addition [No workers comp. ins-trace comp. insurance.[ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself (No workers' camp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no employees [No workers 13.❑Other, comp. insurance required.] 'Any dapllcait that checks box#1 mus a so fill ma Meseen albdow shOwtrg tierwaken ovnmeetsaiM pqi Cy ittomiallal. t I lemeowners whn.mbm it affidavit mdicadng they-are doing all work and then hire onside contractor must submit a new affidavit indicating such. tcbnuacton Gat cheek this box muse attached en addai ori sheet showing the name of cob-contractors and mate whether or me thoseemnes tla e employees. if the sub-ox traYarsflaveanpioiees.they rrxia armidetftr vrokes cony.policy number I am an employe that isproviding workers' compensation insurance for my employees Blow is the policy andjcb site Information. Insurance Company Name: {Fe' Policy N or Self-ins.Lie.#: at-16,c3-1743- 1 C- is4 T Expiration Date: Ce llt)1`Z„D1 o . Joh Site Add __' 1C.µ ress: .ied ST`` Ciry �„,,, /State/2ip: w4 t MA 310)0 Attach a copy of the workes compensation polio/declaration page(showing the pd icy number and expiration date}_ Failure to secure coverage as required under Section 25A of MGI-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 he forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify a ter the pains and allies of perjury that the injiirmation provided above is true and correct. t ^ Signature: 4.i�c......._22 ads ,cid r Date: t)/7e/zolb. Phone f: / (1 3 6+ eir _ 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: