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24C-159 (5) 22 ARLINGTON ST BP-2019-0345 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24C- 159 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-2019-0345 Project# JS-2019-000560 Est. Cost: $120600.00 Fee: $378.10 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT WALKER 034783 Lot Size(sq.ft.): 10890.00 Owner: HYMAN SHERRY B&ARTHUR Zoning:URB000)/ Applicant: ROBERT WALKER AT. 22 ARLINGTON ST Applicant Address: Phone: Insurance: 36 Service Center (413) 584-1224 Workers Compensation NORTHAMPTON MAO 1060 ISSUED ON:9/18/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD 1 ST FLOOR REAR BED/BATH ADDITION WITH NEW DECK 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 Dmartment 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 9/18/2018 0:00:00 $378.10 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner `} 1-7 18 IrZ e�( UCD Department use only .TT'Ts. City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability � Room 100 Water/Well Availability *- Northampton, MA 01060 Two phone 413-587-1240 Fax 413-587-1272 Plot/FitePIE�CP I-VVED� TOthey APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMO ISH O R M F LY C WELUING SECTION 1 -SITE INFORMATION I L� gg 1.1 Property Address: his secbi44fficU/ �y Map l c.i Lot !S% Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: n Name(Print) Current Mailing Address: - 2i32 Telephone Signature 2.2 Authorized Agent: ICY' ('ver of A—Ti,k l ►-9 � Phi Name(Print) Current Mailing Address: 41,. Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building "Z d (a) Building Permit Fee lV U ' 2. Electrical V j (b) Estimated Total Cost of Construction from 6 3. Plumbing C �U Building Permit Fee 4. Mechanical (HVAC) PC 2 5-F F 5. Fire Protection 6. Total =(1 +2+3 +4+5) 1 [ U(>, Check Number 47, This Section For Official Use Only Building Permit Number: Date Issued: Signature: / all 8 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) { GZ:3 i i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [0 Siding [❑] Other[❑] Brief Description of Proposed S Work: 4&0 ) P-(wfL Xe" V? k- A�)YJ,rof-- Alteration of existing bedroom Yes__ZNo Adding new bedroom i'✓Yes No Attached Narrative Renovating unfinished basement Yes o Plans Attached Roll -Sheet j 6a. If New house and or addition to existin_q housing, complete the following: a. Use of building :One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms r r 1 c. Is there a garage attached? t- 0 r d. Proposed Square footage of new construction. I �3 Dimensions l7Pc.� ( 4't e. Number of stories? �/ W�Cr1T f. Method of heating? 6,91I CT c:1`00� / ,p,� tt2�r n%-*O'Fireplaces or Woodstoves ----------Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 2)�,(F W eA i. Is construction within 100 ft.of wetlands? Yes _VlNo. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade F3 k. Will building conform to the Buildingand Z ning 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 I, 49ai i e 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. '1 c 7 I� Signature of Owner Date I, V-b���� ►� ,tLa�r2 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 pains and penalties of perjury. fzvC,Vaa- w � Print Name t7 I I Signature of Owner/Agent 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 �tU Frontage Setbacks Front Owl � Side L: 2V R: 21 L: Z- ` R: lZ. Rear 74. 3�I Building Height Z4t Z 6 Bldg. Square Footage .ZSR Z-3 % zev+ 24 Open Space Footage % (`., �J � �] (Lot area minus bldg&paved S,;32- 1 Z L�0 I 'TL W parking) #of Parking Spaces Fill: r (volume&Location) A. Has a Spe � Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW O YES IF YES, date issued: IF YES: Warthe ermit recorded at the Registry of Deeds? I, DON'T KNOW Q YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO IF YES, describe size, type and location: E. Will the construction activity disturb(coring,grading, exc ation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: U'S 4 7 V, License Number S�2VlC>E C,�►n �-�- . 1"G►? w ''ra ►`' I'L1� L 0 1 Address Expiration Date Signaturell Telephone 1 _ --- 9. Registered Home Improvement Contractor: Not Applicable ❑ 1,, "� L.>ztiU�� 1 -7 zU 1 V Company Name Registration Number Address Expiration Dat6 Telephone 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 buildin ermit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton �a Massachusetts � G DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 Jst%' •� ��a� 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: 22 A-Q (Please print house number and street name) Is to be disposed of at: kj A-t�y q r ( q( (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit 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. The Commonwealth of Massachusetts x Department of Industrial Accidents _ e 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information o _ Please Print Le(_ibly Name (Business/Organization/Individual): Address: ?) City/State/Zip: Phone#: 22a- Are yo an employer?Check the appropriate box: Type of project(required): L 1 am a employer with employees(full and/or part-time).* 7. [RITew construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑De lition 3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 uilding addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:]Roof p repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no 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. tContractors 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. I am 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 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 certify under the pains andpenalties ofperjury that the information provided above is true and correct Si naturate: �T_[ Phone#: 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#: Aco® CERTIFICATE OF LIABILITY INSURANCE DATE( yYYY) � os/o0z/2o2/20 1 a 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(ies)must have ADDITIONAL INSURED provisions or 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: Barbara Grynkiewicz Webber&Grinnell acNn EtI: (413)586-0111 nlc No: (413)586-6481 8 North King Street E-MAIL SS: bgrynkiewicz@webberandgrinnell.com DDIRE INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURERA: West American/Liberty INSURED INSURER B: A.LM,Mutual Robert Walker INSURER C: Attn:Kim Clairemont INSURER D: 36 Service Center Road INSURER E: Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 3/1/19 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. ITR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DDIYYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 15,000 A BKW58372253 03/01/2018 03/01/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 LOC PRODUCTS-COMP/OP AGG $ 2.000,000 POLICY 7)ECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident P $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBEREXCLUDED? NIA WMZ80080065482017A 07/01/2017 07/01/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN "For Insurance Info Only" ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AC p® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 05/02/2018 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(ies)must have ADDITIONAL INSURED provisions or 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: Barbara Grynkiewicz Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481 A1C No Ext), AIC No 8 North King Street E-MAL bgrynkiewicz@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC ft Northampton MA 01060 INSURERA: West American/Liberty INSURED INSURER B: American Fire&Casualty/Liberty Construct Associates,Inc. INSURER C: Ohio Casualty/Liberty Attn:Kim Clairemont INSURER D: NH Employers/A.I.M. 13083 36 Service Center Road INSURER E: Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 3/1/19 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. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/VYYY) (MM/DD/VYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE Fx_1 OCCUR PREMISES Ea occurtence $ 100,000 MED EXP(Any one person) $ 15,000 A BKW58364577 03/01/2018 03/01/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑X PRO ❑ 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT s 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED BAA58364577 03/01/2018 03/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY Per acddent Medical payments s 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LNB CLAIMS-MADE US058364577 03/01/2018 03/01/2019 AGGREGATE $ 1,000,000 DED I X RETENTION$ 10,000 $ WORKERS COMPENSATIONPER OTH. X YIN AND EMPLOYERS'LIABILITY STATUTE ER D ANYPROPRIETORIP /EXECUTIVE F7 E.L.ECC60040007802017A 07/01/2017 07/01/2018 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDEXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,00!) DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached 0 more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN "For Insurance Info Only" ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD