29-412 (4) 121 SANDY HILL RD BP-2018-1286
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mau Block 29-412 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv' ROOFING/SIDING BUILDING PERMIT
Permit# BP-2018-1286
Proiect4 JS-2016-002267
Est Cost' 4250000
Fee $276.25 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MAJOR HOME IMPROVEMENTS 103054
Lot Size(sn. ft.7 12240.36 Owner. GAYBARYAN ANDRANIK O&OLGA A GAYBARYAN
zo in : Applicant. MAJOR HOME IMPROVEMENTS
AT. 121 SANDY HILL RD
Applicant Address: Phone: Insurance:
19 HUNTER SLOPE (781) 913-6405 WC
WESTFIELDMA01085 ISSUED ON.6/512078 0:00:00
TO PERFORM THE FOLLOWING WORKNINYL SIDE HOUSE AND METAL 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 Si¢nature:
FeeTWpe: Date Paid: Amount:
Building 6/5/2018 0:00:00 $276.25
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
Bing illp"nt
Main Street
Room 100
ggeYThegoptopa
ph N - - 72
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I.SnINFORWITION (�n— 1 D ' 2-
1.1
1.1 Pro Atltlresa:
1a 15ainK AC
TL0V--en MA C06d
SECTION 2-PROPERTY OWNERSOMPA%UTHOpQED AGENT
2.1 Owner of Reading:
A n _a-n� C T(A '171M N QXl 01 cS � C
Name(Pnnt) i(fA@iling Qtltl�e6s_ � �
TeepM1 e I (�
Signature
2.2 Authorized Aaent:
Vag lie dd "A
Name(PMt) Cunent Mailing Aetlress:
604
B' naWre Teleph e
rSECTWN 9.-ESTIMATED CONSTWUMM
Item Estimated Cost(Dollars)to be Official Use Only
com leted b Permit applicant
1. Building d �l-� (a)Buildbig Permit Fee
2. Electrical J W (b}EstimaDed TOOl Cost of:
CnnsWctibn kam 6
3. Plumbing Wiggling Fiscal Poe
4. Mechanlcil(HVAC) �- 4„
5. Fire Protection
6. Total=(1 +2+3+4+5) clr Cryept Number
This Section Fee..'.. WUse...,
Building Partial Num IssuDale
Dated.
BusMng wanllnspacltt of Buildings Data
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Atltlltlon ❑ Replacement Windows Alteration($) ❑ Roofing IJ
Or Doom ❑
Accessory Bldg ❑ DemolNion ❑ New Signa ❑] Decks ❑ Siding ] Other EM
Brief Description of Proposed
Work'
Alteration of existing bedroom_Yes ✓ No Adding new bedroom Yes ✓ No /I/Q
Attached Narrative Renovating unfinished basement Yes _No
Plana Attached Roll -Sheet
h1 0.
a. Use of building:One Fari Tiro 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 farm 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
Innd a -"
as Owner of the subject
o
P Pe NY
hereby authorize V Q kd) c "`Ak
to act o my shelf,i all matters relative to work authorized by this building permit application.
S 3 d
Signature of Oii,ni
'' // 1',, 1I� 1,, I, Date
I, V�+ 1 Q Yak f,". C�CX tom(-C�` as OwnerlAuthorized
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 pains and penalties of perjury.
Print Name
Sign of er/Ag n Date
SECTION 8-CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: Not Applicable ❑
Name of Lieenu Holder'. ��Q k1 I ( �ar I h 5 "' I�3 0
License Number
A !�! IQ( I ( y
Address Expiation Date
Teleprome
� [ Not Applicable ❑
n 10.n rYC �l �r Dy ( �S I sb g4 (
Gompari Names, Registration Number
10 ( l a r� S Sf ( �Pc� �IUA OIL
Address � Expiration Date
Telephonq�L,���..,�''// // L,,..--..1:4
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT
\(M����.0.""""L o 152,g 2SC(8))
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....... V, No...... ❑
City of Northampton _
Massachusetts
DEPARTTffirT OF BUILDING INSPECTIONS
212 .Win StreetNUNcipal Building
NorNupton, NL 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation,repair,modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner hascontractedcontracted with a corporation or LLC,that entity mustberegistered
Type of Work1(1 al I Q1)Wt b�V1ku/I l�t(M Yl"j Est.Costj�r/ka1 �
.LY1�(,"Jf) p Q rK!CA! � J
Address of Work: y i �/b !1/ of l—�() lasr .O( cin
Date of Permit Application: 5311 ( d
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
1 hereby apply for a building permit as the agent of the owner:
31 ( K Vag t o ky-kha-fah , k 1 5 c) g,41
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Nsin 9tr"t •Nunicipel Building
NorNsmpton, NA 01060
Debris 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.
The debris from construction work being performed at:
Ids Sri d� � R00A , t�( eno c M E o( o s Z
(Please print house num r and street name)
Is to be disposed of at:
L . -44-66etrf DC
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
M - Nt' &6-yJk � �P �2 cdtl JnL
(Company Name and Address) '
-'/3i �/ �
$�gnature mit Applicant or Owner Date
If, for any reason,the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
Mice of Consumer Affairs t Business Rayulaaon
HOM E IMPROVEM ENT CONTRACTOR Registration valid for individual use only
TYeb,Indiv d0 ai before the expiration Bats. If found return to:
Bgg y ExniraBon M.of Consumer Affairs and Business Regulation
051032020 One Ashburton Race-Suite 1301
VASUE KUKMAFi '- Boston.MA 02108
01B/AM Ofl Hq =EMENTS
r
VASLIE M.KUKHA@
18 HUNTERS SLOT
WESTFIELD,MA 01085 Underexxotary, Not valid without signature
Massachusetts Department of public Safety
Board of Building Regulations and StarWartls
License: CS-1O3f�4 - ..
