35-150 (2) 762 RYAN RD BP-2019-1474
GIS#: COMMONWEALTH OF MASSACHUSETTS
MamBlock:35- 150 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Categorv:ROOFING/SIDING BUILDING PERMIT
Permit BP-2019-1474
Proiect 4 JS-2019-002389
Est.Cost.$12220.00
Fee:$80.00 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contractor: License:
Use Group: ACCENT BUILDING & REMODELING 060967
Lot Size(so.R.): 27878.40 Owner. RHOADES LINDA S
Zoning, Applicant: ACCENT BUILDING & REMODELING
AT. 762 RYAN RD
Applicant Address: Phone: Insurance.,
(413) 529-0527 WC
EASTHAMPTONMA ISSUED ON.6125/20790:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF ON HOUSE AND
REMOVE 2 SIDES OF SIDING AND REPLACE
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:
FeeType: Date Paid: Amount:
Building 62520190:00:00 $80.00
212 Main Street, Phone(413)587-1240,Fas:(413)587-1272
Louis Hasbrouck—Building Commissioner
62,60F . c1 id iAJ 6-
or::CEIVE
Debarment use only
City of Nort amp p LG liscr,
Permit
Building De rtmBnt Driveway Permit
f/ 212 Main treo ��N 2 4 2019 S UcAvailabilityRoom 00 ! r/W II Availability
Northampton, A 0060 ySets f Structural Plans
1 MIN
ION
phone 413567-1240 Pax Sl3u$$�e'( „Aq,,. USite tans
-- Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 .SITE INFORMATION
1.1 Prooerty Address: This section to be compbNtl by omce
7(0A 2d- Mme— 31<— Lot /5-o Unit
f�eA2ACt Zone Overlay District
Elm lI.District CO District
—
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
a a x1a*0dder 7G� aA��tl�.�. K Uto4.Z
Name nt) � )�/� Telephone
',o i(ru,,IJ n
2.2Auth or A s �j g� Q�O7..
1341 1-/tw t LLQ f/4 "c( A:1// Ad Gyu7�t/sf.TDw ./hN.
(Pang Current Melling Address:
-O?
jb
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by permit applicant
1. Building /t rlo2:.., (a)Building Permit Fee
2. Electrical L P (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Penni Fee ���
4. Mechanical(WAC)
5. Fire Protection
a. Total=(1 +2+3+4+6) Check Number
This Section For ONldel Use Orgy
Dais
F
g Permil Num Ilssued:
ure: G-29- ao)9
Building Commissioner/Inspector of Buildings Date
l_.
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING Ali Information Must Be Completed.Penntt Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Thi:column to be filled in by
Building Dcpmtmmr
Lot Size
Frontage
Setbacks Front
Side L R L: R---
Rear
:Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(W area minus Ndg a paved
#of Parking S s
Fill:
a
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW e7 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 Documentit
B. Does the site contain a brook, body of water or wetlands? NO 0— DONT KNOW O YES O
IF YES, has a penrdt 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 V
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 er
IF YES, describe size, type and location:
E. Will the construction activity disturb(deanng,grading,excavation,or filling)over 1 acre or is K part of a mmmon plan
that will disturb over 1 acre? VES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable\
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors El
Accessory Bidg. ❑ Demolition ❑ New Signs [I7] Decks ]4 Siding Other(CA
Brief De gaon of P sed STT;P d—A+EAesf <n�A-� �J '0u� of S ej OF
work dry a oFF o F
J
Alteration of existing bedroom-Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea. If New house and or addition to existin housin complete the followin :
a. Use of building. One Family Tvro Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is Mere a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. 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 consWction 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 ACONTRACTOR APPLIES
APPLIES FOR BUILDING PERMIT
I, Lll'[!.r a. A,4, �� ,as Omer of the subject
property /�
hereMa , rl 0/(r utoalf,in all melte Ialive to authorized by this ing permit application.
Sigralure of Omer Date
I. , � t r
.7 l� .' LCC as Owner/Authorized
OTrfr
Agent hereby decla that the statements anyintormumon on the forego"application are and accurete,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Sk4l
p G ,2017
signature Age Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Subew1w, Not Applicabllec ❑
/,� /
N,me of Cleanse Holdx: ���rb/'�/ /. �IOC(e
Licence Number
ee/Z/u��/{//jj�AY// Ref l /ice S�/>T��� y ouzo 9a`i-�oao
�e� � bastion Dale
Signature Tekphorie
.Re Is ere
Hom Im r v Not Applicable ❑
&4,Vag,4*ho i w c- 117 yW
m n NaV Registration Number
gif-I A":5 d. W. 0102 /,6 .26 -020,:20
Address lfd- , n`'o9 Expiration Date
Telephone
SECTION 16 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L G 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 buildi pennh.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
i f
Massachusettsr
l MPRAROSVWc OF BOZLDZDO ZnS =XMS
212 Nein ateaet • Municipal 11 i1"W
Nor GT tm, MA 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 must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, aheration,renovation, repair, modernization, conversion,
improvement, ramomi, demolition, or construction of an addition to any preexisting owneroccupied building containing
at least one but not more than tourdweiling units .or to structures which are adjacent to such residence or budding"be
done by registered contractors.
Note.Ifthe homeowner has contracted with a corporation or LLC,that entity must be registered
p
Type of Work, AyICb/L r;n �cfr�F"i llr �/ Est.Cost.
W
Address of work: 76 Ivan 1tOl. Nox-e tC-e–
Date of Permit Application: L 016–t 20/9
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 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 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:
Date Contractor Name n p AV NIC Registration No.
OR:
�, Xtdr/^tLcO.'
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
it
i
i
City of Northampton
s
�
MassachusettsDEF
�.
212a in S O 9aZ xCx ZPS ux1diONS 2
212 IYin 8taaat •Nnnicipal Builtlinq
Northampton, !P 03060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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:
761 &Lot 0 . 80."ke -c—
(Please print hou a number and street name)
Is to be disposed of at:
YC�Ir`S' K�°Cy /A1
Please priplyname anoocation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature,oPermit 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
VDeportment of IndmilrialAccidents
I Congress Street,Suite 100
Boston,M4 01114-2017
www.nauss.gov/dia
Rbrkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbem
TO BE FILED WITH THE PERNUTIING AUTHORITY.
Applicant Information fin Print
Name(Business/Orgn"sioMndividuel) eTln
Address: Q/ //4Ud4-1 x1l A"I'
/qs
J r
City/Statc/Zip: 111rJ9id Tot+ Iii r 41017 Phone
Arc employer?Card He appropriate bm: Type of project(required):
I. lamaanployawnh employees(fWl enNorpmt-ame)• 7. ❑New construction
2FBK=awlepmprie mpmmersAipmdhavemanployasworking forme in 8. ❑Remodeling
any capacity.Mo workerscomp.insurance requved.l
3.❑lam ehomeowrierdaing dl xark myself lNo wmkers'cmnp.irsmmae again i.]1 9. ❑Demolition
4.❑1mnahommvm wdwillbehiringconam Wconductmlw onmypmpeny. I will
10 Building addition
ensure Net all contmetms either havewmkers'compw.vatien me sale 11.❑Electrical repairs or additions
proprietors with m employees. 12.[]Plumbing repairs or additions
5.Q 1 con a mepmm conhectormd I have hired am sub-connectors limed m the mWched sheet.
'Klee sul.cono-acmrs neve employees mW have warkers'cmnp.loam ? 13QRoofrepe'vs
6.❑Weereamryomtianm iNoffi rshnveexacisMNeirdgMofexemptimMMGfcr4�14•14"�OHler/ TIItCCO tT-
152.§ we
l(4).endhavenoerepto,eas pJo wohars'comp.insureme requirW.l Ietfw-c aV�U0 f
•Arty appliwm Netchwks box pl must also fill out the section bel.Atoing Nen wmkem•mmpensmim policy inf tion.
t Hommwnem who submit Nis affidavit indicating amy aR doing all work me Nen hire sub
-coraselmrs mum submit a or
affidavit irnicming have rCmammrsthat check NisboxmustanachNeeadditionalsheetshowing Necome ofas sub-icy ruiner state whether or not those entities have
employees. Ifihe subconvacWrs have employee,they muss provide their workers'comp Policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company NameT✓(A V 1 I t�5
Policy#or Self-ins.Lia#: �-Pi U 8-I Yneog/ _5,1 8 Expiration Date: OI /�
Job Site Address: 7� ,� 4 Od (� City/StateJZip: /IC !y 010��
Attach a copy of the workers' mpena don pohcy dec6ntioo 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-yeur 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 ofthe DIA for insurance
coverage verification.
