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29-215 (5) 125 ACREBROOK DR BP-2017-0278 GIS a: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-215 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MOL c.142A) Category: ROOF BUILDING PERMIT Permit BP-2017-0278 Project a JS-2017-000473 En.Cost: $17590.00 Fee: S80.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group NORTH EAST SPECIALTY CORP 065521 Lot Size(sq.ft.): 14984.64 Owner: GALKO THOMAS E&NORMA 1 Zoning: Applicant: NORTH EAST SPECIALTY CORP AT: 125 ACREBROOK DR Applicant Address: Phone: Insurance: 148 DOTY CIRCLE (413) 739-4333 WC WEST SPRINGFIELDMA01089 ISSUED ON: TO PERFORM THE FOLLOWING WORK:REPLACE ROOFING, 1 SLIDER AND 1 BAY WINDOW 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 a Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Departotent 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 $80.00 i/4 Ode 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File# BP-2017-1278 APPLICANT/CONTACT PERSON NORTH EAST SPECIALTY CORP ADDRESS/PHONE 148 DOTY CIRCLE WEST SPRINGFIELD (413)739-4333 PROPERTY LOCATION 125 ACREBROOK DR MAP 29 PARCEL 215 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT.APPLICATION„CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REPLACE ROOFING. 1 SLIDER AND I BAY WINDOW New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License Q65521 3 sets of Plans/ Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INE MATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:* Intermediate Project: Site Plan AND/OR_ Special Permit With Site Plan Major Project: Site Plan AND/OR _Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management D-..sli '' 15-lay Ale 7-13" Sign. . - ofBu di g Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning& Development for more information. Department use only City of Northampton Status of Permit: 1 ~ Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Wet Availability 411 CO 3 \ Northampton, MA 01060 Two Sets ofStructural Plans tUd-1 S� phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans s z ffi Other Specify LICA TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION N, 1.1 Property Address: This section to be completed by office 12-5 Ake eEbYitcw, ILo. Map Lot Unit (Lrit NCE MA (3,04; L Zone Overlay District ..� Elm St District,__ CB District SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT $,1 Owner of Record: '. ....... NORMA &ALB° 115 eaCr2C731404 PD. r'cAZt c pitoot act ams(Print) Current Mailing Adddress: r - 1 /ti Telephone CHi3) S"26 35311 Signature -�'R 2.2 Authorized Anent: Cal`-ELCA -I PAZgErr / Adatol i48 DON C-ICCL 41. SPCAYrfteto ,i4A. Name(Pent)) Current Mailing Address: /✓ � t✓_`— 0913) 1312 1333 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (7 Cat �y (a)Building Permit Fee 2. Etectrical / (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4, Mechanical(HVAC) 5.Fire Protection f� ft -0 6. Total=(1 •2+3+4+5) ."1 /7l 4OO ' Check Number 7 G� (l This Section For Official Use Only Building Permit Number: Data Issued: Signature: Budding 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 (Tot arca minus bldg&paved parking) #of Parking Spaces Fill: I volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document ft B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over t acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Q Addition ❑ Replacement Windows Alteration(s) n Roofing Or Doors /Q�] Accessory Bldg. ❑ Demolition ❑ New Signs ICI Decks [p Siding[O] Other[C Brief Description of Proposed Work: RFPOe e P/6 r Co%rJt,— m fri l Sath7t / 3'7 ate Alteration of existing bedroom Yes .7 No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Rob -Sheet $a.If New house and or addition to existing housing.complete the following: a. Use of building:One Family Y 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 00A{114 (n4L-XC ,as Owner of the subject property hereby authorize Uoeithl W1 S?CCl+Icf1 (Cite, ,to ?- to act on my behalf,in all matters relative to work authorized by this building permit application. CP--- /b Signa tuff Date 5211x"i- 444 err rjoikoc .as Owner/Authorized Agent hereby declare that the statements and information on e foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. revn-1ar Print Name 6 3 !r. Signature of Owner/Agent Date ./ .1 NESCO-1 OP IO', DS ACCPMC DATE(MMIDDNYYY) I` CERTIFICATE OF LIABILITY INSURANCE 07119/2016 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 J Raymond Lussler Ins Agcy Inc NAME:E J Raymond Lussier Ins Agcy Inc FAX 181 Park Avenue,Suite 8 (A/C No Eet.413-737-5359 (A1C,No):413-732-2027 PO Box 499 E-MAIL — West Springfield,MA 01090-0499 ADDRESS:Info lussierinsurance.Com J Raymond Lussler ins Agcy Inc INSURERS)AFFORDING COVERAGE NAICN INSURER A:Western World Ins.Co. INSURED Northeast Specialty Corp INSURER B:A.I.M. Mutual Ins.Co. Nestor INSURER C:Safety Insurance Company 39454 148 Doty Circle West Springfield, MA 01089 INSURER 0 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, NSAADUL SUBW POLICJ^IE POLICY FXP LTR TYPE OF INSURANCE INSD VO/L14 POLICY NUMBER (MMIDNVVYV) (MMIDOIVYVYI