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17A-038 212 NORTH MAPLE ST BP-2017-0205 GIS a: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 17A-038 CITY OF NORTHAMPTON i,ot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: BuiIding DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Pia BP-2017-0205 Project# JS-2017-000345 gst. Cost: $7900.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const_Class: Contractor: License: Use Group; JAMES SZCZEBAK 58968 Lot Size(sq; ftJ: 12893.76 Owner: MASON NATHANIEL S TRUSTEE ,Zoning:RBI 00)NRA(I0,p)/ Applicant: JAMES SZCZEBAK AT: 212 NORTH MAPLE ST Applicant Address: Phone: Insurance: 126 SUMMIT ST (413) 537-5379 WC BELCHERTOWNMA01007 ISSUED ON:8/16/2016 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 Signature: FeeType: Date Paid: Amount: Building 8116120160:00:00 $40.00 212 Main Street, Phone(413)587-1240,Far(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only r' of Northampton Status of Permit RECEIVED El (ding Department Curb Cut/Driveway Permit 12 Main Street Saw'eriSepticAvaliabilay� NG 1 6 2018 Room 100 WaterAmell Availability Norl ampton, MA 01060 Two Sets of Structural Plans , atone 4 3-5 7-1240 Fax 413-587-1272 Plot/Site Plans DEPT OF BUADING NSPECTONS NORRIAMFTON,Mn ores; Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: 1/1101 t� ,DIy/� This section to be completed by office X11'3-_3"t4 $ ,4 FE ¢ 6€ Map Lot Unit Zone Overlay District KOretnt¢/ MA Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 22.1 Owner`yof Record: �t , y 1 pRan//et Alj. ,,{,,� { A�� Name Prin�g.t R risk 7aATYlenitl J, )//sn 11c*- /�' ��/S /1w4.t S}c�' l o /J1.v/�in OM Name(Printll rk C'u `r}a n tchesss.Se 4 / �ysq ,,,aniffieffieeTe PM1ona 4!ii OOO Signature .... 2.2 Authorized Anent: Name(Print) 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(3}. 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=ti +2+3+4.5) 7¢0 ao Check Number a+'7 This Section For Official Use Only Date ... Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date SECTION s-DESCRIPTION OF PROPOSED WORK(check all applicable) i New House LIAddition ❑ Replacement Windows Alteration(s) I f� 1 Roofing El Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs ICI Decks (lam Siding(Dl Other[DI Brief Description of Proposed ^ ks� Work: ("tit-Ar g {� u Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba. 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 stones? f. Method of heating? „ Fireplaces or Woodstoves _Number of each 9. 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR11CONTRACTORt,�^ � APPLIES FOR BUILDING PERMIT I. I, 21rty kM1'4\ - '. M Pi Ih'Irlgtj1t(,(. 4 Nd r9�H ..t!' 4/ •40.3 I” ,as Owner of the subject phereby authorize V •- • (r„ C Ir. ttt// 1-004• to act on in all matters rela ive to work authorizedby this building unit pplication. -ten. -._ 62314 Sig re Owner Date MIMIMIIIIIIMIIIIIIIMIIIIIIIMIIIIC— I, ^1M gS 17r'2_z'f 1< as Owner/Authorized Agent hereby declare the statements and information on the foregoing application are true and accuratei to the best of my knowledge and belief. Signed under the pains and penalties of perjury �A.q Pet SzczC.t A4'" .. Print Ma•- dip we�• /6 i6 Signature dOwner/Agent Date SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed tonsil-gegen Supervisor: Not Applicable 0 Name of License Holder'. -1111M'EC ct(.'yel2f1f< ©58 /60 License Number Iz.6 Ssi n..+ St g+4I U€ecroi..,a rl OtooT Address Expiration Date 7 h'/3Ss ?5324 Sign ure / Telephone 9.Registered Home Improvement Contractor. Not Applicable ❑ �S CoA/ F )-1—"_.S //Sc-c% Company Name Registration Number it 6 Sumps i& s-f - Z e• Address Expiration Date -eacekalastmeserse PIA 0)007 Telephone 5-376379 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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 tie No C -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 l0t3.5,I. 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 pot 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 __ The Commonwealth of Massachusetts artment of Industrial Accidents Jrli Office of Investigations mainle 1 Congress Street,Suite 100 Boston,M4 02114-2017 ,Z1 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legible Name (Business/OrganizatioMndivitlual): —TAMESGett♦3jQ 4( Address: C6 _ J Cit /State/Zip:ge c, g 4;wa PIA 0/007 Phone #: /3 S' '7%C?Zai Are you an employer?Check the appropriate box: Type of project(required): 1.fit] I am a employer with �j 4. D I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors G. New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8, Q Demolition working for me in any capacity, employees and have workers' 9, Building addition [No workers' comp. insurance comp.insurance.] required.] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL12.® Roof repairs insurance required.]t c. 152,81(4),and we have no employees. [No workers' Ct.[Other comp.insurance required.] *Any applhtant that checks box p1 must also fill out the section below showing that workers-compensation policy information. *Homeowners who submit his affidavit indicating they are doing all work and then hire outside contractors must.submit a new affidavit indicating such teontractors that cheek this box must attached an additional sheet showing the name of die sub-contractors and state whether or riot those entities have employees If the sub-contactors have employees,they nest provide their workers comp.pone)'number. ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and ph site information. ..� Insurance Company Name: /,t",4✓jL.'gJ Policy or Self-ins. Lie.#: Fi Nht3-LF34S ' - 8 - a �y Expiration Date: Z • Z Z' I/ Job Site Address: Z d Z—21 V 'fidrer vI,)1 f atnNa3/7/ City/State/Zip: _ 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 MOL e. 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 of the DIA for insurance coverage verification. I do hereby c rt f} under the pains and pe lies tifpetjury that the information provided above is true and correct Signature: C-72--) Date: 8_16- 16 Phone#: yia.S";7 S 7 29* Official use only. Do not write in this area,to be completed by c14'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 4: 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: -Z t - Z iy Uatiz d/rwy € The debris will be transported by: .4. f co,do c,44._< The debris will be received by: ALL A16o43 Building permit number: Name of Permit Applicant jgotE_< Seccrta 4 et Date Signature of Permit Applicant JSCONTR-01 SSHEVLIN A`OR17 CERTIFICATE OF LIABILITY INSURANCE n"` 1)Z016 "`'" Th1 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 ADDITIONAL INSURED,the policy(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). PRODUCER NAME: ... ...... . AMA insurance Columbusce Aves + INTONE FAX 933 East Ave auC,xe,Ea):(413)788-9000 (AZ,NO(413)886-0190 Springfield.MA 01105 ADDRIESS,infoelaxlagroup,net INSURERI9/WORDING COVERAGE NAICY INSURER A:Essex Insurance Company INSURED INSURER a:irav@lers 1 S Contractors,Inc INSURER C: Tammy Szczebak 128 Summit Street INSURER D . Betchertown,MA 01001 INSURER F, INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS i5 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 ADM ASV SUM WED POLICY NUMBER POLICY %m UMITS 'NMR TYPE OF INSURANCE A X COMAERclALonwRAL unwire/ EACHOCCURRENCE } _1,000,r1'1 CJAIMS.MADE X OCCUR 3E134245 08/23/2015 08/23/2018 PAMAGETORENTED SO,Itr PREMISES RENTEDncel $ MED EXP(An5REE person) 5.... ... 1,1i1 PERSONAL ADV INJURY S 1,000,1II GEN'TAGGRE(GATE LIMIT APPLES PER GENERAL AGOJEGATF z 2,000,PRO- I'II X COMET ERE 100 PRODUCTS-COMP/OP AGO S 1,000,11'1 OTHER. ... i.... . _.... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT •S 1,000,1 II {EaaEwen) B ANY AUTO BA-1577L921-15-SEL 12/01/2015 12101/2016 BODILY INJURY IAA person) $ ALE GOWNED x SACHf uLED BODILY INJURY{Pei at e,nt,S ; AUT' X HIRED AUTOS X 21%714E° (Pear accdreYd] ,°aMACE .� ..- ...._ �.... ._E ._ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE, AGGREGATE DEO RETENTIONS S WORKERS COMPENSATION •..- X PER OTH AND EMPLOYERS'MARAUD/ y)N STATUTE ER B ANY PROPRIETOWPARTNEWEXECUTIVE I 6HUB-2E38599.8.16 02/22/2016 02/22/2017 E.L.EACH ACCIDENT S 1,000,01 OFFICER/MEMBER EXCLUDED? `_. I NIA (Mandatory In Nm El DISEASE EA EMPLOYEE S 1,000.111 II y DESCRIPTOR Or OPERATORS Wiese E L DSEASE•POLICY MET S 1,000,E t:Y DESCRIPTION OF OPERATIONS I LOCATORSI VEHICLES(ACORD 101,Addilionel Remarks Schedule.may be enacted d TOM space is NENINE) James E.Szczebak excluded from workers'compensation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN R 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