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18C-148 162 PROSPECT AVE BP-2016-1524 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C- 148 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: ROOF BUILDING PERMIT Permit# BP-2016-1524 Project# JS-2016-002594 Est.Cost: $10800.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: A & J HOME IMPROVEMENT INC 101017 Lot Size(so.ft.): 3005.64 Owner: HAMPSHIRE PROPERTY MANAGEMENT zoning: URB(100)/ Applicant: A & J HOME IMPROVEMENT INC AT: 162 PROSPECT AVE Applicant Address: Phone: Insurance: 60 WASHINGTON AVE (413) 467-1500 0 SOUTH HADLEYMA01075 ISSUED ON:6/22/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF garages 1 - 7 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 Signature: FeeTvugi Date Paid: Amount: Building 6/22/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck- Building Commissioner C'° Department use only City of Northampton Status of Permit: J 2 Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability DEpl.c-e....... Room 100 WaterWell Availability "'n""'"' "" ` --- 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, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address. This section to be completed by office Pro3KBit- LVoodS an—CFS 1-9 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Hampshire Property Management Group,tnc. Hampshire Property Management Group.ine. Name(Print) Current Mailing Address. Hampshire Property Management Group.lnc. Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)b be Official Use Only completed by permit applicant 1. Building 10,800 (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 This Section For Official Use Only Building Permit Number: Date Issued: {�'\J Signature: j���{�/ Building Commissioner/Inspector of Buildings Date SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors Cl Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[O] Other[Q] Brief Description of Proposed Work'. Remove and e.}1 anclIngthil„ew.nnn il®aces on' Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes __No Plans Attached Roll -Sheet ea.If New house and or addition to existing housing, complete the following: a. Use of budding '. 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 MA,r 5chre e art4:—f /%4NGv-e z4- ,as Owner of the subject property !/ ^^ // V 4 1 3- toto herebyctauthorizemy ive t �rng per. _G� to act on my behalf, in all matters relative to work authorided by this building permit application. Signa re of Owner / � �'mDale w I, /CL-a-s-i </i zipercA Oi .y9e A" I(y( /%i', 4f'r''tee-44F— as Owner/Authorized Agent hereby d are that the statements a6d informafion on the foregtIg application are true and accurate,to the best of my knowledge and belief. Signed upder e pains and pe (ties of perjury. Print Name /tel-2o/ice Signature of OvmerlAgeni Date Section 4. ZONING AB Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be tined in by. Buildine Department Lot Size Frontage Setbacks Front Side L. R: L'. R: Rear Building Height Bldg_Square Footage Open Space Footage (Lot area minus bldg&pmd parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q IF YES, describe size, type and location: E. MI 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 Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /n� Not Applicable/❑ Name of License Holder: /Y i rhory ) 19-02 vr. l C5SL- -/C/Oi 7 License Number e �Jrtc f� / > e Serr7`tilisrlel P% ,ao24— ////6/2a/'? Address ExpiratiOn Date Signature Telephone el/ — / /1/son 9.Registered H Improvement Contractor. Not Applicable C 45 / -k,tZ'i-v-yoro„e,n,ra-t:A ? S ? f /� Company Name �/^ r h� /�/,, i f ,(�/ .a Registration Number /'� 6 Wb51, (mol %e, JO c.t-f 3i id; l'! YS L/vJg/2 )/ X Address F� l Expirat�bn Date Telephoftb 3)x/67/Yi 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 Na 0 11. - Home Owner Exemption The current exemption for`homeowners'.was extended to include Owner-occupied Dwellings of one(I) or MO(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 and 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 tune,during and upon completion of the work for which this permit is issued. Also he 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 render 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 150A. Address of the work: / `7 `✓� r iL%a._1 S The debris will be transported by: C20,724..4- t/r cpoc- The debris will be received by: Building permit number: Name of Permit Applicant 8 J J r . r _ ' _ Date Signature of Permit Applicant '"".— The Commonwealth of Massachusetts `i -;', - Department of Industrial Accidents if amit=wi, I Congress Street,Suite 100 l Boston,MA 02114-2017w. �r y' wwmass.got/dia }}'orkers'Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. /1lsplicant Information Please Print 'deathly Name(Business isaniz tlonrindividaal):A&J Home Improvement Inc. Address:60 Washington Ave. City/State/Zip: South Hadley, Ma 01075 Phone#:(413)467-1500 Are you an employer!Check the appropriate box: Type of project(required): 1_0 I nn a employer with 8 employees(full anther pan-time).a 7. 9 New constniCtion 2Dlamasoleproprietororpartnershipandbavenoemployeesworkingformein S. ElRemodeling any capacity.[No workers'compinsurance required.] (t'--Il 9 391 am a homeowner doing all work myself I No workers cramp_insurance required.]- IJ Demolition 4.91 am a homeowner nd gig hehiring innitractors to conduct all work on my property. I will IQ 91}adding ndditiun ensure that all contractors either h - k compensation insurance or aresole II.❑Electrical repairs or aliditiotts proprietors with no employees. n I r_ t J Plumbing repairs or additions 59 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. I3.�Hoof repairs these sub-contractors have employees and have workers'comp.insurance.' G_9 We area corporation and its of ears have exercised It reit right of exemption per MGL c 14. Other _, I5:1.51(41.and we have no employes.Isis workers'comp.insurance required.] ",lay applicant hat checks Mix a I must also lilt out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating W y are doing all work and then hire outside contractors must submit a new affidavit indicating such. empm vers. that check thin gio must attached emplo enc they mut showing the name comp.sub-contractors bcr and stale whether or not those entities have empia}ms- tLlhembmlW Pots have rnxFWvar.Nay meal provide their wxl;ers'erom0.lmllcs npmhm. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name.Challis Policy#or Self-ins. Lie-»:WC003786174 Expiration Bata-05/11/2016 tic:lob Site Address: ern 5R.of 4A'c c Lecr,f L.- 7 City/slnmUip/✓ y _ .. 4f,,, iu,0/6( 0 Attach a copy of the workers'compensation policy declaration page(showing the policy number a expiration date). Failure to secure coverage as required under MGL C. 152,§25A is a criminal violation punishable by a line up 10$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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ander the pains and penalties ofperjury that the information provided above is true and correct. Signature: Da lc: Phone N:(413) 467-1500 Official use on(V. Do not write M this area,to be completed by city or town official City or Town: Permit/License n Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.Citvlfown Clerk 4.Electrical Inspector S.Plumbing Inspector 6, Other .._. Contact Person: Phone#: UMassachusetts Department of Public Safety Board of Building Regulations .sod Standards License'. CSS1-101017 ANDREW J DEREN s 50 WASHINGTON AVENUE SOUTH HADLEY MA 01075 expiration. M� l� 11/1612017 Coinmissloner • r ,///„4 , 57/: ;lKo,;,;f,(//(.C/A • Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration'. 135399 Type'. DBA Trp 419291 Expiration'. 4/112018 A & J HOME IMPROVEMENT ANDREW DEREN 60 WASHINGTON AVE. SO. HADLEY, MA 01075 Update Address and return card.(Nark reason fin rlch change. Address Renewal Employment License or registration valid for and ivid ul use only Office IConsumerIMPROVEMENT CONTRACTOR Regulation before the expiration date If found return to: HOME IMPROVEMENT CONTRALTO pe Office of Consumer Affairs and Business Regulation Registration: 120189T 10 Park Plaza-Suite 5170 Expiration: 411/2018 DBA Boston,MA 02116 A&J HOME IMPROVEMENT ANDREW DEREN 60 WASHINGTON AVE. - - - Not valid without signature SO.HADLEY, MA 01075 L n.ersecretary • ACORD e CERTIFICATE OF LIABILITY INSURANCE DAt (MMIDO fi Y) 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 poficy(ies)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). PRODUCERc OM ACT Barbara Grynkiessicz NAM_._ Webber & Grinnell �yL".E,nJNE. 913)526-0111_ _AE Nol_lalal sss_6aan 8 North King u^treatE-MAaasabgrynkaa rcaSwebberandgrinnell.com INSURERISI AFFORDING COVERAGE NAIC X_ Northampton MA 01060 INSURER Alee r)C1ey ssutanoe/HRECK INSURED suREReSafety Snd¢nmity 33616 A4J Home Improvement, Inc. INSURER Chart e(C1U¢tt Attn: Andy S. Deren INSURERD: 60 Washington Avenue INSURER E: IHSII South Hadley MA 01075 RERF: COVERAGES CERTIFICATE NUMBEREIcp 2017 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 • InWICATEO 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 SY THE POLICIES RESCRKE°HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. USN'.. __._.. . . _.-.. — ADIWTSOBR... POUgy EFF POLICY ENpp _ _ ... ...._. ..._ 11.0 TYPEOf INSURANCE IPSO V4V0 POIICY NUMBER IMMIOpYYYYI .IMMIO0'YYTYI UMITS X COMMERCIAL GENERAL LIABILITY DACHOCOVRRCNCE 5 1,000,000 A CwIM!SMPOE X_OCCUR PREM SE$1E ccurta5cg 5 300,000 ' STTMA0012603 4/22/2016 4122/2013 'MED alp/Any re persx” S E;Cluded PERSONAL BAPV INIURYa 1,000,000_ OENL Ae[,REGATE t3MRAPPLIES PER GENERAL AGGREGATE S 2,000,000 X POLICY LOO PROD CTS COMP/OP AOC 5 2,000,000 OTHEF S - AUTOMOBILE LtAMITY CARHMED5INCSLE F1Mi1 q _ ANY AUTO 'BDJILYINJURY'P person) S 260,000 B - ALL OWNED -X SPMED6224916 IiED 11/21/201 11/24/2016 9O06UR P . tc ) 5 500,000 AUTO AUTOS X .NREOSAUTOS K NON-OWNED PROPERTY DAMAGE _ 100,000 __. AUTC4 -IPo Ssodmll_.__ _ 0000 PIPJtasc , S 0, 0 UMBRELLA LEAD OCCUR EAGSU'CURRENCE 5 EXCESS LIAR CLAIMS-MADE • AGGREGATE _ 5 OSP .N`sh' S S WORKERS COMPFNSA31ON0N X R dY✓.- ANYPROP TOR?A BILITYTNFi _.- Si i ACE _ 0 ANY OFACERA GR EA LUDED%EGJi VE VIN EL EACH ACILFNT5 -10 0,CUO bFCENMEWDE.I> NIA Q YM tl ary in NH) - RC003796379 5)31/2034 $)33)203.3 'Et DISEASE EA EMPLOYEE 5 100,000 DEECNPIICN OF OPERATION$gala, E.L.DISEASE•POUGY LIMIT S 500,000 • DESCRIPAONOF OPERATIONS I LOCATIONS I VEICLES(ACORO301.Additional ROM(JSchad UK,may ba anachy,T montFlxa la mgWred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance CoverageTHE EXPIRATION DATE 'THEREOF, NOTICE WEL BE DELNEREO tti ACCORDANCE WITH THE POLICY PROVISIONS. AMWRIZEDRa %t5ENiATWYE r � ©1999-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD 1N8025(r1401]