24A-159 345 PROSPECT ST (wrong map block on card) 345 PROSPECT ST BP-2019-1354
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:35-040 CITY OF NORTHAMPTON
Lot: - PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Categorv: ROOF BUILDING PERMIT
Permit# BP-2019-1354
Proiect# JS-2019-002182
Est Cost:$10313.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouu: SERGIYSUPRUNCHUK 104327
Lot Size(sc. ft.): 485415.00 Owner: MCLINDON JAMES
Zoning:SR/WSPII Applicant: SERGIYSUPRUNCHUK
AT. 345 PROSPECT ST
Applicant Address: Phone: Insurance:
375 CHICOPEE ST (413) 883-3802 WC
CHICOPEEMA01020 ISSUED ON.512812019 0:00:00
TO PERFORM THE FOLLOWING WORK.•STRIP & SHINGLE ROOF
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:
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:
FeeTvoe: Date Paid: Amount:
Building 5/2820190:00:00 540.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
LCC: r
Department use only
City of Northampt n Status of Permit:
Building Departm nt RECEI yPermit
A
212 Main Stree ptic stability
Room 100 Water ell A ilability
Northampton, MA 106 VAY z 9 Be of ctural Plans
phone 413-587-1240 Fax 13- 7-1272 Plotisit Pla
- DppT _Fnujlow'.iN pec,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVA ONEOR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 2r/nA— 19-t 3 t /
1.1 Prol1pe[rty Address: This section to be completed by office
3 '11 Pin y n i[I1 5-f- y� Map� Lot 1 Unit
Wo r4 � 4t 17 nom M A zone Overlay District
Elm OL District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Recortl:
do L4 34-�_ Phos)ie-d <Y
Name(Prim) Current Mailing Address: 1
t1�3 6877 T S
Telephone 7
Signature
2.2 Authorized Agent: /
A I -'S
t7<
Name( Cuna�t Melling Address:
(/lam-rGO to 1717
Signature Telephoiw /
SEc-n -ftrnmATED CONSTRUCTION CQM
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /O �j 3 (a)Building Perk Fee
2. Electrical J (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) v
5.Fire Protection
6. Total=(1 +2+3+4+5) /n / Check Number
This Section For Official Use Only
Building Perk Numn Date
Issued:
Signature: 5-28 -ZOi y
Building Commiaeionedlnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Infomwtlon IAu t Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This wlumn to be filled in by
Building Department
Lot Size
Frontage 0 0
Setbacks Front O O O
Side L:0 R:0 L:O R:O
Rear 0 ��
Building Height O O 0
Bldg.Square Footage O 0, O O
d.at aria ammi�nwbds&&paved
parking)
N of Puking Spaces O
Fill:
volunu&4,cetioe _..__.A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book Page and/or Document H
B. Does the site contain a brook, body of water or wetlands? NO 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 ^
IF YES, describe size, type and location: C _.
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
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
Vy
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK tcheck all applicable)
New House ❑ Addition ❑ Replacement Windows Atteration(s) ❑ Rooting Ja
Or Doors l7
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Deeks [p Siding[3] Other[Cq
Brief Descrin of Proposed ^ ( ( ( (/
Work: P64MO VP �l 91e / A�kw�tO �P t �I C�Q�(� NSL' /-'/— sl, ,t u�� Ae .
Alteration of wasting bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement YesNo
Plans Attached Roll -Sheet
ea.If New house and or addition to existing housing, complete the followlna:
a. Use of building : One Family_�< Two Family Other
b. Number of rooms in family unit; Number of Bathrooms
c. Is there a garage attached?
d. Proposetl Square footage of new consWctio . Dimensions
e. Number of stories?
I. Method of heating? R s or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck ergy Compliance form attached?
h. Type of construction
I. Is construction within 100 ft.of well ? Yes No. Is construction within 1 floodplain_Yes No
j. Depth of basement or cellar or below finished grade
k. Will building conform 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 on my behalf,in all matters relative to work authorized by this building pernit application.
Signature of Owner Date
as Owner/Authorized
Ag#nt heffigedeciaat the statements and nformation on the foregoing application are true d accurate,to the best of my knowledge
and belief. rVh
Signed under the pains and penalties of perjury.
Pnnt Nam
o s 28 9
/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suoe'rvb/o^r: Not Altolicable ❑
Name of Liosnae Holder: Sy ^l l y ��.10 / C:IlM1 �— / 30,z z
License Number
Aad F�4atim ate
y/ 3 .983 soz
re Telephone
9.Registered Home Improvement Contractor: ® Not Applicable ❑
_h I1 � � r-0- Ff�w e I �oJe� a �� /S Liz le
Company Name ` Registration Number
Aad t Expiretipn Date
!7/O/3Telephone /J 6�J�c!
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MAL c.152,§25C(8))
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
e
E
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Straat • Municipal auiltl q
Northampton, Mx 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 perforating 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,modernization, conversion,
improvement, removal,demolition, or construction of an addition to any pre-existing owneroccupied 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
Krhhas contra d with a corporation or LLC,that entity must be registered
Type of Work: ' `lz Est.Cost/:: /b 3 / ,[_ y ,�
Address of Work: S r�S �� /P� (oil P K
Date 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 pemummi n a agent of the owner:
05�2Q � 1� 8lr f61v �`2ou2 � j /S�(z � �
Date I Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
�LT2I��
MassaChue9tt8C4�L
D212 Min S OF HUILDIci IN3 uiloUn NS
212 Min Bthw oMwicipal Building
Northampton, NA 01060 Y��J
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:
Prosbe C'V' 5-�-
(Please print house nurVber and street name)
Is to be disposed of at: n('�
eq .5e I /q
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
f86 �K Sf �of foE (�
(Company Name and Address)
Sig Ore 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.
The Commonwealth of Massachusetts
IV
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-1017
www.mass-gov/dia
\Corkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leath]
Name (Business/OrgmaaatioNlndividu): L'SZ
Address: 3 �7 S S'
City/State/Zip: Coj�it es, Phone#: Y 13 3 380
Are y man employer?Chack fllo,.pp epilate me: Type of project(required):
1. em a employer with 2employces(full and/or part-time).' 7. []New construction
28 am a sole pmpr ewror petneship etd have m employees wmking forme in 8. ❑Remodeling
any capacity.[No workers'comp.insurance rryaroull
3.01 an a homeowner doing all work myself[No windom'noW.insurance"mood.]s 9. ❑Demolition
4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
emote that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprieora with no employees.
12.[]Plumbing repairs or additions
5.[:11 am a general contactor and l have hired the subrontracton listed on the attached shat. 13 oof repairs
These subcontractors have employees and have workers'comp.insurance.t
,s[]we as a corporation and its often have extracted their right of exemption per MGL a 1 .❑Other
152,§I(4),and we have no employees.[No workms'comp,insurance required]
'Any applicant that checks box#1 mon also fill out the section below showing their workers'compensation policy information.
I Homeowncn who submit this affidavit indicating they are doing all work and then hire outside contractors at submit a new affidavit indicating such.
iContraetors that check this box most aniched an additional sheet showing the moms,of the sub-eontracmrs and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide thine workers'eomp.policy namber.
1 am an employer that is providing workers'compensadon insarunte for my employees Below is the policy andjoh site
information.
x
Insurance Company Name: QI''�EC/cll'Q f� v1 �K r�i-N zC �}
Policy#or Self-ins.Lic.#/:, NAP AP f, /-a `3O/7 og2S Expiration Date: / Z b � - (�/�
Job Site Address: 3 LI-T- Pros pe Sit City/Stak/zip: g 1 L Y f
Attach a copy of the workers'complamund policy declaration page(showing the policy number and expiral o 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 imprisorunent,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. l
I do hereby card polos and information provided above rs bus,emit
Si awre: �j Date: d SZ-2 8
Phone#: d O
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.CityiTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I
J10Bme
rob AN heTe nc
improvement mnvraaors and sueconttmengaged gaged in
home improvemeof central onlna avecifiolly exempt from
rtgl]wtion by Provisions of Chapter 14M of the general laws,
��rupO l�i mug be neghrtered with the COmmonweMh of M wN Gx
Inquiries about regatratlon and ml should be made to the
AWnnex Names/mpewuwmen[ Director. Home Improvement Contras Regional One
Ashbumn Place,Room 130L Boron.MA 03108(6177)727-8598
375 Chicopee 5t.
Chaopee,MA 01013
Phones:(413)883-380]
(413)331435) UfA
Idol LT m63Sg4]
Fax:(413)3314358 oD oBD Pay more,but you cm'1 buy MA b°rt�'
wwwoldlienceHomelnc.con, J�-F -7-F�
SUBM`TT'DTO' r Phone:91�'(�l/' `[a3 Cell:
Email: jfildj/1�7 � �/.0m
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A Rod CERTIFICATE OF LIABILITY INSURANCE
D3Jnrz01e
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 M an ADDITIONAL INSURED,the policy(in)must be endorsed. H 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
eenifieate holder In lieu of such endorsame s).
PRO)KER NMIe DSV a Jeny
Nsih&Neill Insurance Agency Inc
882 RWemale Street —41}7323137 tl3.731.6629
West Springfield,MA 01089 Pxoxe dj®nelllins.wrn
WURE aAFFORxxa CmNsIME
x . Stab Auto Insurance Companies STA
INSURED Alliance Horne Improvement,Inc MBMpLa SAFETY INSURANCE COMPANY 39164
Sengly Suprunchuk
375 Chicopee Street 1 • Acedle Insurance Company A0236
Chicopee,MA 01013 xaw o:
xeuRMe:
wourear
COVERAGES CERTIFICATE NUMBER: 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. NOTWITH6rANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTMCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONSAND COMMONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
xN TlTapppRNW7 "M w tsars
A asNSllaLurury PBP2669283 03/12/2019 03/12/2020 EACH OCCURRENCE a 1,000,1100
COWNGRLLN:NEMLLLVNUryPREMISESIF.ecumscal a 300,000
UNIeLWIE GzOCCUI MEDEXP a 5,000
PDDIOnV.aADV INARry a 1,000,000
aEra:RP�vDaaEaAre t 2,000,000
GxM1ADOaIWTEUMrRPAJE9 PER: PROUlCiS-C9IPAPAOB a 2,000,000
Po c oc a
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AND EMntm M•LIVUHLITY
ANY PROPRIETCRRARTNERUINa Y� E.L.FACNACCIDENT { 110W.000
CFFICERMEMBER E%CWDED'1 MIA
(MRMFbryIn NN) E.L.DRERBE-FABIPIAYFE { 11000,000
Hfv 91=0Ncer 1,000,000
DE9LLflIPnONOF OPEPATI EL geEMa-FCUCY WR 1
pEMIIIOXMpall/,TMXB/LO41MNSIVpWl1 M4FR1MgpIx.NMNnYRaYNMM.a,,,sa RPFx Y,yIYM)
CERTIFICATE IS FOR PROOF OF.INSURANCE PURPOSES ONLY
CERTIFICATE HOLDER CANCELLATION
Alliance Halle ImpMValMnl,Inc. SHOULD AMY OF TME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Sergly SuprunGluk THE EXPIMTON ATE THERN
EOF, NOMCE WILL BE DELERED IN
375 Chicopee Street ACCORDANCE WIT EPOLMY PROVISIONS.
Chicopee,MA01013
wTraRoxolTePwM t
1
m 1888-2010 ACORD CO RATIO ghb reserved.
ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Masbachusetts 02118
Home ImprovemeZt_Qpntractor Registration
f
{ Type: Corpora154218lion
ALLIANCE HOME IMPROVEMENT, INC - -
Registration 154218
375 CHICOPEE ST - Expiration: 02/19/2021
CHICOPEE,MA 01013 -
Update Address and Return Card.
seat O A 17
HOME IMPROVEMENT CONTRACTOR
TYPE,,, oRegistrationfor Individual uu only
Caaelm beifore theexpirat date. Ireturn
to:
uaw_` \ Figbagal Office of Consumer Affairs and Business
Regulation
J 07/1&R021 1000 Washington Strsst-Suite T1
ALL MCE HO [1T,INC Boston,MA 021
SERGIVSUPRUNCHOR'- ]2C.LA.P
375 CHICOPEE ST (�
CHICOPEE,MA 01013 undersecretary N t valicKwithout signature
Con rnonweahh of Massachusetts
IFDivision of Professional Licensure
Board of Building Regulations and Standards
ConstryttMn l$oPernaor
cs-10u27 Fiplrm: 11/29/2019
3SERMY75CHI SUPRUNCfRRI
CHICOPEE
MA 01
ONCOPEE MA 911/011,7(e�
Commissioner �/--_