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38B-291 (3) 284 SOUTH ST BP-2019-0459 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-291 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:FIRE DAMAGE BUILDING PERMIT Permit# BP-2019-0459 Proiect# JS-2019-000740 Est.Cost: $95000.00 Fee:$617.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BAYSTATE RESTORATION GROUP 056785 Lot Size(sq.ft.): 4094.64 Owner: CAMPBELL CATHERINE Zoning:URB(100)/ Applicant: BAYSTATE RESTORATION GROUP AT. 284 SOUTH ST Applicant Address: Phone: Insurance: 69 GAGNE ST (413) 532-3473 WC CHICOPEEMA01013 ISSUED ON:10/18/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIRS FROM FIRE - REPAIR AND REPLACE AFFFECTED AREAS INCLUDING MECHANICALS 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: FeeTyae: Date Paid: Amount: Building 10/18/2018 0:00:00 $617.50 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0459 APPLICANT/CONTACT PERSON BAYSTATE RESTORi.TIOIN G'.20iJP ADDRESS/PHONE 69 GAGNE ST CHICOPEE (413):)3--3473 PROPERTY LOCATION 284 SOUTH ST MAP 38B PARCEL 291 001 ZONE URBJ00 / THIS SECTION FOI,OF'F'C':A I- U.SF Oi9LY: PERM1'T APPLICATIO:4 C:JEC_K,IST MOSED11 QUIRED DATE ZONING FORM FILLED OUT _ Fee Paid Buildinp,Permit Filled out Fee Paid Typeof Construction: REPAIRS FROM FIRE-RE IR REPLACE AFFFECTED AREAS INCLUDING MECHANICALS New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building Plans Included: Owner/Statement or License 056785 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQRMATION PRESENTED: �/Approved Additional permits required(see below} 1 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 Demolition Delay to l7 L ' Signature orBuilding Official Date� g 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: ' Building Department Curb Cut1Driveway Permit 212 Main Street Sewer/SepticAvailability. . Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans APPLICATION TO CONSTRUCT,ALTER, REP IR, R L X ON[OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION OCT 12 20IThwisctio, 1.1 Property Address: to be completed by office ��'r I .yob � DE !�WSPECT+a WNORt a� 'Unit 0104o Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current,M/ilipg Add!r d Telephone �c Signatur 2.2 orize epi . hdWkS 60P) ,e 6? Name(Print) Current Mailing ddress: pF�4 D wl 3 zi Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building '�j g d` (��, g')-r 0(0�'' (a)Building Permit Fee 2. Electrical "7 716 70 . W (b) Const Estimatnotion Total Cos6t of 3. Plumbing 0A X400'ob Building Permit Fee 4. Mechanical (HVAC) J, 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: IIsssued: Signature: Building Commissioner/Inspector of Buildings Date doL,kg • c4oLvd @ �Stck r ci, < co EMAIL ADDRESS (REQUIRED; EITHER. HOMEOWNER OR CONTRACTOR) t-j 1r 'Jl -ANO ����f � 6Xi SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding 0] Other[OJ Brief De cription of Proposed q Work: 14,0Airf ,i2�L "�' l V22&61 acv*` Alteration of existing bedroom Yes 2c No Adding new bedroom Yes _�No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.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?- 00 0 d. Proposed Square footage of new construction.- 11Z SF Dimensions y x a 3 e. Number of stories? f. Method of heating? ( fS Fireplaces or Woodstoves it/0 Number of each g. Energy Conservation Compliance. i Masscheck Energy Compliance form attached? h. Type of construction Amy I-dM.P 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 5-6 k. Will building conform to the Building and Zoning regulations? _X Yes No. I. Septic Tank City Sewer X Private well City water Supply_1->(I SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, t6D ��)ZY1��j�/(� as Owner of the subject property hereby authorize to act on my beh f ' atter tive to work authorized by this building permit application. Signatu wne Date ®a t�vf /' 1�c5�$ ,Q�„ as Owner/Authorized A ent hereby declare that the statements and information on the fore oing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. -a4l�s © . Print Name Signatur of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑/ p Name of License Holder: Mv` l< A Daw-0 �S 0-5-6, 7a License Number Address --� Expiration Date Signature Telephone 9.Registered Home Improvement Contractor. Not Applicable ❑ CickS k-4 616,I) Company Narrt6 Registration Number Address Expiration Date G C i�IO�� NYT. 0)1013 Telephone#13�53�'�H7� T 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....... PC No...... ❑ City of Northampton r _ Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building �vyL.S Northampton, MA 01060 8b �1 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 has contracted with a corporation or LLC,that entity must be registered co Type of Work: 1k r, �¢'d ml)YA �^ // c ,,/ Est. Cost: S, �• Address of Work: c)J'7 �J" 9, /lld✓ �itila .�/ r 'X* 0/06-0 Date of Permit Application: 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: I hereby apply for a building permit as the agent of the owner: tic do y �� Date Contractor Name HIC Registration No. OR: Notwithstandi he above notice,I hereby a r a building permit as the owner of the above property: Date Owner Name an ignature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Jib Northampton, MA 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: CAO q 36 S� 0,q (Please print house number and street name) Is to be disposed of at: .J (Please print ame and location of f cility) Or will be disposed of in a dumpster onsite rented or leased from: VSI� Z"/ /5-z'qo Au A/ 412 (Company Name and A ess) /0 -P-tel nature 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 Department of Industrial Accidents d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia «'orkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le-zibly Name (Business/Organization/Individual): gGM'VI)e �Q&ft6r& , a Address: (o C-ZxAze S� - City/State/Zip: t /�l _ D/C3 Phone#: 53,,)- :3'1 7� Are you an employer?Check the appropriate box: Type of project(required): 1.%I am a employer with AS employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in g. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.F1I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.E]Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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. :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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Az_44 Policy#or Self-ins.Lic.#: �E C C (000 17' 000 g 7o)d 1,?A Expiration Date: Job Site Address: c;�eq ©VTC City/State/Zip: it),ku. 0 0 D 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 pain Orkies o that the information provided above is true and correct Si ature: Date: 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#: DATE(MMIDD/YYYY) A�D® CERTIFICATE OF LIABILITY INSURANCE 10/09/2018 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 Marion Lentes NAME: Berkshire Insurance Group,Inc. acNNc Etl: (413)935-1200 Fvc No): (413)567-5300 138 Longmeadow St. EMAIL ADDRESS: mlentes@berkshireinsurancegroup.com INSURER(S)AFFORDING COVERAGE NAIC# Longmeadow MA 01106 INSURERA: Philadelphia Insurance Companies 23850 INSURED INSURER B: Tokio Marine Specialty Ins. Baystate Restoration Group,LLC INSURER C: A.I.M.Mutual Insurance Co. r/ 69 Gagne St INSURER D: INSURER E: Chicopee MA 01013 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1810955309 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 EF POLICY EXP LIMBS LTR INSD WVD POLICY NUMBER MMIDO MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000,000 DAMAGE TO RENTE5 100,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ X PD Deductible 1,000 MED ERCP(Anyone person) $ 5,000 A PPK1892057 10/07/2018 10/07/2019 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ❑ JECT 7 LOC PRODUCTS-COMP/OPAGG $ 2'000'000 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 UMBRELLALIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LAB HCLAIMS-MADE PUB650405 10/07/2018 10/07/2019 AGGREGATE $ 1,000,000 DED RETENTION $ $ WORKERS COMPENSATION v AND EMPLOYERS'LIABILITY STATUTE X ERH YIN 500,000 C ANYPROPRIETOR/PXCLUE (EXECUTIVE � N/A ECC60040008972018A 01/14/2018 01/14/2019 E.L.EACH ACCIDENT $ (Mandatory in NH) IXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Limit 1,000,000 Professional/Pollution B PPK1892059 1010712018 10/0712019 Deductible 5,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe 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 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 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improver 'l t Contractor Registration ! Type: Corporation r Registration: 180478 BAYSTATE RESTORATION GROUP,LLCM 69 GAGNE ST / � Expiration: 11/18/2020 CHICOPEE,MA 01013 Update Address and Return Card. SCA 1 is 20M-05/17 .�� �0,77/�'J.C/li!'PCLL(�0���¢J.1CJ.C/Ll13PL�J Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:.Corporation before the expiration date. If found return to: Reaisthiti®h-, Expiration Office of Consumer Affairs and Business Regulation 180f8 j 11/18/2020 1000 Washington Street-Suite 710 BAYS-FATE R�OF.ATJON GROUP,LLC Boston,MA 02118 MARK DAVIAU 69 GAGNE ST CHICOPEE,MA 01013 Undersecretary Not valid without signature s Commonwealth of Massachusetts Division of Professional Licensure i 'YJ Board of Building Regulations and Standards Con stgwfiibn'Supervisor t I CS-056785 4pires: 09/0912019 '-* _ k MARK R DAVIAU 75 GILBERT RD SOUTHAMPTON,MA 01073 a\ Commissioner