23B-059 (2) ,t/e _ Nff cs e- r
Department use onh
City of N rth In Statu of Permit:
Building epa fin18 X19 mb ut/Driveway Permit
212 M in St eelt�MAA ewe Septic Availability
Roo 10 ate ell Availability
,rA Northampt ,1,1 nlNc,msPFcm S 1s of Structural Plans
phone 413587-124 Fix" 10100 ' Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 .BITE INFORMATION
1()q
1.1 Prooertr Address�: A This section to be cmplleteetedd by office
I�� I4 s"vh Map Lot 0-5q
7 5 Unit
Zone Overlay District
Cim SL DIStdct CB Db d
SECTION 2-PROPERTY OWNERSHIPIAUTHOR12ED AGENT
f(�nI-) � rh r / 23 S . Mach S7L 4;rae4 0A 1A
Name(Print) Curr�m Melling Adldress)! _ t I vt.
V12 � Ja�G "40
Ttle 'ho a
Signature
Autho 'zedA t:
��e e��Qv1e Syi6�e e Pntile 14
Name(Pant) Curenl Ma1b 9 Address:
1 -�7-74 - U33
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by permit applicant
1. Building li (a)Building Pemlit Fee
2. Electrical / (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) ,IW7.Kl 1"I
5.Fire Protection
8. Total=(1 +2+3+4+5) Check Number
This Swdm For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissionerdnspector of Buildings Date
�y 1Ao� @ S - LLC . Cou,(
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoolirable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing
Or Doom ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Docks [❑ Siding[D) Other[DI
Brief Desrdp'on o PLp e A uak L mmack k aL AorkPww� &a1"t ad r (ZI ✓
Alteration of writing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ga. 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?
d. Proposed Square footage of new construction. Dimensions
s. Number of stories?
f. Mahood of heating? Fireplaces or Woodslows Number of each
g. Energy Conservation Compliance. Masscheck Energy Complianceform attached?
h. Type of conetnxfion
i. Is construction within 100 ft.of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No
j. Depth of basement or teller floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yea No.
I. Septic Tank CitySewer Private well_ City water Supply
SECTION 7a-OWNER AUTHOR17ATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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.
Pont Name
Signature of Ow hkgcat Date
SECTION S-CONSTRUCTION SERVICES
SA Licensed Construction
(�Sup(ervviissor nn "✓ J Not Applicable ❑
Name of License Holder. n 'at l��c.16Wt j' Passani!-i'
Llmpe Number
14Q fl11�d 1-� /f1'Ie C� O19W7
Address Expiration Dale
Signature Telephone
9.RealsteredH m Imprithrunnumt Con Not Applies le ❑
aJ f � .,.x,� LLQ I�j'
Copan �ms I Registra6 n NurrPer
`� i
Addre,ys_s.� '10/3 ) )) Faire nDate
p�� 11 �b� Telephone —7a3'QY�J
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.763,12liC(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...... ❑
City of Northampton
SS C t/
Massachusetts
DPP/la1TISNT
OF BNZLOZNO INSPECTIONS
212 Nein w •Municipal Bui3Aing
xorthvM�ton, m. 01060 r4ry-�1,0C
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 name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
L c c, AcrW4" 0(/110
(Company N e and Address)
( 041�y�
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.
A ROC oe CERTIFICATE OF LIABILITY INSURANCE 01/3012019
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: R the pNficate hold is an ADDITIONAL INSURED, the pol"Ies)must have ADDITIONAL INSURED pno islcns or the endorsed. If
SUBROGATION IS WANED,subject to the bane and conditions of She pol",certain policies man,reauln an endorsement. A statement on this
certificate does not confer rights Wthe cartlRcate holder in lieu of such endomemen s.
..CFR ONTA CHT JEFFREY R000
SME
INSURANCE
RANCEB BONDING,INC. rv £m 961-536-7000
12ROOSEVELTAE
INDBOX M)
MY %eVREN(S aFFpIpxOCOYERAOE � IMM•
MYBTC,ROe3f3 _IeNwERA ARCH SPECIALTY INSURANCE CDMPANY 27199
wun® WamERe NOM INSURANCE COMPANY 14798
QUALITY HOME SOLUTIONS LLC xsLRERc AMOUARO INSURANCE COMPANY
PO BOX 2055
NORWALK,CT 06952
mSWER F'.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS M 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 MY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONSANDCONDDIONS OF SUCH POLICIES LMTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMB
q� WO
TYPE OF IItlURANLE _ I p _ POLICY HUMBER
A X carehLClALaexINALIJAxJrr AGL000M-05 _- 01130118 071301201uoHOc"REHCe _ 1 1.000.000
_ CLAaMAAAoa EXI ocuw I Is 100,000 .
h GERsdfMLa I,W NaM' a y00 000 ..
1£MML/Od+EaATE UT�r APP_Liffi EB[ OExeRN AL%MEwTE { 2,000000
IPCLICT ox 'T& I PROOUCTa-CCAi.CPAGG t 20y00000„
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NNspw Wp — a.LoeFASE I ESvLYIE s 500.000
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CERTIFICATE HOLDER CANCELLATION
- '- SHOULD ANY OF THE ABOVE DESCRIBED MUMS BE CANCELUM BEFORE
THE EXPIRATION DATE THEREOF, NOTICE Wal BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUMONIZAD REPREEENTATNAE���..���,�\�
I.YYAxvA��SI¢A�v U T`rv.-�wu.�_
RPO i Hg m mse
AOORD 25(20103) The ACORD name and logo are mglaWmd marls of ACORD
�\ The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contactors/Electricians/Plumben.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information (� Please Print
Name(Bwin�es/s/OrgmizatioNlndividoapL 1 J
e O -N U—
avC
Address: ( — -- II 5T r1
City/State/Lip: �sw41(- (-�- ODUO Phone#: 010 72J1 93
Anyoe ate employer'Clunk the appropriate box: Type of project(required):
L[3 l an a employs welt employees(full end/«parrume).' 7. New construction
2.❑Imamlc proprieomspmmeahipab have memploynsssarking fmmem g, ❑Remodeling
a,cepcity.INowmkris'comp.imomece required)
3.�lam ahome.,doing all work myself IN.workcrs'romp mm.milmed.)t 9. []Demolition
4.❑1 wn a homeowiwr and will he hiring connactmon
s to conduct all wmk on my property. I will 10 F]Building addition
emaethnallcontmcmrseitherhaveworkers compsmoonins ,nio¢sole 11.❑Electrical repairs or additions
proprietors wim no employs.
12.❑Plumbing repairs or additions
5.flErrmn a geneml connector and I have hired the sub-mumacmm limed on nominal sheet. 13,❑Roof repairs
These sub-contonaom have employees and harm workers'comp.ins
6.❑We am amrponaoo aM es omen have eaemm l thar right.feaemptim ps MGL, 14.00ther
152,1EO,ual we have no employees.fNo xwkeri romp.insurance required.]
'Any applicant that checks box#I most also fill am the section blow showing mein workers'coma ention policy information.
t Homm one.who submit this andarit indicating Joey see doing all work sed own hire ounide cmhncmrs must submit a mw athdioo indicating such.
tComrators that clock this biz man atachN an additional sleet showing aw tome of the wb<o matans and sate whether or rot hose entities have
employees. If the sheontmctas have employees.they met provide heir wakem'romppolity number.
I am an employer that is providing workers'compensadon insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: n r�L G c� ( fj L✓fanCQ /�
Policy Nor-Self-ins.Lie,h: ` iWIA� '{V Expiration Dsdc �! ,�n
Job Site Address: J � 3 S IY IM I'( rCity/State/Zip: OfuH" IVI � 010U.).
Attach a copy of the workers'compensation policy declaration page(showing the puticy number and expiation date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
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 n�de �.tondpenalnes perfury that the informafion provideda cek�l�/('e�alyndrormt.
S'enamre / fx�t/✓`7/ Date >�j
Phone
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
laving Authority(circle one):
I.Board of Health 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing l nspector
6.Other
Contact Person: Phone#: