31B-151 (8) 17 TRUMBULL RD BP-2019-0707
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV Block: 3 1 B- 151 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2019-0707
Project# JS-2019-001156
Est.Cost: $19755.00
Fee: $140.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SURGE HOME CONCEPTS LLC - DAVID WOELPER 1101 3
Lot Size(soft.): Owner: MESSY TANIA
Zoning: Applicant: SURGE HOME CONCEPTS LLC - DAVID WOELPER
AT. 17 TRUMBULL RD
Applicant Address: Phone: Insurance:
66 SOUTH BROAD ST SUITE E8 (413)454-2154 WC
WESTFIELDMA01085 ISSUED ON.12/21/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIRING FLAT ROOF ON 2ND FLOOR UNIT
AND REPAIRING INTERIOR DAMAGES**per original plans"
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:
Cas: Fire Depgrtment Fireplace/Chimney:
Rough: (Ill: 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 12/21/2018 0:00:00 $140,00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0707
APPLICANT/CONTACT PERSON SURGE HOME CONCEPTS LLC-DAVID WOELPER
ADDRESS/PHONE 66 SOUTH BROAD ST SUITE E8 WESTFIELD (413)454-2154
PROPERTY LOCATION 17 TRUMBULL RD
MAP 31 B PARCEL 151 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid PC-2 0R%Gw4P(1-
iypeof Construction: REPAIRING FLAT N 2ND FLOOR UNIT AND REPAIRING INTERIOR
DAMAGES (,r+NS
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License 110193
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)
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
G 12/Zo/l �
Signa eof Building Official Date ��—
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.
Versionl.7 Commercial Building Permit Ma 15,2000
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address: This section to be completed by office
1�j,M'l�-'I lYti Map 31 -5 Lot nit
Zone Overlay District
Elm St.District CB'District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
Name(Print) Current Mailing Address:
v
Signature '-et C.,-U leA Telephone
2.2 Authorized Ascent:
Name(Print) Current Mailinq Address: 7
Signature Telephone
SECTION 3 STIMAdWCONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building % (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) I I L4D.
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number z 1
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
/j- w 0 e- 0-f\a ur\lkpia
v
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition Repairs❑ dditions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing[a Change of Use❑ Other 62"
Brief Description Enter a brief description here. azQ4"4-rn'5 X4 cln secc oc-k 4''�rtNr
Of Proposed Work: VjAi+- GvrO riga 17%3j 1 yl.��ibC J-�,yvi.l�.5e3 .
SECTION 5'-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H Hi h Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group: r---
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): I —u�
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
k
St St ...
2nd 2nd
3rd 3rd
4tr,
4th .
Total Area(sf) � - Total Proposed New Construction(sf)
.
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood one Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal [:] On site disposal system[:]
Versionl.7 Commercial Building Permit May 15,2000
i3;,NORTHA*TU ,,ZONING`
Existing Proposed Required by Zoning
This column to be filled in by
Building Department ��y
Lot Size
Frontage - —Setbacks Front
Front
Side L: R: L: R:
Rear - �
Building Height
Bldg. Square Footage % Q
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Findin ver been issued for/on the site?
NO 0 DONT KNOW YES
IF YES, date issued: I
IF YES: Was the permit recorded at the Re ' try of Deeds?
NO ® DONT KNOW 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 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 l NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exca 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.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant): _
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address _ (Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number _
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
12,rsie Not Applicable ❑
Company Name:
Responsible In Charge of Construction
GIb SA,,44) 31` 5+ SO�te k:e L,.,'eS+k JA 10
Address
- it
ture Telephone
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10•STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No
SECTION 11 -OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
IQ L� �.-e. �i�y��—_�j'� as Owner of the subject property
hereby authorize[:S: V —_Lys to
act on my behalf, in all matters relative to work authorized by this building permit application.
5.e 1
Signature of Owner Date
now—
I n.P 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.
Si ned under tho Dains and mnalties of edu
G'e
PrQ4ame
i ature of O n Agent Cfat6
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:- Not Applicable ❑
Name of License Holder: J
License Number
1,4 0 L012 � I
Address ^ - Expiration Date
Signa tu Telephone
SECTION 13-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 No 0
City 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:
The debris will be transported by: U5 R tt&jj-1 K(6 -
The debris will be received by:
Building.permit number:
Name of Permit Applicant
I� /(do-
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
'r www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aaolicant Information / Please Print Leeibly
Name (Business/Organization/Individual): SL�ceC 1,J5 UL.
Address:U& ILIA _(� S+ S LOW-e- E
City/State/Zip:LNM�,1,� IN►'19 OlpL�— Phone#: Y/3
Are you an employer?Check the appropriate box: Type of project(required):
1.[ I am a employer with 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 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
9. El 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.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
rance.t .p
These sub-contractors have employees and have workers'comp.insu
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other t L_e�
152,§1(4),and we have no employees.[No workers'comp.insurance required.] Aara-(_
*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: 1 1'l'1 /tJ(�v✓1� l 1�
Policy#or Self-ins.Lic.#: (� t (,l ��0213 LP/ ( -7 Expiration Date:
Job Site Address: 1 aim LJ✓ 0 VA City/State/Zip: A14 0/0� (�
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.
Ido hereby certify under the pai andpenalties ofperjury that the information provided above is true and correct.
Si nature: // // Date:
`�1
Phone#: 3._ 37v?— l��
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#:
Massachusetts Department of Public Safety
rvl------,-Board-of Building Regulations and Standards
License: CS-110193
Construction Supervisor
DAVID WOELPER
116 GARDEN STREET
WEST SPRINGFIELD MA 01089
Expiration:
Commissioner 02109/2020
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
SURGE HOME CONCEPTS,LLC Registration: 186413
66 SOUTH BROAD ST Expiration: 11/07/2020
SUITE E
WESTFIELD,MA 01085
SCA 1 20M•06/17
Update Address and Return Card.
6
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
.186413 11/07/2020 1000 Washington Street-Suite 710
SURGE HOME'CONCEPTS,LLC Boston,MA 02118
DAVID WOELPER 41�4
66 SOUTH BROAD ST ;:Zi
SUITE E Undersecretary Not alid without signature
WESTFIELD,MA 01085
® DATE(MM/DD/YYYY)
AC�
CERTIFICATE OF LIABILITY INSURANCE 09/21/2018
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 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: . Gloria Linzi
BATES FULLAM INSURANCE AGENCY INC PHONEExt): (413)737-3539 aC No:
E-MAIL
ADDRESS: Glinzi@batesfullam.com
975 ELM ST INSURERS AFFORDING COVERAGE NAIC d
WEST SPRINGFIELD MA 01089 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666
INSURED
INSURER B
SURGE HOME CONCEPTS LLC INSURER C:
INSURER D:
66E SO BROAD ST INSURER E:
WESTFIELD MA 01085 INSURER F:
COVERAGES CERTIFICATE NUMBER: 317189 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR POLICY NUMBER MM/DD MWDD
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE 1:1 OCCUR DAMO RENTED
PREMMISES Ea occurrence) $
MED FRCP(Any one person) $
N/A PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY F-1 JECPRO ❑ LOC PRODUCTS-COMP/OP AGG $
PRDT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS N/A BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
UMBRELLALIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATIONX SPERTATUTE T7OTH-
AND EMPLOYERS'LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000
A OFFICERIMEMBEREXCLUDED? I NIA N/A NIA 6HUB71182361617 12/21/2017 12/21/2018
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached N more space is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/lwd/workers-compensation/investigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Agawam ACCORDANCE WITH THE POLICY PROVISIONS.
1000 Suffield St
AUTHORIZED REPRESENTATIVE
Agawam MA 01001 -Dwk ';4
Daniel v
Daniel M.Cy,CPCU,Vice President—Residual Market—WCRIBMA
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD