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17A-076 (9) 8 CLOVERDALE ST BP-2020-0156 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 17A-076 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2020-0156 Proiect# JS-2020-000086 Est.Cost: $6525.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: FREDDY CAMPOVERDE 106011 Lot Size(sq.ft.): 11107.80 Owner: CULVER TRACEY A P&DAVID G Zoning: RI(100)/URA(100)/WSP(100)/ Applicant. FREDDY CAMPOVERDE AT. 8 CLOVERDALE ST Applicant Address: Phone: Insurance: 20 TATTAN FARM RD (508) 873-1884 WC WORCESTERMA01605 ISSUED ON:8/8/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP AND 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 Si(3uature: FeeType: I)ate Paid: Amount: Building 8/8/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton f Pe it: .•�° Building Departme �r`�1 C - Driv way Permit i A , 212 Main Stre V Sewer/S ptic vailability Room 100 W r/W 11 Ava lability Northampton, MA 01 60 - F p A�� o Sets f Stru tural Plans phone 413-587-1240 Fax 41 -58 -1272 Plot/ s APPLICATION TO CONSTRUCT,ALTER, REPAI , RENO EMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION ig�• C90-7S b0' ezo F 1.1 Property Address: This section to be completed by office YCIoa_I� � Map Lot (/ Unit Q Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �'Y CIC�u f I I C I D v�erd 0- Name(Print) Current Mailing Add ,�_ _ Telephone Signature ` I 2.2 Authorized Agent: Name(P nt Current Mailing Address: " 013- 33�_--1 Signature Telephone SE T10 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by permit applicant 1. Building . 6 (a)Building Permit Fee 2. Electrical (b)l (b)Estimated Total Cost of V N I' Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection N 71/ 6. Total= 0 +2+3+4+5) I Check Number ' This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO C J DONT KNOW 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO (2� DONT KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained O , Date Issued: C. Do any signs exist on the property? YES 0 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 er 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 O 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 ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[0] Other[pJ Brief Description of Proposed V-1 (;o j A f N l Work: '`�Z.l 1 'Vy T Alteration of existing bedroom Yes 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: Number of Bathrooms c. Is there 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 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, ` 1 al-e� C Lk l 4 "r as Owner of the subject property 1 hereby authorizetd?n r to act on my behalf,in all matters relative to work a thorized by this building permit a plication. Signature of Owner Date I, / 6) b 6L( Ct as Owner/Authorized Agent hereby decl that the statements and i formation on the foregoing appli ation are true and accurate,to the best of my knowledge and belief. SignedTAand penalties of perj J "-fiW6 Print ame �gu <21 Win Signature of Owner/Ag Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: J /' ,�(� `f J j� Not Applicable ❑ Name of License Holder: �-fcld"1 �1a.�1 t �p© 1 "lJ� ( ��jL— 't)Q Q ' Lic sne a Number Address Expiration Date Sign ture Telephone 9.Realstered Home Improvement Contractor: Not Applicable ❑ ,C,0 6(n o),kC ins -MC-hbn co( la I -7U I 18, Company Name Registration Number 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 builging permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts lt` � i DEPARTMENT OF BUILDING INSPECTIONS X 212 Main Street • Municipal Building Northampton, 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.C.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied 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 has 1contracted with a corporation or LLC, that entity must be registered. Type of Work: Est. Cost: Address of Work: y C I()lf`Cx d(�•:1.(, Date of Permit Application: Q/1 `'"I 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 I42A.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: c4 �Q i i ci 6oAfn ,(iro,,o ms�- onf Date 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 Massachusetts DEPARTMENT OF BUILDING INSPECTIONS a a; 212 Main Street • Municipal Building yJ` cep * Northampton, MA 01060 r�►h `�`� Massachusetts Residential Building Code Section 110.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 farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section 110.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.R5,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 S`S SSC Massachusetts L• ,{ DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building yvi �a C-^a 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: �S �1 xNwd 1�- E& u b"ffi^,�� (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) �l � L49 g'I � ( �� Signature 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. oft*of Consumer Maks i SuMnsss Raqulatlon Registradiun WSW for kidtvidW1 uM ortty HOME IMPROVEMENT CONTRACTOR fefor*&�fr I*jItiondyy Rrendr*Earnhx TYPE:CaMmtion Or6u of Coro~Affs"Old Sus"" IO^ Reoistratlen EEQ1CIIf w 1000 WashWV n Syset-Sufts 110 174718 03111/2021 Boston.MA 02118 GOLDEN GROUP CONSTRUCTION CORP. FREDDYCAMPOVERDE " 20 TATTAN FARM RD. _yyy Not va d v tAout Signature WORCESTER.MA 01605 Undersecretary Massachusetts CWntonwealth of Division of Professional Licensure Ree lations and Standards Board of Building r Specialty COnstruct` w` "�' m j ()6,02j2021empires CSSL-106011 s 10 7 FREDDY CA1?0PA 20TATTAN f*R . y,RCESTEI .yrns��ao _OMMissioner s - r- - .. t+' - , .. ` - ,. x - .r .i, � f 4i. ��.. .,-^+�...