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12C-085 (4) 12 RICK DR BP-2020-0456 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C-085 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: Stair BUILDING PERMIT Permit# BP-2020-0456 Proiect# JS-2020-000773 Est.Cost: $200.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ALISHA PHILLIPS 106378 Lot Size(sq.ft.): 14984.64 Owner: SL1WA EDWARD W Zoning: RI(100)/URA(100)/WSP(100)/ Applicant. ALISHA PHILLIPS AT. 12 RICK DR Applicant Address: Phone: 40 PINE VALLEY RD (413) 586-5986 W(' FLORENCEMA01062 ISSUED ON:10/10/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR FRONT STEPS 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 10/10/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0456 APPLICANT/CONTACT PERSON ALISHA PHILLIPS ADDRESS/PHONE 40 PINE VALLEY RD FLORENCE (413)586-5986 PROPERTY LOCATION 12 RICK DR MAP 12C PARCEL 085 001 ZONE RI(100)/URA(100)/WSP(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out Fee Paid Typeof Construction: REPAIR FRONT STEPS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106378 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 LAa�u- � T)ozre )0 A Sigr#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 Northampton Status of Permit: Building Department Curb Cut/Driveway Permit a 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 0106E IEFS-eftof St uctural Plans phone 413-587-1240 Fa 413 - Plan Other S ecify_ APPLICATION TO CONSTRUCT,ALTER, R PAI , RE ATERRVAWIOLI I H A I INE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION DEPT.OF BUILDING INSPECTIONS 1.1 Property Address: on to be completed by office 12, Map_ ZC. Loty Unit r1ofm<(I /"04 0/1)6 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Q ,� / �Z pt c'k Q!�{tee - Ickler1C�/� G/06 Name(Pri _ Current Mailing Address: Telephone r Signature 2.2 Authorized Agent: Iff54-1T s Llo p„� ��ir� �,, , MA a ora Name(Print) Current Mailing Address: z:5�- �/-5— y13- Sfs6 - SS 6� Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 42-00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date 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 0r0 Open Space Footage % (Lot area minus bldg&paved parking) A of Parking Spaces Fill: (N olume&Location) A. Has Spe al Permit/Variance/Finding ever been issued for/on the site? NO A DONT KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T 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'1�' DON'T KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,exc on,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 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 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O] Other Brief Description of Propose Work: 2 t/ f-1 Sir /rn S r nml r/-.tC 10 Alteration of existin 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 ORCONTRACTOR /CONTRACTOR APPLIES FOR BUILDING PERMIT I, f J I 1 V✓-12% as Owner of the subject property L hereby authorize 141tS 4 44 l r � r, r(fs to act on behalf,' all matters relative to rk authorized by this building permit application. SignatYre of Owner Date I, A'r S 4 ,r 1 /�/ p J? //4&S as Owner/Authorized Agent hereby declare that the Itatements 0d inform tion on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed/under the pains and penalties of perjury. ,U // i k s A'Axaf Print Name l0 3 Signa 9 Owner ge Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: f f S 1 /Us i 0<0 WQ License Number n o,d Ac-nVfz Address Expiration Date S, Sigu re Telephone 9. Realstered Home Improvement Contractor: Not Applicable ❑ Company Name 1 _ / Registration Number Ay;* h Address Q '/ l/ n ,/� 01042 / Expirati n ate "iv Ant ✓'t 6l/ P&* 10"M Ce 10 Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavitmust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildXg permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts ar DEPARTWNT OF BUILDING INSPECTIONS ° 212 Main Street • Municipal Building ga 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.G.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 contracted with a corporation or LLC,that entity must be registered. Type of Work: e ny �r(� ftp/+Le sfPps f& 7'tioi doves Est. Cost: ��1_00 Address of Work: Pf'4K U,-,'v e- Fl&ledc( M iVoC z Date of Permit Application: 1013111 I hereby certify that: Registration is not required for the following reason(s): ork 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 IMPROVE51ENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.C.