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41-046 1260 WESTHAMPTON RD BP-2019-0939 GIs#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:41 -046 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category TEMPORARY TRAILER BUILDING PERMIT Permit# BP-2019-0939 Proiect# JS-2019-001572 Est.Cost:$19000.00 Fee:$144.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: AMERICAN MOBILE HOMES INC 081119 Lot Size(sa. ft.): 44866.80 Owner: SMITH DONALD RAYMOND&LISA A Zoning: Applicant: AMERICAN MOBILE HOMES INC AT. 1260 WESTHAMPTON RD ApplicantAddress: Phone: Insurance: 51 MOORE RD (781)331-0333 WC EAST WEYMOUTHMA02189 ISSUED ON:3/4/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.PLACE A 12X44 TEMP MOBILE HOME IN YARD FOR LIVING QUARTERS DUE TO TREE THRU HOUSE 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: Drivewav 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: FeeType: Date Paid: Amount: Building 3/4/20190:00:00 $144.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner t>eaa unem os City of Northa pt0 u: Building Depa menIL'Url Caro Permit 212 Main St eat MAR 4 20 AvageDIIMY . A Room 10 W all Northampton, M 0 o=oun on c,ruP ^" phone 413-587-1240 F 72on mA APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by ocis Map Lot Unit of Zone Overlay District Elm St.District Ce District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.11 Owner of Record: Name(Print) Cgent Mailing Address''177a Telepphonhon KY/IC�i..r H/I s3S- ,'sL33 e Signa ura 2.2 Authorized Agant: Kgaa:. . . 14W& .0" 10'r76±4 /-/s,-ef S t )nra+t rt-l- F Wy..,.m flli Name(PqfitCument Mailing Address: -7Sf- 33f -o333 Signature Telephone SECTION 3-EEITIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of J JAN Construction from 6 3. Plumbing ' Building Permit Fee aea 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) OMS Check Number This Section For Official Use Onl Date Building Permit Number: / Issued: Signature: / Building Commissioner/inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doon 1 Accessory Bldg. ElDemolition E] Now Signs [0] Decks [p Siding[01 Other[t$ Brief DVcription of Proposed _ - Work: Yla� n )1�4y rt.n� bK 'L L-b ufFL Fo Lt 5 ® µ7f 5 7rec Th(✓ Alteration of existing bedroom_Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.If New house and or addition to existlnc 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? A(C d. Proposed Square footage of new construction. IS 30 Dimensions 1.1 Y LJ e. Number of stories? f. Method of heating? £li.,iY«- Fireplaces or WOOdstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction V(kc 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 I, boAlt OI SM r'I t1 as Owner of the subject property hereby authorize +r• Md � �"�^�3 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Data ` ,r,�'jY/a. G✓WI2161 /�J/%Yz..h I'd 5 4 1�•�S ,as Owner/Authorized Agent hereby d lare 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 Na Signature of Ownerl Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction/Su Not Applicable 11Name of License Holder:Wl I!�' (�n2t'Y/ •`' 91115' License Number Atltlre Expiration Date Signature Telephone 9It"Istared Nome lmnrowmnn Contractor. Not Applicable ❑ /61 d'(- Company Name Registration Number tW -/ 1" /n6 b 4 fly s -7 1-2-)/do Address Expiration Date sl A'W66A�— A-2 < 4j ,*1 "'W 1015 Telephone 33/ T533 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§26C(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....... W'dNo...... ❑ City of Northampton _ Massachusetts c r.� z DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building � s " Northampton, Mn e1060 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,modemization, 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''cooLrporation or LLC,that entity must be registered. Type of Work: T Jw8y Y// Est. Cost: /1;dc's Address of Work: /1 LO t t/!37 A,4»2 r?X)r ✓7 eq- Date 2Date 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: - /L, i id f?�,Er�a Muk; 4 /oc-� Y7c Date Contractor Name HIC Registration No. OR: Notwithstanding the aabboveJ/t,yoheer,I hereby apply for a building permit as the owner of the above property: ,7 A/ f I/lJ( 'r ri-1'C Date OwncrAame and Signature e City of Northampton _ '� - - Massachusetts \" DEFARTNENT OF BUILDING INSPECTIONS �'• ,�' 212 Nein street .Municipal avilaing Northampton, Ir\ 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'. /1 Lb t✓esr h4?7tm a (Please print house number and street name) Is to be disposed of at: Cit 6y1 lease print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Co/mpany Name and Address) 'Signature of P mit 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. �QN The Commonwealth of Massachusetts Department oflndustrial Accidents I Congress Street,Suite 100 Boston,MA 01114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant I f t' Please Print Legibly Name (Business/Orgeuizetioalndividual): (!J/t M66i4 li,-es, Address: <-1 _Mds( K-e_ City/State/Zip: 4 i d e yr l Me- "1 FIS Phone#: -7;7/ ' 33rd ,3 S 3 Are you an employer?Check the appropriate box: Type of project(required): L�lam a employer with_121employces(fun and/orpan-hoc).• 7. ❑New construction 2.❑I am a vile poorness,or providing and have no employees working for me in g. ❑Remodeling any capacity.[No workers'comp.insurance required IO 1 am a homeowner doing all work myself [No workers comp.insurance regmentl` 9. ❑Demolition 401 am a homeowner and will be hiring contractors to conduct all work on my reorient, 1 will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I i.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions Sf]l am a emeal contractor and l have hired the sub-consommes listed on the attached sheet Mo Roofrepairs These sub-contractors have employees and have sonveri comp.insurance: 6.❑We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§IN),and we have no employees.[No workeri comp.insurance required.] 'Any applicant that checks box#1 most also fill out the section below showing their workers'competanlon policy mfotma'em t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new andava indicating such. :Contractors that check this box must attached an additional sheet showing the name ofthe sub<ontmemrs and state whether or not those entities have employees. If the subroontractnrs have employees,they must provide their worker'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: a '*Miff l Policy#or Self-ins.Lic.#: Jilt - L ,jy l i- dspy Expimdon Date: a' f Job Site Address: I41w ije,,TAAgxt V,I /Lei City/State/Zip: L4-r&Vc4 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 ma 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 it he pains a pen ties ofperjury that the information provided above is true and correct ser m `(//�/ Date 2/e1k/i2t Phone M Official use only. Do not write in this area,to be completed by city or town offciaL 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#: ��yy Cammg mveabn oI MassLne sells Ifq,y�' Olof Professional licensure ��✓✓ BoartlAt Sufl Builmng,Regulallans and Standards ConstrurM1 m liael'bif(n 1 r, J 'ral,11 P/ pp CSFA-081119 EXPlres'. 06/18/2019-' WILLIAM J GARRITY a.z`f 25 KIMBALL BEACH go t �. HINGHAM MA 02043 - .. Commissioner OT, .......area/l✓c�P/Gf a�r/umrWa Office of Consumer Auer;&Bualness Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Suoolemeol Card before the expiration date. If found return to. Registration Excitation Office of Consumer Affairs and Business Regulation 105386 0//22/2020 One ASnbudon Place-Suite 1301 AMERICAN M081LE H0MES INC. Boston,MA 02108 i; A FRANCIS V.WARD IIIi'i 51 MOORE RD E WEYMOUTH MA 02189 Undersecretary Not valid without signature CERTIFICATE OF LIABILITY INSURANCE of/30/'1B THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLUBR. "HIB CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TME COVERAGE AFFORDED BY THE PCLIC ES BELOV,'. THIS CERTIFICATE OF INSURANCE DOES NOT CONST'-UTE A CONTRACT BETWEEN THE ISSUING INSUREat AUDHOR.ZF.i REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT. If the canlllcate holder IF an ADDITIONAL INSURED INe Ac tT,IIAa) must be endorsed If 6UBRCCATI0N IS WAIVE:, auojact 10 the terms and coneltlons PI the policy, Dodoln polloles may require an endorsement A at.UNR t Do 111s canlllcate does nal conte= r,11V to Icr cenlfkaad tailor In Il an ofauEh endoreementls) _ Yd" DEAD"Yiney _ DVNCAN MACKELLAR INSURANCE AGENCY, INC. v (781) 335 -- 11] Ar so 1181; 331 - 835 SHOLED STREET paula0 kellar.co EAST WEYMOVTH, MA 02189 m Dino Al"AAce _ , [ eaurvec A Bcotteaalte Insurance Co. Nacna0 D. Amer_can A.1,11. K...., Inc. ae Granite State Insux ansI Co._ cArbella-Protection I(tauian . rvsuseaca Co 51 Moore Road Nsdsaso. East Weymouth, HAS 02189 COVERAGE$ CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LI6TED BELOW HAVE BEEN ISSUED TO THE INSTRED NAMED ABOVE -OR HE P :NICE INDICATED NOIwHHSIANDING. ANY REQUIREMENT, TERM OR -CONDITION OF, ANY CONTRACT OR OTHER DOCOMCNT ALIN RESPLCI - CERTIFCATE MAY EE ISSUED OR MA' PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SVCJEC- TO ALL 'HE TER",S I EXCLUSIONS AND CLAD NONE OF SUCH POLICIES.DMIT55M0WN MAY HAVE BEEN PEOUDED BY PAID C.AIM115. ImWANTLYN IMNIL`PY'�Y1 Lm.Ln Rwc. 11111E ALSjI1ALn111 r c'I BCSC03369C11 02/04/16 02/04/19 t E �E0 C xC PcR$QNALaAEV1NJVL` 0 2.0 . oucAoY PPo AP r r7 LDL _ _ _. eLa uAe,uTr ANI s 1 DTo 102C014699 02/26/18 02/26/19 RYIP¢, ANVL:U eov of a {au cHSEe X D roALT NHL-71 - — - Esu as Arvorv�anveD DITAD hal e 6T CE wale uAa X cuR E.vMN_ _ _.. 0 . ;_. A X XLSO101417 02/04/18 02/04/19 AOOBECATE B o cwDEcs usv WC 024-16-0994 08/12/18 08/1]/19 1EI EACH Acc DENT 0., OCC ITTwME:E cxEl _ _.._ L-EA EMPL—E E 1,ODD.00C eITREASE-IDLAYUn 1,000,COC cwonory or cPaw,nwua I mcanous NEH¢rea IAmon AcoBo tat Aeemonl RE,n=x,o"11" n»un•w=•1.,.A. sal ' Rental of Mobile Homee CERTIFICATE HOLDER CANCELLATION 1 SHOULD ANY OF THE ABOVE DE11RE11 POLICIES BE TAN OFvFD IE —-_ THE EXPIRATION DATE THEPE OF, NOTICE WILL BE OF a ERP: ACCORDANCE WITN THE POLICY PROVISIONS. AUmauT[O PEReSENTAEVE ©19882010 ADDED CORPORATION. All,ht. ADDED 26(2010105) The ADDED name and logo are re9latAMd marks of ADDED til �� Y �� � ♦ � �� .h � . � ' n¢r F a1 .t. •v� �r Sr +'� t •� ' xJ..'r � •ryry 44.1 r J F 'I H