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36-329 (5) 196 CARDINAL WAY BP-2019-1317 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 36-329 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category, BASEMENT RENOVATION BUILDING PERMIT Perron# BP-2019-1317 Proiect# JS-2019-002125 Est.Coat:$39976.00 Fee: $259.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: PETE MONAGHAN 047809 Lm Size(w. ft.): 19906.92 Owner: ICATES JACOUELINE S&ERICA H KATES Zoning: Applicant- PETE MONAGHAN AT. 196 CARDINAL WAY Applicant Address: Phone: Insurance: 60 SHAWMUT RD (781) 801-0744 WC CANTONMA02021 ISSUED ON:5/24/2019 0.00.00 TO PERFORM THE FOLLOWING WORK.FINISH BASEMENT - PLAYROOM 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 Department Fireplace/Chimney: Rough: Oil: Insulation: Fluid: 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 5/24/20190:00:00 $259.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-1317 APPLICANT/CONTACT PERSON PETE MONAGHAN ADDRESS/PHONE 60 SHAWMUT RD CANTON (7F;)801-0744 PROPERTY LOCATION 196 CARDINAL WAY MAP 36 PARCEL 329 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CIM IC 'LIST ENC D REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Fillout Fee Paid TyoeofConstruction, FINISH BASEMENT-PLAYROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 047809 3 sets of Plans/Plot Pim THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: _Approved_Additional permits required(ace below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Spacial Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Parmit ,3 Variance. id Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Requited: 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 EM Street Commission Permit DPW Stomr Water Management Demolition Delay 5--23- 2 v 01 _ Si eol'Buiidhili-d Bial Dare Note:Issuance of s 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. W Valences are granted only to those applicants who meet the strict standards of MOL 40A.Contact Office of Planning&Development for more information. Department use Dory City of Nord am ECEIVE use Permit: Building De art u C Dnveway Permit 212 Main tre t Se r/S Ac Availability Room 00 MAY 2 0 2019 w er/W II Availability < Northampton, 060 Tw Sets of Structural Plans - phone 413587-1240 ax ae lam DEPT.OP BUedNG INSPE city_ NOR AMPTON.M�OII erB 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 office /9(� Lwz"�iAA4 p_ VV; y� Map Lot J, Unit -t- le/ZiYca=r VA v�06 9?pZone Overlay District Elm St Dlssict CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �- 7.S. -4 £. 14. KA ?-S P/' �.M.Q7a+tt w.c �'-lo ze-•.ems hrt rt Name(Pring ,µ . P Current Mailing Address: r� •� Sti/44Telephone 9i�• T% T� Signature 2.2 Authorized Agent: A-�*r` jYk^'K4/ItW lux Rp✓eKfrg. if 60 earF 4".+ Mf? v2b2/ forma�iPmed Current Melling Address'Slg : ure Telephone SECTION 3.ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by penmit applicant 1. Building (a)Building Pennh Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee ry 4. Mechanical(HVAC) S.Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Pennit Number: Date Issued'. Signature: 5-23-2019 Building Commissionerllnspector of Buildings Dope �f110NMg6AA) @ if kS7bN . \"OPcI EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING NI Informal on Must Be W Completed.Permit Can Be Denied e To Incomplete Information , Existing Proposed Required by Zoning This column to be fi11W in by ' Building neminnnot Lot Size Frontage -------- ----- Setbacks Front —_ f', Side La R:-- L�r' R:= Rea O Building Height Bldg.Square Footage __ % C Open Space Footage (Lot ues mists bids&pnel #ofParkin Spaces -- Fill: voluma A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aooliciii New House ❑ Addition ❑ Replacement Windows Alterationls) Reading Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [[31 Decks [p Siding[O] Other(C� Brief Description of Proposedw Q)Work: elzww— Alteration of existing bedroom_Yes No Adding new bedroom_Yes No Attached Narrative Renovating unfinished basementYes No Plans Attached Roll -Sheet Sa If Now house and or addhion to e7dsdna houslna.comDiete the f6howina: a. Use of building . 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? I. 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 I, as Owner of the subject Property hereby authorize to act an my behalf, in all matters relative to work authorized by this building pemnit application. Signature of Ownm Date I, rJy/O/vb�j rlll.� Luk R x/e✓H-7-o J as Owner/Authorized Agent hereby declare that thetatements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. 9gliadjunder the pains and penalties of perjury. 12bv !„fn) P ame 21 Sign re of Owner/Agent Dale SECTION e-CONSTRUCTION SERVICES 8.1 Licensed Construction SupeMsor: t Not Applicable 13 Name of Ucan"Holder: � � JZbry /IRrt1� Ucense Number e36 R! ogs-v I—zm Atltlreu Eaplialion Date Telephone 9.Reaisterad Home Improvement Contractor. Not Applicable ElL�/K 2,�a✓•aT/ems cwrhf �.iw/^y �3aYy3 Company Nama ��rr�� Registration Number (o'c 21'Gt�(s✓�I+rT � �ifMbn! K1h aro2 f 'Z'Y•2 1 Address o� Expiration Date Telephool 'CI-[1060 SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.125C(S)) 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 Massachusetts _ D2PABDf✓aiP OF BUILDING ZNaPa ZCNS 312 Bnin 34.t • IN ipal auilai sorrL ton, O 01060 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 most be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, ahere6on,renovation,repair,modernization, conversion, improvement,removal, demolition, or construction of an addition to any preexisting avneroccupied building containing at least ono but not more than lour 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 corp oration or LLC,that emity must be registered Type of Work ��> redvl�Tl Est.Cost: 37 9 r1/At+mt y Address of Work: Dale of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Wmk excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): _Building not owneroccupied 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 RESPONSIBH.ITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the 'ury: 1 hereby apply r a but as the agent of the ownef: S q I WV_7 Dad Contractor Name HIC Registration No. OR: Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton // Massachusetts ' DEPAATHENT OF BDZLDING INSPECTIONS 212 Hain Btveet • Nun— al Building i C` \\ Northampton, N 01060 Massachusetts Residential Building Code Section I I O R5.1.2 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 farts structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section I I O R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.85, provided that if a homeowner engages a person(s) for hire to do such work,then such homeowner shall act as supervisor. 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. City of Northampton Massachusetts (i) D PAN NTOF BMWZM INSPECTIONS212 Main Street *Mnicipal BuildingQ, MortLaa,,tan, 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: y96 <frm41--K u^�ee-Y. `aR (Please print house number and street name) Is to be disposed of at: &.-lt-4�y '10V tPS2ra2S 'kAMA. )�Y tAhow (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Sign tuNotmriffAppkant 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. The Comasonweahh of Massachusetts WNI'sorkers'Compensation Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02174-1017 www massgov/dia Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant tufo alio , Please Print Legibly Name(Buainco/Orgam ioNIndividual): Address: City/State/Zip: Phone#: Are you an employer?Check the approp 'ate boa: Type of project(required): I.❑lamaemployerwiW empio es)full avNmpmt-tmul' 7. New construction 2.❑I mn a sok po,twororpuaershipmd no ce,lo ces wohmg frame k S. ❑Remodeling myczpecay.[Nowmlms com,maumncee aid.] J.�lamelwmeowaer doing ell work myselE[No ohers comp.msmsnce/.�� d 9. ❑Demolition 10❑Building addition wmluctallworkonwmkeric munmmcc11.❑Electrical repairs or additions pmprs.with m,.mploees. l2.❑Plumbing repairs or additions S.�lama genmuuta haveshur and plawehave s dthave wrkens,chat.edonw13.❑Roof repairs These subeonoxmrs have emPloea erd have wohm'cbinp.imman6.❑Wemc ecarporahonand to oR have cxcmisNdrth right efesemg14.❑Other 152,51111.and we haven.mpkyea.INo wokers'comp. "My epplimrc that checks box el must also fill out the section below show daa workers'compensation policy infommtion. T Hommwnm wM10 submit this eflidevit ivdiwting tlrty aR doing all work then hire outside mammtm must submit anew affidavit mahl a Ing such. tConvncmrs Wat check this box rami amched an additional Shen shuwin ofthe sub-conm cion ad state wh ffi+er nor thou amines have employees. If Wemb-mntmcmnhavemployee"theY must provide work omP WlicYramh. I am an employer that is providing workers'comp¢ anon insuranef for my employees. Below&the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Dale: Job Site Address: Ci /State/Zip: Attach a copy of the workers'compe ation policy declaration page(showing t policy number and expiration date). Failure to secure coverage as required der MGL c. 152,¢25A is a criminal violation nishable by a fine up[o$1,500.00 and/or one-year imprisonment,as wel as civil penalties in the form of a STOP WORK O ER and a fine of up to$250.00 a day against the violator.A copy ofthi statement may be forwarded to the Office of Investi tions of the DIA for insurance coverage verification. I do hereby certify under Me pains and allies ofperjury t ' tru hatthe information provided abov e and correct. Si nature: Date, Phone#: Official use only. Do not write in this area,to be completed by city or far City or Town: Permit/License# \� Issuing Authority(circle one): L Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contac)Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the smite of another under any contract of him, express or implied,oral or written." An employer is defined as-m individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also stales that"every state or local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised thin this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Alm be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or I-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Kates,Erica 196 Cardinal Way Floream MA o1962 917-7967756 CONTRACT Cs. 7m„ mre SKETCH C tmd Dare. S --- ATTACHMENT Cw�am.rcnane X117 Gam— rns.n rna G ,, . . . . � . .. . . L. 7" f' V�X4 � p / 4,Zj� yg.y iv Sasau(R ,,,.w o la��"t ,N 6`co Awl �! NP S1V2u�nAL cJn2� 'K IJo Bdli2vc'n`!7 Specification Data PanasonicPanasonic Energy Recovery Ventilator Descriptiont!hispe�Com/brt- Energy Recovery Ventilator provides a tempered air supply,humidity control,and a baboned amount of exhaust W help maintain neutral pressure throughout the home. Parouranc ERV shall not be installed in a bathroom. Only one nnit is needed for a 1,750 sq.R.2 bedroom O4VE7 �� CM 20`F ) home to meet the ASHRAE 62.2 venillation requirement. motor/'Blewer: • 7btaliy enclosed AC condenser motor rated for continuous run. • Two highly e®cient blower wheels running an single motor for lower power consumption and decreased noise. • Power rating shag br 120 volts and 60112 I °\ • Motor equipped with thermal cutoff lure conrol. / Housing: • Rust proof paint galvanized steel body. • Dual 4-intake and exhaust ducts. / �•� • Built to hackdraft damper on exhaust duct • F6ters on supply and exhaust air e#end the sife ofthe ERV com. • Expandable mounting bmdwt up to 16'on ranter. _ Grille: �I p • Attractive dealgn using ABS material. • Attaches directly to housing with torsion springs. ------\ Warranty: ,•,a:»\ • Brie factory antanty arts.be a minimum of 3 years lim - ited warranty on parts. Typical llSpecifications:bfe ERV shall be of the ceiling0 Cmount type with no lest Man 40 sone, on Me Inexhaust cro port,30 CFM on Me supply port,and rd more Man tic sone u tested N accordance with pHVIower ons and 916 standards at at static pressure In inches water gauge. Power .for heating shah be angreater 1.than /A.. 23 watts. Apparent Sensible Elle r 32QF g for heating shall accordance less than 6696 at 3 .CFM net air Row under t. (0°C) as tested a .the,with at 29C FM Tota]Recovery Effectiveness for cooing shall be no less then lose at to CFM net air Row under flees ng of t Bre supply port damper shall close below 20°F(-Bon) to prevent freezing re to core. Bre motor shell be totally enclosed, AC condenser D type engineered to run sscontinuously. Power rating F•n curt wMv9t shall be 120v/60Hz. Duct diameter shall be no less than C. Ventilation Performance: ••• AIr Volume SettkqI 40CFM MCAd +OCFM srao wa�w.9nNNwaw.s. a+ at at exhaust Air VoMma r" a m 10 i suPpyAkvawrw lcFul m m to 9ii1i Rath eoABI A.0 WA Pawrewwanptlsn psatwl Pa Rt tT apssd fill" sins 1r9Y 1096 01° pOwsr Rasp t90e0 ERV tion Technology: q10 • Indoor and outdoor air passes through Panasonic's capillary core technology. This process tempem supply air while transferring moisture and energy. • Built io Frost Prevenffon Mode prevents the care from fiwzing, o io a a a m Frost Prevention Mode is five of Interaction and operates without intervcmion. En Performance: mdat Appvant asnsWa Eilac9venav for i+saai9 M%tl90CM and 02°F p°C) TOM Rawvary FMcienry for raolhg 98%e[anCAA eM BSF(96't7 For t©� For Complete Installation Instructions Visit www.panasonic.com/buBRhtg Model Quantity Comments Pro'ect Location: Architect Engineer Contractor. Submitted by. tate: Panasonic Home A Envimnmant I n—P----m-or—I cam_..__ ...--.. ' 1.....-----r - The Commonwealth of Massachusetts Department ss IndustStreet, Suite 10 encs 1 Congress Street, Suite 100 Boston,MA 02114-2017 www massgov/dia MWorkers' Compensation Insurance Affidavit:Builders/Contractors/Electdcims/Plumbers. TO BE FILED WITH THE PERMiTTDVG AUTHORITY. AooEcaat Information Please Print Leeibly Name(BustasUOtgaovatiodlndividual): LUX RENOVATIONS, LLC Address:60 SHAWMUT ROAD City/state/Zip:CANTON, MA.02021 Phone M 781-821-0060 A sent u®ployerr feed,the.Ppromaie box: of men used Type project(required): 7 1.21 ma employer with 17 ®Woyen(full end/.pan-time).• 7. []Newconstruction z.❑l mawk proprietor orpmtombip end Lave no.ploys working formem 8. Remodeling any cgmcity.[No workers'comp.insuruvw mquir xil 3.❑Imahomwwn.domgellworkmyseff.(Nowodrms'comp.imursncewquved.11 9. Demolition 4.❑lmahomeown ran wmbehbing contr>7orr w wvdtut all work colo 10❑Building addition Y property. I will ware than all conuadon ehherhavewakm'c.mpeveatiov ivawmce or ere sole 11.[:]Electrical repairs or additions propriewr with no employ... 12.❑Plumbing repairs or additions 5❑I m a geomol cennecmr.d uan.tired the wbcovhwwr lined on We attached eh.d. .❑ROOFre tb.e sub-.nnav amon he employe.and have worker'comp.ivcurusa? 13Pairs 6.❑W em acorporatiov and its office.have exncixd Weir right ofexmp4on per MGL c. 14.[]Other153,41(4),and we have no.playas.[No work..'camp.insurance requimd] - *Ay ap,1kot dint cliecka b..#1 muvt also fill via the..do.below showing reit working, o,poo lino polio,information. t Hom ...who subrwt this aeidavit ivdicatwg they m doing all work and then hue onside conownnrs must wbmit anew affidavit adiontivg such. [Contractor tlut cbeck W.box mart awched.edditiawl she.showing the vane of the suMovnnwto.nod aide wheNar orvot those entities have employees, ffhesub-conte.-.torhaveemployagtheymwtpmviderh,U work,Wcomp.polioyno rr. 1 am an employer that is providing workers'crornpmsanion inswr "for my employees Bidowis thepolky and job site information. // Insurance Company Name:�_ Q�'3 f ilmr / Po' #or Self-ins.Lica#:XW057350"9 5/2412019 Policy ////� Ar xpimtion Date: Job Site Address: `/O (�iNrQ'ja3AZG✓>0� City/smwzip: Attach a copy of the workers'compensation po cy 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. pains and tries ofperjury that the infornwtion provided above is true and carred sienatme vt Date' Phone#: 781-821-0060 Official use only. Do not swite in this area,to be complded by city or town officiaL City or Town: Permit(License# Issuing Authority(circle one): 1.Board of Health L Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Horne Improvement Contractor Registration Type: Supplement Card LUX RENOVATIONS,LLC. - '` - Registration: 137943 D/B/A OWENS CORNING BASEMENT FINISHINISTYSTEht$. E.,onatlon: 02/04/2021 60 SHAWMUT RD CANTON,MA 02021 Update Address and Return Card. SCAT O ZuJCv11 W �if s&Business Regulation d 011ica ME IMPROVEMENT M RO EMlENT CONTRACTOR Rpukaon 91f HOMEI TYPE:SMENT CONTRACTOR Rifore tti expirvalid for eti. If fo nd only TYPE: tioobmaN Cab before of fa/e. and Bu Mum to: fteolatrntion 1:a9imdPn Offiu of Consumer Affairs and Business Regulation 137913 02/ON2021 1 on S4wt-Suite 710 LUXRENOVATIONS,LLC. n, 02118 D/B/A OW ENS CORNING BASEMENT FINISHING SYSTEMS PETE MONAGHAN 60 SHAWMUT RD U CANTON,MA 02021 Undersecretary, fie Valid without signature Coff4monweaRh of Massachusetts Division of Professional Licensure Board of Building�Regulations and Standards BASEMENT Constructioyvpery.llp5.1 8 2 Family nmsxlNa mrrw i/ CSFA-047809 Intpires: 07/22/2019 ijot PETER M MONA PETER MONAGHAN 136 RIDGE ST.•a�•ytE`E[ PROJECT MANAGER MILLIS MA 60 shawmut LUX C9fIbg10a 0: mobile 14 /1 RENOVATIONS. LLC 0-mill pmmaghao@ocdosoctc%mn Commissioner Il/L'•�- i�� Owens Corning Basement Finishing Systems �® of New England KajC4 Erica Contractor / Agent Authorization From 196 Cara'aat mo x A E1 rene�9 91St+ 919- I, /be , ens Corning Basement Finishing Systems of Boston to sign the building permit application on perform the work at: Home Owners Signature: _ Date: Project Manager Signature: Date: 7 1 60 Shawmut Road • Canton, MA 02021 • Phone: 781-821-0060 • Fax: 781-821-8552 0 www.ocboston.c0m ACCPJZbP CERTIFICATE OF LIABILITY INSURANCE O1RB2019 THIS CI3RF3GTE IS ISSUEDAS A"A -OF IRORMATNNI ONLY AND CONFERS NO RIGHTS UPON THE CERTIFN:ATE HOLDER.THIS CERTIFICATE D06 NOT AFRtYAiIVELY OR NEGATWELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CBLTiRLATE OFBISULANGE DOES NOT CONSTRUTE A CONTRACT BETWEEN THE ISSUBIG INSURER(S).AUTHORIZED REPRF.S@ITATNE OR PRODUCER,AND THE CERT GATE HOLDER IMPORTANT- F dr utfvfe hdda'a an ADDFLIONAL INSURED,Ha poh,(.)nawt have ADIXTIONAL INSURED proelsmnf at be erYlwfwL I5110RO WTg11IS MMN®.abjaC m Ne toms W mMYions d tla pdky.wrtain pdiciae nuY FaWIFe an endorsenrnc A steYnrm on tll"a CatFole dda b fdlM rigs m U,e catfTiate hddar in Iieu d suds erldwsemantlsj. wawl® xRME: Jaw Logen GOIdT AI�rc lrveal� FxaxE (/81)6542262 (1B1)efi n5 306 Wa gon Seaw ap�RL !w GWmona6anfdmwall® weu AFORMNe cpvmAec xMt• Nn J MA 02061 SRC,/,_ American Flre eM Cmuelry Ca. 21066 ew .SE Balety In wwwe C¢ 39a5Y Wi RanYaEwM.LLC waMRER C: Olio CmYY husarm CanWY 2e 4 d>a Oawd CwN,gd Naa,Englwb weM D' 608hewme Rd. wswd E: Cation MA 02021 wfwdR F: COVERAGES CERTIFRCATENUMBER: Maw JL8 8 REVISION NUMBER: TIS ISTO CEQTBY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED RM ED ABOVE FOR THE POLICY PERIOD fVBCA NODVRHSTANOING ANY REQUIREMENT.TERM OR CORONION OFANY CONTRACT OR OTHER DOCUMENTWDH RESFECTTO V CH THIS N8[RS MWY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 0 SUBJECT TO AU-THE TERMS, EXa1610t6 AND CONDNIONS OF SUCH POUCIEB UMMS SHOWN MAY HAVE BEEN REDUCED BY FAD CLAIMS. 7A�SR.E Nati f 1.DO Aw 6/A6JMOE ®OCfM `RBIISES f15AM BK/5T950M9 DID512018 OBOYJDI9 f ix%m z00%0002AW.m 3 Pmp Ding BpnpM f wwLlfY 6al p4 f o BOOILYINJVRY(W,.) f BI&MCBL B CW NED ifwlWLm 5902280 01g42018 OIOV2019 eover lwuav lPu dwlN f BIa PDCSL MHOS tlLY ANO$ HwEo NONaNe LY PROPEnTMouuOE fBIaPD CSL .WIOS,YLr Au1MMLY iY. UMalinsure0 mowul Bl f �FllAt1Re OOCR BLf1000IlRRENCE f 1'�'� C . ,.. =. DBOST150CA&FIXLOW FORN OB954MB OBO5�19 RECRTE f vEn IXR.$ 10.000 s NORIORS COYPENSATgN . AtIDEYPIDYEAY WB61Ir Y/N L. .WY PROPRIERWNARTiEP/E%ECVINE � N/A XVPOST3� I9 OYIA/LO1B OY1KNl9 EL EAOIfWOEM 3 1`LL'O'OOD DFTICBCR®mea Exnupept 1.000,ODO IlludnuYl^RHI El m4aSF-EapYIDYEE the0 OLet OESLRIPRIPOM` OF OPERATIONS Lebn E1wSEAg-PWCY LIMIT f 1.000.OPo pESLRPININ OF OPB4 'umu IOa/TROs Nm®1w.MOWd bvbB[IrrJ,I4M YttlFGOO Y,m�q�a�4,p.vM1 Home Onp..m CawaJa CERTIFICATE HOLDER CANCELLATION SHBILDANY OFTHEABOVE DESCRIBED POLKIES BE ^BEFORE THE E)5 W ATMIN DATE THEREOF,NOTICE VIaL BE DEl1 V ER ED w L.RwNwdiaES.LLC do Ox Canmd New Engmd ACCORDANCE WIIIITIIE POLICY PROVISIONS inswede Dopy d Cerlifom I.IIfIpR®REp1E8pITATrvE fi0 SlwMmw Rd, Cwmn MA OM21 O 19 WHSAOORD CORPoRATIOTL Ad d9hm reserved. ACORD25(201803) The ACORD name and mgo ale registwed maks of ACORD