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31B-120 (4) 9 EDWARDS SQ BP-2020-0151 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:3 1 B- 120 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categry: Bath reno BUILDING PERMIT Permit# BP-2020-0151 Proiect# JS-2020-000247 Est.Cost: $20700.00 Fee:$134.55 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ROBERT WALKER 034783 Lot Size(sa. ft.): 3920.40 Owner. DEFAZIO JOSEPH J Zoning:URC(100)/ Applicant. ROBERT ROBERT WALKER AT. 9 EDWARDS SQ Applicant Address: Phone: Insurance: 36 Service Center (413)584-1224 Liability NORTHAMPTON MAO 1060 ISSUED ON:8/6/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENO 2ND FLOOR BATH 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 8/6/2019 0:00:00 $134.55 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0151 APPLICANT/CONTACT PERSON ROBERT WALKER ADDRESS/PHONE 36 Service Center NORTHAMPTON (413)584-1224 PROPERTY LOCATION 9 EDWARDS SQ MAP 3 1 B PARCEL 120 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST E OSED IRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out Fee Paid Typeof Construction: RENO 2ND FLOOR BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 034783 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: 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 Elm Street Commission Permit DPW Storm Water Management Demolition Delay ,,, G-2oi9 Sign ure of Building Official Date Note: Issuance of a 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. , *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. Department use only City of Northam on _�� s er Building Depart ent Cub Drive ay Permit 212 Main Str et oSewer/ ' ptic vailability Room 10 J ter/ ell ailability Northampton, 0fd80n,, Two S is of tructural Plans phone 413-587-1240 Fax 4 7N4 N,NSp , t/ ite PI ns MAO, R&Sspe fy APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMO-LIS14 DEMO-LA ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office + Map Lot-- . /40-Unit Vl AAA Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: J0St►� Jyc' (7t �ro 1-1 EaW4' s Name(P' Current Mailing Address: Telephone /), / r �� Signature 7 2.2 Authorized Agent: Na— m�rint) Current Mailing Address: If CA Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 7 (a) Building Permit Fee 7(Q C)- 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing ��.� Building Permit Fee 4. Mechanical (HVAC) utJ 3�1 r 5. Fire Protection 6. Total = (1 +2+ 3+4+5) C Check Number / This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled' y Building Departure Lot Size Frontage �— --� Setbacks Front Side L:= R:= L•0 0 Rear Building Height �n Bldg. Square Footage Open Space Footage % / (Lot area minus bldg&paved parking) #of Parking S ces F' . volume&Location A. Has aSpe ial 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 O DONT KNOW O YES o IF YES: enter Book — I PageF and/or Document#�-j 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: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO e("' IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,exc ation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 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 17-1 Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [M Siding[O] Other[O] Brief Description of Proposed Work: TZ WQDQ Alteration of existing bedroom Yes V--'No Adding new bedroom Yes ✓No Attached Narrative Plans Attached Roll t6heet Renovating unfinished basement Yes No 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? OA d. Proposed Square footage of new construction. Dim e. Number of stories? f. Method of heating? -o< F'`places 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 ands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement Ilar floor below finished grade k. Will build' 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, J(25 e 2 h he r'� as Owner of the subject property hereby authorize to act o be in all matters relative to work authorized by this building permit application. Si er Date I, ` � �`� �Y�'�-� � 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. Print Name Signature af Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:- �(Ij(�(�—i� 'f� ��f C (; (D� 4 License Number Address Expiration Date-I Signature Telephone n n Not Applicable ❑ l T Lu K 1-1 �, Company Na (n Registration Number S-( i-2) z Address Expiration Date Telephone 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 buildigg permit. Signed Affidavit Attached Yes....... No...... ❑ 1. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of 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 farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. 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 buildiniz 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. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: Cl Fe 0"r"0S f,Ci vetr,—p , N Vx �►��'� 'T The debris will be transported by: (cDhV4-f_ 4 YWCA/ The debris will be received by: Building permit number: Name of Permit Applicant 1�J�,�c i✓ titi-.�--- I') Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: �O �� C City/State/Zip: /W Phone#: 4 L_s- S - l 2 Z Are you an employer? Check the appropriate ox: Type of project(required): 1.E24am a employer with 10 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. modeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#l 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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 andpenalties ofperjury that the information provided above is true and correct. Signature: Dat e: 94 ( I Phone#: — � - w,z �- Official use only. Do not write in this area,to be completed by city or town offacial. 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 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/21/2019 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 Barbara Grynkiewicz NAME: Webber&Grinnell PHON o xt (413)586-0111 AAC NII: (413)586-6481 8 North King Street E-MAIL bgrynkiewicz@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: West American/Liberty 44393 INSURED INSURER B: AIM 33758 Robert Walker INSURER C: Attn:Kim Clairemont INSURER D: 36 Service Center Road INSURER E Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 3/1/20 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 ADDLI,5UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1'000'000 DAMAGE100,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence S MED EXP(Any one person) S 15.000 A BKW58372253 03/01/2019 03/01/2020 PERSONAL&ADV INJURY s 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY jE F7LOC PRODUCTS-COMP/OP AGG 5 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident) ANY AUTO BODILY INJURY(Per person) 5 OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per accident S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB HCLAIMS-MADE AGGREGATE S DEC I I RETENTION S �/ S WORKERS COMPENSATION X PER ETH AND EMPLOYERS'LIABILITY YIN 500,000 ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT S B OFFICER!MEMBEREXCLUDE1 7 N/A WMZ80080065482019A 07/01/2019 07/01/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 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 "'For Insurance Info Only— ACCORDANCE WITH THE POLICY PROVISIONS. 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