I do hereb rdfy ander e s d aloes ofperjury that the information provil"abore,k true and coned
Si alma: LLenl/_ /n1, /, Date:
Phone#7 n-62(a-O'7n(l
Oficial use only. Do not write in this area,to be completed by city or town official
Cit,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#:
VDAC
TRAVELERS/l'
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 0000 01 ( A)
POLICY NUMBER: (7PJUB-1 K06041 -5-18)
RENEWAL OF (7PJUB-1K06041 -5-17)
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
1 NCCI CO CODE: 13579
INSURED: PRODUCER:
ACCENT BUILDING & REMODELING A%IA INS SVCS INC
LLC 933 E COLUMBUS AVE STE 1
81 LAUREL HILL ROAD SPRINGFIELD MA 01105-2512
WESTHAMPTON MA 01027
Insured Is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown In the schedule(s) attached.
2. The policy period is from 12-01-18 to 12-01-19 12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
Rem 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 500000 Each Accident
Bodily Injury by Disease: 8 500000 Policy Limit
Bodily Injury by Disease: 8 500000 Each Employee
_ C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 OGB
D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classiticatlons, Rates and Rating
Pians. All required information Is subject to verification and change by audit to be made ANNUALLY.
ST ASSIGN: MA
ACCEBUI-01 CINOROWSK
CERTIFICATE OF LIABILITY INSURANCE X19
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 INSURERS),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cem/kate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or 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 cerUOeate does not confer rights to the certifbate holder In lieu of such endorsement(s).
PRpmMER
ARIA Insurance Smices PHoxE . 419 788-5000 =.,,(413)88&0190
933 East Columbus Ave
Springfield,MA 01105 .Into®and rou •net
AFFORpNa OOVER.teE INIL•
INSURER A:National Granae Mutual Ins.Co 14788
INSURED INSURER B:Main S&W Araerica AssufanDB Company 99999
Accord Building a Remodeling LLC INSURERC:
91 Laurel Hill Road HISURER 0:
Westhampton,MA 01027
IXSURERE:
PdSURERF:
VERAOES CERTIFICATE NUMBER: REVISION NUMBER,
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT HATH RESPECT TOWHICH 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.UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAIMS.
INBII TYPEOF MBWIWDE ADBL WORPgL1Ly NIMBFA ROHCY EFF POIKYESP MYAa
A X DOMYERL11 MMULLNMITT' HOCCUflRFNCE 1,000,000
CIAIMO#1PDE O OCCUR MFT2437C 21,14112018020
7D79 9/179 MME TO Rr.Rn §ggrggg
MEDEW 10.000
P �M/UIV 1 1,000,000
MLMSGREGATEpLRMpr APPLIES PER tiFHE ADgVEGATE 9AD0,000
POLICY❑,IECT LOC PRODUCTS-CO P/OPAGG 4WD,000
OTHER'.
B A11101Ma�DAe�, COMBINED SMI-E LMR 1rgDRBOO
Axrnuro M7P0778D 9H02018 WIGM19 BODav Mr Rr IW
oNMED SCHEDULED
Hxllpf�o�s ONLY
X ryAryUUpTTJO.pSµµxx�� BpOpDpEr URr Pr
X AUTOB DNLY X AUTOSONLB
U EW WB OCCUR EACH OCCURRENCE
EXCIUMLMB Ld cljuwa DE AGGREGATE
DED RETENipNf
N�xO FEA6 vE1a'uAM1�xl1Y PEROTH-
ANFIEP WIInTBDER WNE�WOttECUTNE NIA ELEM*IACCIDENT
�NI119� EL DISEASE-FA EMPLOYEE
Iyea Ee TION OF ,
OESC llatioN OF OPERATIONS lebx E L aMEAOE-POLICY LMR
A IoeIaINHom9uiMar Mi 9/192079 91W079 LIIM 100,000
pE8CWI110110F OPFAAMIN6/LOCATIe16/YFIBCIfa(ACe1DYe1.AOlEVM1YW&IIYY,wry EearxaMXmaeFpu NIgWOO)
CERTIFICATE ER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE NOTI
Hampton East Condo Board ACCORDANCE WITH THE POLICY PROVISIO SCE WILL BE DELIVERED IN
C/O Classic Management
15 Benton On.
East Longmeadow,MA 01028 AMORUED RMESE.A.E
ACORD 28(201693) ®7988.2078 ACORD CORPORATION. NI rights reamed.
The ACORD name and logo are registered marks of ACORD