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18-035 (2) 66 EMILY LN BP-2020-0124 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18-035 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY'FUND (MGL 042A) Category:ADDITION BUILDING PERMIT Permit# BP-2020-0124 Project# JS-2020-000201 Est.Cost: $18772.00 Fee: $124.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WRIGHT BUILDERS 060378 Lot Size(sg.ft.): 42383.88 Owner: VON ROSENBACH SHELBY zonina: Applicant. WRIGHT BUILDERS AT. 66 EMILY LN Applicant Address: Phone: Insurance: 48 Bates St (413) 586-8287 (116) Workers Compensation NORTHAMPTON MAO 1060 ISSUED ON.713112019 0:00.00 TO PERFORM THE FOLLOWING WORK.-NEW SCREENED PORCH 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: FeeTvpe: Date Paid: Amount: Building 7/31/2019 0:00:00 $124.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner t R Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit �. 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 ( J _ L M ;� w' Map Lot 03,5 Unit iN b art.', A-10 (tb NI_+ �� Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ske" D Name(Printj Current Mailing Address: 1 19A Telephone SignaturAl 2.2 Au ent: VV h'�r-f R40 `� Name(Print) Current Mailing Address: yts- 8�-g�-g'� Signature UTelephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building n/ d O (a) Building Permit Fee 0 a • 2. Electrical $ (b)Estimated Total Cost of L � Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) / 5. Fire Protection / 6. Total=(1 +2+3+4+5) `,— ,. Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: /3 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Au- t4t7W Wo pie- f° B� b�N� Wj'j)-yN Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Xfilln This column to Building Depar Lot Size Frontage _.. ... Setbacks Front --� Side L: R: Rear Building Height Bldg. Square Footage % f" Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Sp s Fill: ume&Location) ol A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW O YES O IF YES: enter Book Pagel and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 ® , Date Issued: C. Do any signs exist on the property? YES O NO )�;r 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 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 ® 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 0 Accessory Bldg. ❑ Demolition ❑ New Signs (O] Decks Siding [O] Other[p] Brief Description of Proposed NE-0i �` - 1 � �0 0� exi � JJ SL/�(�/�OU(`��� Work: '`�e V" G Y Alteration of existing bedroom Yes—.X- No Adding new bedroom Yes ` No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. 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: Iq lec Number of Bathrooms c. Is there a garage attached? � d. Proposed Square footage of new construction. IK x Dimensions IK g e. Number of stories? I f. Method of heating? N (� Fireplaces or Woodstoves Number of each g. Energy Conservation Compliiance. Masscheck Energy Compliance form attached? mp h. Type of construction t p i. Is construction within 100 ft. of wetlands? Yeses No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade N& k. Will building conform to the Building and Zoning regulations? I)IC 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 DPERMIT as Owner of the subject property 1 n) ^D hereby authorize "" r to act on my behalf, in all matters r ativeto ork authorize¢-o this building permit application. ZZ Signatur .-fowrhkr Date W Pi,&-i-K A-v( 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 an�dTielief. Signed under the pains and penalties of perjury. L.uO pP< S.A�tJD Print Name L. - 3a I Signature of Own r/ gent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: t V 1 1�'v� `1 J � 'vv� 0 License Nu mer _ �S' �Ams sr•� �b �>�PT'o N, M� q �"�2� Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Wb � ►c� s f 61S�b Company Name Registration �Number ( 'g B/4-Tl� ST. , N o VDtA-M io o MA,- Addres/s �p Expiration Date (�- Telephone6�gpo 7 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 building permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS a 212 Main Street •Municipal Building yvb Ca Northampton, 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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: LA-057, jYa A-T-ft-AVK-P rbPj , MA— (Please print house number and street name) Is to be disposed of at: v�� P-< q�jjG+.1'PJ6-- (Please p int name and Ibcation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Wrmit 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 Department of Industrial Accidents a I Congress Street,Suite 100 Boston,MA 02114-2017 s` www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business Organization/Individual): yi p,G"f 4_V)t.,bW Address: �tc As7' - City/State/Zip: NO ,p�N 1/MV Phone Are you an employer?Check the appropriate box: 611) 6 Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition In I am a homeowner doing all work myself[No workers'comp.insurance required.]t • 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs Or additions 5.I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.] 6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'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: f4. /v l • N�� _ _ p� Policy#or Self-ins.Lic.#: M CP. 310 a�-O 0 D 3 �I o Expiration Date: 3/1 Job Site Address: (pb L>M i — -1 L tJC City/State/Zip: NO A-T-rt-AA rn /4 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).b(O,6 0 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Signature: Wk; Date: D It 41 Phone#: 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ,aco" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) `� 03/11/2019 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 is an ADDITIONAL INSURED,the policy(ies)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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jenna Duval,CISR Elite NAME: Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481 A/C No Ext): AIC,No): 8 North King Street E-MAIL ADDRESS: duval@ webberandg rinnell.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Arbella Protection 41360 INSURED INSURER B: MA Employers/A.I.M. Wright Builders,Inc. INSURER C: INSURER D: 48 Bates Street INSURER E Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER: Master 2020 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. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YMLIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 17— CLAIMS-MADE �OCCUR PREMISES Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A 8500068268 03/01/2019 03/01/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO- LOC PRODUCTS-COMP/OPAGG $POLICY F-1JECT 2,000,000 OTHER: Employee Benefits $ 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED 1020070845 03/01/2019 03/01/2020 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X HIRED NON-OWNED PROPERTY AMAGE D AUTOS ONLY X AUTOS ONLY Per accident $ PIP-Basic $ 8,000 X UMBRELLA UAB X1 OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS MADE 4600068266 03/01/2019 03/01/2020 AGGREGATE $ 5,000,000 DED I X1 RETENTION$ 10,000 $ WORKERS COMPENSATIONY/N PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBEREXCLUDED? NIA MCC20020005342018A 03/01/2019 03/01/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Informational Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reseryed. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD '� � Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, M usetts 02118 Home Improv c for Registration Type: capora ion Registration: 101536 WRIGHT BUILDERS,INC_ !z 48 BATES STREET 1�1 Expiration:. ation: 0625/2020 NORTHAMPTON,MA 01060 F _ lL< Qi Update Address and Return Card., SCA 1 4 2CM-05/17 Office of Consumer Affairs d Business Regulation HOME IMPRO�CONTRACTOR Registration valid for individual use only I ration before the expiration If found return to: Exniradon Office of CorummerAffairs and Business Regulation 06/25/2020 1000 Washington 16eet-Suite 710 WRIGHT BUIBoston,MA 09.. $ 51 JONATHAN A.41i r 48 BATES STREET` NORTHAMPTON,MA Y1060 Undersec�reLmy o valid without signature J i Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstrVctb111�0F>5�rvisor CS-060378 :? �pires: 09/2512020 11"Wi LINDA M GAUDREAU O 157 MAIN ST tM EASTHAMPTONI-iIAA 0102?k- �r Commissioner C,""