Construction Supervisor
VASE M fCtMlMHYC1401
18 NlN7TERS SL
wBSTFfELB MAS
u
( jzuv .til Expiration:
CommissWrter 081242818 1
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
UV Boston,MA 02114-2017
www-massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Infrmation /y, , a Please Print Legibly
Name Business/Org=matiiool Individual):: r//h r� VI oot-e CoY wl�l)4-s
Address: I ktuAF�1L/ej�l
City/State/Zi .QS '�Cd PAak)a, Phone#:
Are you an employee.Check the appropriate boa: Type of project(required):
to Iameempl.yerwith employees(full and/or parttime)" 7. New construction
2❑l am esole pne,wea ca,mancoh,and have no employees working for mem 8. (—j Remodeling
any capacity.INo workers'comp_mantnce required. L
) �`JS
]❑lamammommerdoingellwodemyself[Neworkas'mmp.insumncere10 Building quiredit 9. Demolition
addition
n
4[]1aa horrowner and will by hiring eors to conduct all work m my property. Iwill
m mrado
uw mat simmmcmrs comer have wodkeralcomemccon insurance.,me sole I IElectrical repairs or additions
�[pmpnetonaimnoempl.yeea 12. Plumbing repairs or additions
51 YJ 1 am agene.[contractor and 1 have hired me sal.contmdors usledson he attached shed. I3 rgoafrepairs
These mlboommcmfs have employees and have workers'comp_in ce? 11VVLjrI'r-,',-j,- f ,,..// �� ,,,,
6EJWe am awtproxion and its officers have exercised their right ofexemption per MGL c. 14' er�
152,41(4),and we have no employeeslNo workers'comp insmbee required.)
Any applicant hat checks box pl most also fill nue the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and men hire outside contractors must submit a new affidavit indicating such.
tCommemrs that check this box must attached an additional sheet showing the name of Ne subcontrion n andave whether a not thou entities have
employees. Ifine s.brummeto..have employees,they must provide than workers comppolicy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the posey and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.4: 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 MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby eerbfy under thetial nd penaities ofperjury that the information provided above is true and corners.
Si nature: Dine-
Phone 4:
ate:Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Licame#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
0
' CERTIFICATE OF LIABILITY INSURANCE �,
THIS CERTIFICATE 18 MSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UP04 THE CENNFIGIE HOLDER. TRW
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE OOVERAIUE AFFORDED, BY THE FOLCCIE&
BELOW. TNN CEROFlGCTE OF INSURANCE DOER NOT CONSTITUTE A CONTRACT BETWEEN THE G$MM0 NIRWE"I, AUTHORGED
REPRESENTATIVE OR PRODUCER.AND.THE CERTIFICATE SOLDER
nPORTANT: IMcaa111DraM hOMW ban ADOfRONAL INSURED,thepWWV(Ws)must W NMm6Gtl. NSDE�T1gR*wwED.PNEjsettuff
arhb and Dl of Iw PPSkY,erbb poudes OM'raquire an aMeremlrNit A stets and on this doss not Naflr rIghm,m ft
frfSCMah MN N.Nou ofeoeh-. }
PRODUCER ANDRE SILVA
PONT INSURANCE INC
191 CONCORD ST
FRAMNGHAM.MA 01702
NYCi
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THIS&'R)CERTIFY THAT THE POLCGS OF WSURANCE LISTED 6ELON HAVE SEEN ISSUED TO THE INSURED NAMED POR THE POLICY PERIOD
NVICATEO. NOIYdhISTAmCwc ANY Rwu*eE TERM OR CONDITION OF ANY CONTRACT OR OTHER URBlt NRH RESPECT TO NHICH THIS
CERRFlCATE MAY SE 19SUm'OR MAY PERTAIN.THE INSURANCE PPFOPDED BY THE ROUGES DESCip�D�HCE1{ERf IS SUQILX T TO ALL THE TERAS,
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INW NC D13A.MajorHOme lmprwerswdn aHOUtD ANY OF THE.ASME DEPO{1118E0 LI 9 SCAN . .mom
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CERTIFICATE OF LIABILITY INSURANCEM�,;Wit/)
THIS CERTIFICATE IS ISSUED ASp MATTER OF INFORMATION ONLY AND COMFERS NO RgI rS UROM THE CERTGWYI7E MOLDER. 7MIS
CERTIFICATE DOES NNT'AFfIRMATpN:LY OR ON OF AMEND,.EXTEND, OR ALTER 7NE COVERAGE AffiORDED BY THE POLICIES
BELOW. THIN CERTIFICATE OF CE DOES NOT CONSTITUTE A COMTRACT-BETWEEN 7116 HINDNB IIISUREiRS); AU77iOR@ED
REPRESENTATIVE OR PRODUCERLAANND�TFNIE CERTIFICATE HOLDER
IMPORTANT.N use cer6Rcdt0 polder Is an ADDITIONAL WBUREO,the po9cylleS)must be endonUm. ItIMISROOATNUf IS WAIVE
the umnsand conditions ofMra pofwy,wL¢in pohckemaymqukeenandor8ament Astabor enton It"ce�eafe does not confer==
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INDICATED. NOTydiHg'ryNpINO AtN' REQ{IIRENENT, TfRM OR GOtOITON OF ANY CONTRACT OR OTHER pOpA7EMT WSH R�PECT TO %RICH 1n*5
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CERTIFICATE HOLDER CANCELLATION
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