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17C-248 (12) 67 NORTH MAIN ST BP-2020-0308 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-248 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2020-0308 Proiect# JS-2020-000524 Est. Cost: $3935.00 Fee: $40.00 PERMISSION IS HEREB Y GRANTED TO: Const. Class: Contractor: License: Use Group: BARRON & JACOBS 60475 Lot Size(sq. ft.): 23870.88 Owner: SAITO LORAN D&MAKOTO Zoning: URB(100)/ Applicant: BARRON & JACOBS AT. 67 NORTH MAIN ST Applicant Address: Phone: Insurance: 70 OLD SOUTH ST (413) 586-8998 Workers Compensation NORTHAMPTON MAO 1060 ISSUED ON:9/10/2019 0:00:00 TO PERFORM THE FOLLOWING WORKSTRIP & SHINGLE ROOF - ONE PORTION OF HOUSE - 500 SF 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 9/10/2019 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 Status of Permit: Building Department Curb Cut/Driveway Permit I212 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, LTER R DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Vtu 1.1 Property Address: 9 2019 This section to be completed by ffice Map ��Lot Unit DEPT.OF BUIL UI INSPEg�� Overlay District DING.MA 01060 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: l Name(Print) Current Mailing Address: t-u' \fV-0 iVVy1-A- ,7i1 lz� Telephone Signature 2.2 Authorized Anent: `', Name(Print) T— Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building2 CAI-17)(S (a) Building Permit Fee 2. Electrical J` 7 (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee �q6 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2 +3+4+5) �\ Check NumberI C5 117 This Section For Official Use Only Building Permit Number: Date Issued: Signature: U, 1 /d I 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 �l 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 © DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW © YES O 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 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 O NO G 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 -Q 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 Kri Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [O] Other[O] Brief Description of Proposed rr Work: 00u_ r,� JZ/� f�� �L'wl) c 5'9U S�- 1(e.rv1ti' e-JY'E'tjy cz fLG�1�X.'_-±). Alteration of existing bedroom Yes C 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 r I, ��" r' ( y�`�4 .�,��i✓� �iU � as Owner of the subject property p� 1� \ _ '``/,� hereby authorize f �`�►S"l� i� 1�' r�1�AYJ> I P� G11/ ,e�C^uU, to act on my behalf, in all matters relafive to work authorized by this building permit application. Signature of Owa r Date 7belief. \(\(,\�1� ,( ��L v` as Owner/Authorized declare t t the statements an'd information on the foregoing application are true and accurate, to the best of my knowledge Signed under the pains andpenalties of perjury. Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Gble ElName of License Holder: LN,\ y� t' � z bS L V ia 1 License Number Address Expiration Date Ye Signature Telephone 9. Registered Home Improvement Contractor: �� Not Applicable ❑ Company Name Registration Number c� S� � 1zvl 2-,oAddress E�xpiration 15ate NV, Telephone `771 k 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....... 11, No...... ❑ SIGNATURES _ By signing below,you agree to items A, B and C. DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES. A. Alternative Dispute Settlement(Arbitration Clause): The Seller and the Buyer hereby mutually agree, in advance,that in the event of a dispute concerning this Agreement, the parties shall submit such dispute to a professional, state-approved arbitration service(cost, if any,to be paid by the submitter)prior to either party proceeding to legal action in the courts. B. By signing this agreement,you,as the owner of record,are hereby authorizing Barron&Jacobs Associates Inc.to aq asyour authorized agent in all matters pertaining to the building permit application. C. This is a binding Agreement. You may not cancel it except as stated. This Agreement covers and supersedes all conversations, statements and agreements,expressed or implied, between the parties, their agents or representatives. &11�IA�7A 2AI, � You,the Buyer,may cancel this transaction yer Date at any time prior to midnight of the third business day after the date of this transaction. See the attached notice of cancellation form Buyerrte �. Date for an explanation of this right. j Seller retains an equal right to cancel. jjq � Barron&Jacobs Re esentative Da ############################################################################################# Contact Information Office Manager: Sandy Scavotto Office: 413-586-8998,x100 ® Chris Jacobs, President CT HIS#0554397 Cell phone:413-250-6677 Home phone: 413-665-9113 Office phone ext: 103 ❑ Todd Lever, Senior Designer Cell phone: 413-923-7003 Home phone:413-297-6602 Office phone ext: 106 MA Construction Supervisor License 060475 MA Home Improvement Contractor 100809 CT Home Improvement Contractor 518617 Purchase Agreement Page 15 of 15 Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation BARRON&JACOBS ASSOCIATES, INC. Registration: 100809 70 OLD SOUTH STREET Expiration: 06/22/2020 NORTHAMPTON, MA 01060 Update Address and Return Card. CA 1 13 20M-05/17 l7leomiptanu�¢�I�o� .vG�kt2c/Eudetf Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Rtgishydon Expiration Office of Consumer Affairs and Business Regulation 100809 06/22/2020 One Ashburton Place-Suite 1301 BARRON&JACOBS ASSOCIATES,INC. Boston,MA 02108 CECIL R.JACOBS C -- 70 OLD SOUTH STREET �� V NORTHAMPTON,MA 01060 Undersecretary Not valid without signature Commonwealth of Massachusetts ® Division of Professional Licensure Board of Building Regulations and Standards ConstrAtction Supervisor CS-060475 Upires: 11/10/2020 CHRISTOPHER R JAM* 70 OLD SOUTH ST NORTHAMPTOUMA 01060 Commissioner CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) 1/16/2018 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). PRODUCERGON NAME: Atil.na Edgett Webber & Grinnell PHONE (413)586-0111 FAX 413)596 6G61 L'ON A/C No Etl: A/C,No): B North Ring Street E-MAIL aed tt@ Iaebber i nnpll.com ADDRESS: andgr INSURERS AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER M33I1 Street America/MSA 29939 INSURED INSURER B:NGM/MSA Barron & Jacobs Assoc. Inc. INSURERc:A.I.M. Mutual/A.I.M. Attn: Cecil R. Jacobs INSURER D: 70 Old South Street INSURER E Northampton MA 01060-3833 INSURER F COVERAGES CERTIFICATE NUMBER:Exp 03/19 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 NSR ADDL.SUER POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER I.LTR MMlDDNYYY) fMMIDDNYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE 1OCCUR DAMAGE TO RENTED 500,000 PREMISES (Ea occurrence S MPT8049D 3/9/2019 3/9/2020 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER GENERALAGGREGATE $ 3,000,000 X POLICY JECT PRO- F LOC 3,000,000 PRODUCTS-COMP/OPAGG 1$ OTHER I EPLI is 10,000 AUTOMOBILE LIABILITY COMBINEDSIN LIMIT $ Ea accident B ANYAUTO BODILY INJURY(Per person) $ 1,000,000 ALL OWNED SCHEDULED Mi TB049D 3/9/2019 3/9/2020 BODILY INJURY AUTOS X AUTOS (Per accident) III X HIREDAUfOS X N OVMED PROPERTY DAMAGE $ Per accident Medical payments $ 5,0001 UMBRELLA UAB OCCUR EACH OCCURRENCE $ ]3 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED X RETENTION$ 10,000 CUT8049D 3/9/2019 3/9/2020 $ WORKERS COMPENSA PER E OTH- APID EMPLOYERS'LIA X STATUTE E2 ANY PROPRIETOR/PARTNERIEXECLITNE OFFICER/MEMBER EXCLUDED? N/A EL EACH ACCIDENT $ 500,000 C (Mandatory in NH) WMZ80063652017A 3/1/2019 3/1/2020 EL DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES tACORD 101,Additional Remarks Schedule,may be attached if mare space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of Insurance Only THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE W Grinnell, CPCU, CIC �w. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) \ The Commonwealth of Massachusetts = Department of Industrial Accidents 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 Please Print Lesibly Name(Business/Organization/Indi%idual): ?)c ,,rp,-\ Address: _'0 G Q tV, City/State/Zip: bN c)obO hone 5(cAcl Are you an employer?Check the appropriate box: Type of project(required): I.®I am a employer with _employees(full and/or part-time).* 7. 0 New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 F1 Building addition 4.[:]1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole I I.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.a 1 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.j *Any applicant that checks box#I 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. y Insurance Company Name:� m \ _ Policy#or Self-ins. Lic.#: WbMA 00 &''>(,''j 2,Q M A Expiration Date: 3 I % 12-02-P Job Site Address:Lh N ��.�,;� ��' City/State/Zip: _J IN",A- 0� ri4,i 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. 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. /do hereby certify under the pa' and penalties of perjure'thin the in formation provided above is true(Intl correct. Signature: Date: G Phone#: 'i 1�, ;�n!EN-,f 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#: DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit # was issued with the condition that all debris resultine from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: Name Wast acility Address of Waste Facility I11.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a bud&ng or structure, M.G.L.c.40 s. 54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c. 1 I l s. 150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department. If the debris will not be disposed of as indicated, the holder of the permit shall notify the building official, in writing,as to the location where the debris will be disposed. 780 CMR—6`h Edition 4�1 /bz-�'-� Signature of Permit Applicant Date Barron &. Jacobs DESIGN . BUILD . REMODEL Dear Code Official, Enclosed please find an application and supporting documentation for a requested building permit. I have enclosed a self-addressed, stamped envelope for your convenience. Please mail the building permit to our office. Thank you. Sincerely, Chris Jacobs A Tradition of Building Satisfaction, Since 1986! 70 Old South Street,N rthampton, Massachusetts 01060 413.586.8998 barronandjacobs.com