LIMITS A X I COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE I 1,000,000 CLAMS-MAOE X OCCUR NPP8326163 0311 812016 03118/2017 PREMIiSEES(Ee ocNcurrrnce)• 100,000 , MED EXP(Any one Pe,-olp 5,000 PERSONAL a ADV INJURY 1,000,000 GEVL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 2,000,000 —1POLICY JECT LOC PRODUCTS-COMPIOP AGO 2,000,000 I I I OTHER AUTOMOBILE LIABILITY SINGLE LIMIT _ 1,000,000 C (Es - _ ANY AUTO ,2433825 03/11/2016 03111/2017 BODILYILY Q iNJURY JURY(Per person) IAUTOWNED X SCHEDULED 'BODILY INJURY(Per Rodent) • X HIRED AUTOS X NON.OWNED PROPERTY DAMAGE AUi05 (Per mpenll UMBRELLA LIAR I OCCUR FAO,OCCURRENCE EXCESS LIABCLAIMS-MADE ,AGGREGATE DED I RETENTIONS WORKERS COMPENSATION 1 PER I I OI& AND EMPLOYERS'LIABILITY VIN STATUTE I ,ER B ANY PROPRIETORIARTNERIEXECUTIVE VVWC60039e2016 107/09/2016 07/09/2017 EL.EACH ACCIDENT 100,000 'OFFICER/MEMBER EXCLUDED? NIA ((Mandatory In NH) E L DISEASE•EA EMPLOYEE 100,000 If DEes.describe FSCRI?TION OFOPERATIONS below E.L.DISEASE-POLICY LIMIT 500,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD101,Additional ROMA°,Schedule.may 0e attached If more apace la required) CERTIFICATE HOLDER CANCELLATION CUSTOME 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 J Raymond Lussier Ins Agcy Inc l ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD l' c1% o vtm./.0ne,A PJZ'n.//tt.Ja httzei a IllOffice of Consumer Affairs and BusinesslRegulation ' 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 103713 Type: Private Corporation Expiration: 7/14/2018 Tr# 419291 NORTH EAST SPECIALTY CORPORATION. SHARON TARIFF 148 DOTY CIRCLE WEST SPRINGFIELD, MA 01089 Update Address and return card.Mark reason for change. CA a �� El Address 0 Renewal 1] Employment 0 Lost Card 05111 ✓T tif;in mon wee/de f .c,hetd •. Mike of Consumer Affairs&Business Regulation License or registration valid for individual use only L'"r `1HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 'Ikins fip'�Registration: 103713 Type Office of Consumer Affairs and Business Regulation N Expiration: 7/14/2018 Private Corporation 10 Park Plaza.Suite 5170 Boston,MA 02116 NORTH EAST SPECIALTY.CORPORATION NESCOR SHARON TARIFF r /'J - /^ J 148 DOTY CIRCLE WEST SPRINGFIELD,MA 01089 Undersecretary Not valid without signature v. I ri Massachusetts Department of Public Safety \\r Construction Supervisor I t�1 Board of Building Regulations and Standards Restricted to Supervisor - ) License: CS 065521 llntestricted^Budd rgs ai anyuse group which contain less Man 35 OD4r hir-__{�riuo1r.ef.y. _,. . Construction Supervisorz enclosed space _, . -. sreVEN F DARREYT I 4?Ma HAMAL WA � ... ..— Fmlurci Aa secs- .-urreneition thrliassachvsetts--� ... ....t - (- "A- C1-1, Cornmwsioner 61/2512%s ff State Brnfditg Code iscause for revocation otthis license. DPS Licensing information visit: WW W.MASS,GOV/OPS • SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: JftVe.)0 areee r LS O(Cc 2 License Number '1C Lilt rHAPitt 4 M $r"un a-70 ) , rM oder a /Lc/2oiff Address Expiration Date • • (9/5) ?31 - q333 Signa• e Telephone 9.Registered Home Improvement Contractor. Not Applicable ❑ kitC lo37J3 Company Name Registration Number Md Rtftf5T Verocri CoCP. 7d/y LOC Address Expiration ate iu r 00''1 C/eCLe- GJ, 56'EAkvcm20 MA. Telephone(`lin ntr-v333 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(tat..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 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings 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 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 Department of Industrial Accidents H'- = Office of Investigations '' . 1 Congress Street, Suite 100 = ir Boston,MA 02114-2017 �; www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): PUE1Neit5T ca-Carvg ‘thee. _ Address: /tf Dory Ctecte City/State/Zip: WC5T t1'e(tkact&z0 ,M4 Oi Wl Phone #: (yt3 ) 13 - `(333 Are you an employer? Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and 1 employees (Poll and/or part-time).* have hired the sub-contractors 6. New construction 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. ❑ 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 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL y * c. 152, §I(4),and we have no 12.❑ Roof repairs insurance required.] 13.0 Other employees. [No workers' comp. insurance required.] 'Any applicant that checks box#1 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: 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 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 of the DIA for insurance coverage verification. I do hereby certify . - - the p ns and , e tfpe 'ury that the information provided above is true and correct. '— Si ature: Phone#: 013) -t3 — K333 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#: 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: 12c 642,Ode fir? The debris will be transported by: ?sP06 Lec a-- The rrThe debris will be received by: C HiCoPEe 1st_ rtrq /b4i ti c- Building permit number Name of Permit Applicant kUttHeR5 9Cu4eT'i rdOP. CA/fac Date Signature of Permit Applicant