+.....,,,`...�...,,,��1�(+17�, yrs:)l (�s1 �.• y ..,� w f w__,,, _ �';�,'w+la • y. r m. u�r.. � ,'��4..�. ter+ "'r,..w..,... «, ., r.l. .,)i�, ->.'',`� �. :. ':�4 kr�� r � iq: _:. 1$4- ��aii1' - .. ... ,,kf... �74'.1'W:Y�} ... s�';_ " * �9t. �SyS .k i.Yf,•.p'+{dA:.,�' .r� ay . tv'!�: r. >?'R .1M�'.Y:M:(r^Yf111Y"'l.'.tS' M*''+u4 :y. .�,�_..,u:if .t'.-,.f:i�AY��j fir+ •ay.w a. ,�.�-:y.. �bp;u. +yw w�!'v f,;�a;�+ ,." .r�}ae,,a�rq F�.�,... ,�e+rrr ,#..r , ..... ,„,......� .. ...,._....._ .�.... .,....r....... F r- ' � ' .' � . - y "' r,, CERTIFICATE OF LIABILITY INSURANCE 77/MMODIYYYY) 11/ 19 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 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 UUNIACT NAME: Crislina Atcild A-Costa Insurance A enc Inc PHONE 508-875-3488IFAX 9 Y HO E Ext): ac,No): 508-875-9388 1 Franklin Commons MAIL ADDRESS: Jonga-costains.com _ INSURER(S)AFFORDING COVERAGE NAIC N Framingham MA 01702 INSURER A: Mesa Underwriters Specialty Insurance INSURED INSURER B: LIBERTY MUTUAL FIRE INS CO GOLDEN GROUP CONSTRUCTION CORP INSURER C: 20 TATiAN FARM RD INSURER 0: INSURER E: WORCESTER MA 01605 INSURER F: 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. 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 - ---� ----T___-- DDL SUBR -POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEC OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A MP0020006000549 9/26/2018 9/26/2019 PERSONAL 8 ADV INJURY $ 1,000,000 GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 7 JECT F]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: DEDUCTIBLE $ 2,500 AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ Y EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIL I UPJPAR i NLWFXLCU I IVF Y/N X STATUTE ER E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? � NIA WC231S385387029 4/19/2019 4/19/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached H more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN CertainTeed SELECT ShingleMaster ACCORDANCE WITH THE POLICY PROVISIONS. P 0 Box 20126 AUTHORIZED REPRESENTATIVE �� Lehigh Valley PA 18002-0126 JE'?&ei lle' f-1'4 er&efCl.✓ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD -_ The Commonwealth of Massachusetts ai Department of Industrial Accidents s K,. 1 Congress Street,Suite 100 ' Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �+ Name(Business/Organizational/Individual):Golden Group Construction Corp Address: 20 Tattan Farm Road City: Worcester State; MA Zip: 01605 Phone#: 508-873-1884 Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am an employer withaemployees(full and/or part time)' ❑7. New construction ❑2. 1 am a sole proprietor or partnership and have no employees working for me in any ❑8. Remodeling capacity.[No workers'comp.insurance required.] ❑9. Demolition ❑3. 1 am a homeowner doing all work myself.[No workers'comp.insurance required]t 1:1 10. Building addition F-1 4. 1 am a homeowner and will be hiring contractors to conduct all work on my property. ❑11. Electrical repairs or additions I will ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. ❑12. Plumbing repairs or additions ❑5. 1 am a general contractor and I have hired the sub-contractors listed on the attached -113. Roof Repairs sheet. 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. 1:1 14. Other c.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. tHomeowners 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 attach 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: Liberty Mutual Fire Insurance Policy#or Self-ins.Lic.#. WC231 pS�3853�87029 \ Expiration Date: 4/19/20 n n Job Site Address:�r�C1\)Q.l�lUQQ `l 0_00f WA A )b� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL.c.1S2,§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 of perjury that the information provided above is true and correct,and that clicking this checkbox and typing my name in the field below will act as my signature. Name: Freddy Campoverder Date: Phone#: 508-873-1884 Email: info goldengrouproofiing.com CC O INSIGHT .O., Homeowner's Authorization to File Permits t, am the owner of the property located at address: C- loyQ-,�-CaQc ���-i-Q�� . 1��c� a �►n-�o�IM,� 010x0 I hereby authorize Insight Solar and their subcontracting company OAn ' Cn�d �x�lio►n Ca.to act as my agent for the limited purpose of applying for and obtaining local building and other permits from the Authority Having Jurisdiction as required for the installation of a PV solar electric system located on my property. This authorization includes the transfer/re- administering, and/or cancellation of any existing permits on file for the purpose of updating/applying with an alternate subcontractor. Homeowner's Signature: ap Printed Name: 1 U Date: 06/08/2019 Insight Solar 180 Pleasant St. Suite 2 413-338-7555 Doc ID:97e6125245c6b09cd3af3a7ced4b1ac7540aaea9