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29-076 (6) 62 ACREBROOK DR BP-2019-0611 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-076 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:REPLACEMENT WINDOWS/DOORS BUILDING PERMIT Permit# BP-2019-0611 Proiect# JS-2019-000996 Est.Cost:$2899.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WINDOW WORLD/ROBERT E BUSHEY JR 165641 Lot Size(sa. ft.): 20821.68 Owner: KOLEMBA EMMANUEL J&JUDITH L KOLEM13A TRUSTEE zonine: Applicant: WINDOW WORLD/ROBERT E BUSHEY JR AT.- 62 ACREBROOK DR Applicant Address: Phone: Insurance: 1029 NORTH RD (413) 485-7335 WC WESTFIELDMA01085 ISSUED ON.1112612018 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE 4 WINDOWS AND 1 STORM DOOR 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 Deaartment 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: FeeTvpe: Date Paid: Amount: Building 11/26/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner EIVED F�EC Deportment use agJy ,, ' City of Northai nptoiN O V 1 9 20 0t"' of P Jt:= Building Depa met Curb ut/D veway Perm T 212 Main St eet sip' Availability x Room 10 DEPT OF[3UILDING INS ell' vallability c `k Northampton, M oRTHAMPTON,MA Strucatural'Plans phone 413-587-1240 Fax 413-587-1272 PloVSlte Pians Other$pec�fy.� APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 6 t"—/#'0i`/ 1.1 Property Address: This section to be completed by office map ... Lot Unit C� V 0��( 1 ��1 I 6 D(a a Zone Overlay District u t ►'T� Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner ofRecord: Name(Print) Current Mailing Address: (See Telephone Signature 2.2 Authorized Anent: Robert &)Shea 1029 N.&Y. Rd "e5ffi6 d MA 010 Name(Print) Current Mailing Address: 413-419S-1336 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 I 6 (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: I Lg Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 % f' Open Space Footage (Lot area minus bldg&paved amn #of Parking Spaces Fill: volume&Location .a .. .. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW/ O YES O IF YES, date issued:; IF YES: Was the permit record/,,'d at the Registry of Deeds? NO © DONT KNOW Q YES O IF YES: enter Book Page: and/or Document#' B. Does the site contain a,; rook, body of water or wetlands? NO 0 DONT KNOW © YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: , C. Do any signs exist on the property? YES Q 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 O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO Q 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 Addition 0 Repiacementgkildlows Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[Ip] Other[a Brief Work ascription of Proposed Z�1 aC S + S- �Ocyn Lw r Alteration of existing bedroom Yes No Adding new bedroom Yes No 1c: Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 8a.If New shouse and or addition to existing housing.,gomolete 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 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 as Owner of the subject property j^ hereby authorizePV L t to act on my behalf,in all matters relative to work authorized by this building p rmit application. _t SeL Gonfira c O k l Id Signature of Owner Date 1, R©yArfi Ll��( tc` _ ,as Owner/Authorized Agent hereby declare that the statementil 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 Nam ` 1/;-u � 4 N' Signature of Owner/Agent Date 1 SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Supervisor: Not Applicable 13Name of License Hol 1der: 1 ect t"f��UShfA— License Number ` ��©11 Address Expiration Date Signature Telephone b 'Z 0 1 1`7 9.R9uIstemd:Hgme Improvement Contractor: Not Applicable ❑ Robert bl f,�Nl 1 b5 b 41 Company Name I Registration Number Window Worid a W-eatsitn MASS Inc, 3114 f2-0 Address s Expiration Date X429 N or�1n Rd MStfif\ d(?4A O10SSlephone 413-4!651335 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(90 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....... No...... ❑ 11. --Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 �L� ��vq-k�~Cc C The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations kVJ 1 Congress Stree4 Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibly Name (Business/Organization/Individual): 0i Wtbtr n MA Address: 102.4 W OY-A)rn R d Ci /State/Zi : Nfbiffid MA b I QS5_ Phone #: 1 - '+�5S- Are you an employer? Check the appropriate box: Type of project(required): 1.X I am a employer with�_ 4. ❑ I am a general contractor and I employees (full 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' insurance.$ 9. E]Building addition comp.[No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no 13. Other (Zf rel QCt°.Mf,`(1�" 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. tContracwrs 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 employee& Below is the policy and job site information. Insurance Company Name: U bR YN Mutt co rysuro n c-f. Policy#or Self-ins. Lic.#: CA Expiration Date: rq Job Site Address: City/State/Zip:o()r oce, 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 u the pains p aloes of perjury that the information provided above is true and correct. Si tore: Date: Phone#: 4-t 3 r 41' S ',37,5 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#: - ..«narryl Re - "r`�aeasure s9wat1als and SMRdards .=etmr SOW-,t<N C5701 E71p+res: E OF LIABILITY INSURANCE oB ae DRMATiON ONLY AND CONFERS NO RIGHTS UPON 03/23/2019 THE CERTIRCATE HOLDER, THE IELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING tNSURER(8), AUTHORIZED Commissioner � � INSUREM, tte poi Cy(tsls must-le endorsed. 0 SUBROGA to ! =W MWIM an 611460raemerd. A *W meat on this oertlNaate doss not oonsx rigida to the BCA t 8 1dAt�6rn HAM =+s►urenCe R. irorrest ofts� muna"qMoff�111aR j N, 418 858 2680 IN,Z,413 858 2685 ,) ADDRESS: � ' INSURlR(t1 APFORo1M0 COYERAeE NAM=e WINDOW WORLD012WESTaft MASS No � MaURMA:Arballa Protection Insurance Company aaum a: ROBERT BUSHEYJFL 1029NORTH RO MAIM c: WESMELD.MA 010W C sNwRmr o= U17d alsuncR E: NiWRER P: REVISION NUMBER: THIS 18 TO CERTIFY THAT THE POLIC198 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 16 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPBO►MCJNRANOa P�ICYNUYeSR (UAWWf M ( LIMITS ADM POLICY LTR 1t16A yryD A eeNeRALLwp mr x rerw =RRENCE S 1,000,000 K Tu CDMMERCua.eeaERALLIABILITY 7520025998 04/09/10 04/09/19 �Ee s 100,000 a NMs-MAoe ®OCCUR P("are perem=) s 10,000 NAL&AOV KURY s 1,000,000 AL Aeaft"Ts s 2,000,000 GENLASGREGATELIMIT APPLIES PM' PRODUCTS-OOMP/OPAM s 1,000,000 POLICY X LOC S FA;W UABMarY 1020063881 04/09/18 04/09/19 „,M.„I s 1,000,000 TO BODILYMLA)RYIPetI)MR) s ED X PULED BODr.YMIJUiRY(PetemWenq s UTOGAUTOS X NOror0 8NYGtED Par $ i A XUMBRGUAUAsg OAR 4600055451 04/09/16 04/09/19 EACHocruRleNCE S 1,000,000 8 VAING us CLMM"ADE PMRWATE s DED I I RETENTION ss Wow"c0MPN=T= Certi f irate Of TORY LM m _ AND BMPL NIOW LNBM.M Vill AP P�VII ❑ N/A Zusurance TO rollow E.L.EACH ACCIDe1T i te. OFFICI�rNtMI E.L.018EASE-EA EMPLOYEE 9 R de1M4e muter E.L.Inques-POLICY LIMIT S DESCRIPTION OP OPERATIONS hebw V MORIPTM OP OPERATIONS/LOGITIONSI VOOM Nlteeh ACORD 101,AddkWW Renwks bbKWK M moor W"IN MR&OMM tERTIPICATE HOLDER CANCEU.ATION :ity Oi: 1Torthowton► SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE :12 Main Street THE EXPIRATION OATS THEREOF, NOTICE WILL BE DELIVERED IN lortha wt-on, Ma. 01060 ACCORDANCEWITHTNEPOUCYPROYMONS. lttention: Building Department AUTNORI?gDREaRMENTA7IVE q a 1988.2010 ACORD CORPORATION. All rights reserved. CORD 95(2010100) The ACORD name and logo are reglMmd marks of ACORD ®oa►o— ,,,��_ ..:.. .�--�. �� p CERTIFICATE OF LIABILITY INSURANCE DAU(WOD"�) 5=01 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 IEPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. APORTANT: If the certNlcate holder is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed. SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on is certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ucER FORREST INSURANCE AGENCYCONTACT NARL, VA 603 NORTH MAIN STREET PHONE E LONGMEADOW, MA 01028 .MAIL °' INSURER(81 AFFORDING COVERAGE NAIC E INSURERA: Libedy Mutual Fire insurance 23035 )OW WORLD OF WESTERN INSURERS: 3ACHUSETTS INC INSURERC: NORTH ROAD INSURERD: 'FIELD MA 01085 INSURER E: N ZRER F: zES CErTIFiCATE NUMBER:41675072 REVISION NUMBER: O CERTIFY THAT THE POLIC' 'INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD D. 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'2'A"a1- ,$ted j zo �, t04,5` a��5 ap '411 ��� a�aa�`� ° tea NZ +� X15 Ns��' ooti�O o } �.}O024` a��` �Q�`s°�,O• °o`y°��0�2}2Q�mt 4���°a�, 2�,ao.2yo� S�,w2c�y°�S'' �,t`° `o°�' ``,� y 2a�0 0`4'4��`e c�w� oQ �°�2• ao�. ; y 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: 62 Acrebrook Drive, Northampton MA The debris will be transported by: N.E. Waste The debris will be received by: N.E. Waste, 28 Moylan Ln Agawam MA Building permit number: Name of Permit Applicant: Robert E Bushey 11/26/2018 Date Signature of Permit Applicant