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: 1 hereby apply for a building permit as the agent of the owner: JoI3111 A is ;Avs l yy/8 D)Itc t 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 y1ti SlC Massachusetts � r i DEPARTMENT OF BUILDING INSPECTIONS T. yJ 212 Main Street *Municipal Building 'Ss, r Northampton, MA 01060 a� ti1 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: 12 121<-/c p.I,'&- �e,,voc< 10W o/aC;? (Please print house number and s(reet name) Is to be disposed of at: v^ �1 t A C G f f'� 2.3 ,E�sf��»� �w, I�v� l�/�- tip, air q D/vG (PI se print n me an cation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 1013115 Signatu of rmit Appli ant or Own r Da 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 www mass.gov/dia NN-orkers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/individual): /qY/o►r) `.w /sCq tm-t Address: Vu P/tky, 4//,.- Qfigd City/State/Zip: RuIT-1 f MA UIUG), Phone#: Are you n employer?Check the appropriate box: Type of project(required): I am a employer with W _9—emptoyees(full and/or part-time).* 7. ❑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 3J71 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeow-ner 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 l I.❑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.❑Ro 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. 1 Other PIW�Va 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. tContractors 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: A M MOTV AC p Policy#or Self-ins.Lic.#: �W fi'$��`s�x 8 )� Expiration Date: tfZo _ Job Site Address: ls1 Rt r k4, Q R iy 49 City/State/Zip:VIOWK15,M A oJ t)6.2 Attach a copy of the workers' compensation policy declaration page(showing the policy number and ex iration 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. I do hereby certift under the wins andpenalties ofperjury that the information provided above is true and correct. Si nature: Alp` 'Y Date: la 3 Phone# Olfcial 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#: 40 A 0 CERTIFICATE OF LIABILITY INSURANCE °AT lo/3/2o19Y' 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 NAME: Sarah Premo Martin J Clayton Insurance Agency, Inc. 11C.PHON u Ext. (413)536-0804 AtC NO: (413)534-79 4 1649 Northampton Street E-MAIL remo@m'cla tan.com ADDRESS: s P y P. O. Box 989 INSURERS AFFORDING COVERAGE NAIC p Holyoke MA 01041-0989 INSURERA:Safety Insurance Company 0014 INSURED INSURERB:Safety Indemnity HO Preferred 33618 Axiom Landscape & Home Improvement LLC INSURER C:AIM Mutual Ins. Co. 053 40 Pine Valley Rd INSURER D: INSURER E: Florence MA 01062 INSURER F, COVERAGES CERTIFICATE NUMBER:19 MASTER 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD SUER POLICY NUMBER MMDPOLICY EFF POLICY FXP LTR DNYYY MM DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE ToRENTED' A CLAIMS-MADE FX OCCUR PREMISES Fa occurrence $ 100,000 BNA0028548 1/11/2019 1/11/2020 MED EXP(Any one person) E PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO- LOC 2,000,000POLICY 1:1JECT OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ee awldent ANY AUTO BODILY INJURY(Per person) S B ALL OWNED SCHEDULED AUTOS Ix AUTOS 5907002 1/11/2019 1/11/2020 BODILY INJURY(Per accident) $ XHIREDAUTOS NON OMED PROPERTY DAMAGE $ AUTOS Per accident Medical payments $ 5,000 UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS)JAB HCLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION TH- AND EMPLOYERS'LIABILITY YIN STATUTE. ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? ❑N)A C (Mandatory In NH) WCC5005020083 4/17/2019 4/17/2020 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) RE: 12 RICK DRIVE, FLORENCE, MA 01062 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF NORTHAMPTON THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPT. ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET, #100 NORTHAMPTON, MA 01060 AUTHORIZED REPRESENTATIVE Michael Regan/FMT 1724.1- �- ;g4j „ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)