36 AC�'V CERTIFICATE OF LIABILITY INSURANCE DATE(0710061206/20YYYY)
18
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 PHotN . (413)586-0111 'No: (413)586-6481
8 North King Street rMAIL
Amoss. bgrynideWcz@webberandg6nneil.com
INSURERS)AFFORDING COVERAGE NAIC s
Northampton MA 01060 INSURER A: West American/Liberty 44393
INSURED INSURERS: American Fire&Casualty/Liberty
Construct Associates,Inc. INSURER C: Ohio Casualty/Liberty 24074
Attn:Kim Ciairemont INSURER D: Liberty Mutual Insurance 24198
36 Service Center Road INSURER E:
Northampton MA 01060 INSURER F:
COVERAGES CERTIFICATE NUMBER: Exp 7/1119 REVISION NUMBER:
THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDING 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.
POUCY1FF POLICY EXP
INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER M M LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE a OCCUR PREMISES Ea occurrence s 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 JECOT 7 LOC PRODUCTS-COMP/OPAGO $ 2,000,000
�
5
OTHER:
AU MOBILE LIABILITYC(WFMNSD SINGLE LIMIT s 1,000,000
Ea acridsn
ANY AUTO BODILY INJURY(Per person) $
B OWNED X SCHEDULED SAA58364577 03/01/2018 03/01/2019 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIREDX NON-OWNED C' $
X AUTOS ONLY AUTOS ONLY Per acddom
Medical payments $ 5,000
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000
C EXCESS UAB I CLAIMS-MADE US058364577 03/01/2018 03/01/2019 AGGREGATE s 1,000,000
DED X RETENTION$ 10,000 S
WORKERS COMPENSATION X AET UTE ER
AND EMPLOYERS LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
N E.L EACH ACCIDENT $ 500,000
D OFF10ERtMEMBEREXCLUDED? NIA XWS58364577 07101/2018 07/0112019
(Mandatory in NH) E_L DISEASE-EA EMPLOYEE S 500,000
Ifyes,describe under 500,000
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY OMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS/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 Purposes" ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
C 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
W Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FiLED R'iTH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: � ;t c
City/State/Zip: Phone#: 4i3 1 y d---vZZ
Are you an employer?Check the appropriate box: Type of project(required):
1. am a employer with t U employees(full and/or part-time).* 7. n New construction
2.Q 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. ❑Demolition
3.F_1 1 am a homeowner doing all work myself iNo workers'comp.insurance required.]'
4.❑T am a homeowner and will he hiring contractors to conduct all work on my property. Twill 10❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.F]Plumbing repairs or additions
5.❑1:nn it 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.
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_
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatnig such.
$Contractors that check this box must attached air 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.
1 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 tinder MGL c. 152, §25A is a criminal violation punishable by a tine 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 and penalties of'perjury that the information provided above is true and correct.
Signature: Date: (�
Phone#:
Of ficial 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#:
A.
LicLQQcLt—.LiLAQ= ..e
i
DEPARTMENT OF BUILDING INSPECTIONS z
212 Main Street •Municipal Building
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:
(Please print house number and street n e)
Is to be disposed of at:
A-c.0 "
(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.
JLN i tVt• V 'vVt�J i f\i,J i+t iV1V JLt\vtrrCV
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
XA� r!_ �N Cf �v 1\Z' 1nlJ+. l 0 ( L� � 2'y L c(
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
2 y L
Company Name Registration Number
(,�- I X31 Z-0 aeo
Address Expiration Date
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 building permit.
Signed Affidavit Attached Yes....... z No...... ❑
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 [❑] Decks Siding[❑] Other[❑]
Brief Description of Proposed -
Work: (%�wI'sw
Alteration of existing bedroom Yes____t, Adding new bedroom YesN�o -
Attached Narrative _. Renovating unfinished basement Yes No
Plans Attached Roll SheeO
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? CV`
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? �� Fire ces 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 w ds? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or ar floor below finished grade
k. Will build ing-conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNfR AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AG "R CONTRACTOR APPLIES FOR BUILDING PERMIT
G� AEo tlx-r'61s4w as Owner of the subject
hereby autho ' e
to act on f, in all matters relative to work authorized by this building permit application.
////S /k
na of Owner Date
I, 1`'C'6- 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.
Print Name
Signature of Owner/Agent Date
Section 4. LUNINU All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be fille n by
Building Departm
i�
Lot Size
Frontage
Setbacks Front
Side L: R: R
Rear '
lJe
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking S ces
Fill:
(volume&Location)
A. Has aSpe l Permit/Variance/Finding ever been issued for/on the site?
NO V DONT KNOW C) YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, excayatr6n, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Uepartmem use only
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
ROOM 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fr���IVEcUr
sans
Spe ify
APPLICATION TO CONSTRUCT,ALTER, REP IR, RENOVATE OR DEM LISH A ONE OR TWO FAMILY NOV 1 6 2018 tq -00�l�DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: L���'
tion to be completed by office
70
Lot VV Unit
1 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: �1
t 7� ,2f1 l 7b �,2���yc- /�41� /L7ff/�►�/�T�IU /��f
Name(Pr' Current Mailing Address:
Telephone
,��d—'1,6 77
e
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
114,-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building r;Ul) (a)Building Permit Fee
2. Electrical 1 S� (b)Estimated Total Cost of
`t ti Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) / 7 0
5. Fire Protections '
6. Total=(1 +2+3+4+5) ct Check Number t271
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: f
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
70 SOVEREIGN WAY BP-2019-0606
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 36-291 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-2019-0606
Project# JS-2019-000991
Est.Cost: $18950.00
Fee: $122.85 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT WALKER 034783
Lot Size(sq.ft.): 63946.08 Owner: VALDISERRI LEO
Zoning: Applicant: ROBERT WALKER
AT. 70 SOVEREIGN WAY
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON:11/16/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-FINISH INTERIOR OF BONUS ROOM ABOVE
GARAGE
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 Departmeut 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 Sianature:
FeeTvpe: Date Paid: Amount:
Building 11/16/2018 0:00:00 $122.85
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner