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17C-104 (7) 13 STILSON AVE BP-2020-0501 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 104 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-2020-0501 Proiect# JS-2020-000856 Est.Cost: $7768.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: WALTER TOMALA JR 068454 Lot Size(sa.ft.): 8799.12 Owner: OLANDER WILLIAM P&DEBORAH L Zoning: URB(100)/ Applicant. WALTER TOMALA JR AT. 13 STILSON AVE Applicant Address: Phone: Insurance: 470 SOUTHAMPTON RD (413) 584-3919 0 WESTFIELDMA01085-5144 ISSUED ON:10/22/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF ON REAR 2ND STORY 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 Signature: FeeType: Date Paid: Amount: Building 10/22/2019 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner _ vV� "`--�--- - Department use only City of No ha I_-=�� _�tatus f Permit: .>� Building D partlrnent urb C�t/Driveway Permit 212 Mai Street �T 2 1 ewer eptic Availability ROO 100 v 2019 at er ell Availability ' Northampton, MA-L1 060 wo S is of Structural Plans phone 413-587-1240 Fgk'4 tM8- Qi �PECTIO lot/S to Plans NORTHA%4PTON,p,1A 01060 Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION AP- w'6o / ` 1.1 Property Address: This section to be completed by office Map 6/ 7C Lot /61Y-Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT \ 2.1 Owner of Record: Name(Print) Current Mailing Address: I - SEC-' C t'.VriC�4�T Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signat re 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 ! z yo 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee D 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: 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.l� Rear Building Height Bldg. Square Footage , % Open Space Footage % (t.ot area minus bldg&paved [. parking) #of Parking Space Fill: volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW 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 Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 6 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 O NO a 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? YESQ 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 9K Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other[p] \ Brief Description of Proposed / ,(• Work: !Tf ai/1 L Yc:. 2 dT0 Llyt7J i v1(x. �l /te ,i y-4 M- CC�Twn T'Y<sf C�iv�y J�rs- /r�e.t 1 L 7/.. ; Alteration of existing bedroom Yes ;Z- No Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basement Yes DL 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 ORCONTRACTORAPPLIES FOR BUILDING PERMIT 1, )F 4 �.� , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date ONE- XZJI, , as Owner/Authorized Agent hereby declare that t 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 Zv Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 7 \ 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:�1 �ClA��r 7ros)r)a�a) �A'-� License Number ,Arlo � v Rte; k.,)aekk $�� I zn Address O`GIRzIs Expiration Date Signature Telephone \ 9. Registered Home Improvement Contractor: Not Applicable ❑ mc t3o l 4 Company Name Registration Number H qC 3 i�)d rl 10 IF- 1 Address ' Expiration Date t) .` -�, �1'4 0�OmS Telephone(q LS\1532.'0 \ 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.......X No...... ❑ City of Northampton Massachusetts r ':G ' DEPAR774MT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building yv`•., OD` 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: cl(l Est.Cost: (p Address of Work: 3 S'�► Sy a ���-�-►u..� 1� ,� y\A Date of Permit Application: (t�CA v"O, `�T�U 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 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: I hereby apply for a building permit as the agent of the owner: /0//Y,11 -7;U7- 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 s� ."•^.sic Massachusetts ',A W: /L "�- DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building yvd, Cs Northampton, MA 01060 ssVjy -"j��0 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: (Please print house number and street na e) 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: ll eft F-z-"--f- z„I -T..>L . P. 0 13v" Q (Company Name and Address) Signature of PermitApplicant 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 s I Congress Street, Suite 100 e Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apolicant Information Please Print Lezibly Name (Business/Organization/Individual): U C­�:,V_:�N lr"), L V`N`f� ? i rJ(g-- -V4 C. - Address: .4-7 0 SV k&T"YNP-N M0 P i IF'D W ri S-1 P i t:.W m► nJ d S-5 City/State/Zip: 0`d�Phone#: CL4 1 5 - 0_�pa- Are you an employer?Check the appropriate box: Type of project(required): L ,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. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]i 10❑Building addition 4.❑lam 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 1 L❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.0 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.t 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: Policy#or Self-ins.Lic.#:LI'PQ —5Q0 3 k—ZQ LgZlExpiration Date: I l Zn20 Job Site Address: 11 Stj t\s 0 14 �-Nwr City/State/Zip: !-Ao A'Ka,r y'�yr� 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. \ I do hereby certify 4nder the pains and en allies of perjury that the information provided above is true and correct Signafore: Date: /e / Phone#: N/ Official use only. Do not write in this area,to be completed by city or town ofJiciaL 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#: AIJGA "r'%V'j'W.r J of, %for ts" ttV, tiv- 1 S.• 1.". i t..—1..^ti H It 1 414 .-1.i.mi, �"c Nk:,% .v'I SJ �VW.1, A'k, kr'."o.,= r Ilk J'.w IF 7F 11'r 44. IF Mx +';0n 3C '.'v fiq 1 ;4 flqlj(6 Q111C.Ot j 'i, 'Ac '1W1 :1.1%1 A AC" ® DATE(M / Y) O CERTIFICATE OF LIABILITY INSURANCE 09/244/20192019 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 ondorsement(s). PRODUCER CONTACT Bridget Robare NAME: Sumner&Toner Insurance Agency Inc PHONE (413)567-1051 —FAX ): (413)567-2151 No Ext: A/C,No 813 Williams St E-MAIL brobare@sumnertoner.com ADDRESS: INSURERS)AFFORDING COVERAGE NAIC p Longmeadow MA 01106 INSURER A: Risk Placement Services,Inc INSURED INSURER B: Travelers Cas&Surety Of IL 19046 TNT General Contracting,Inc INSURER C: AIM Mutual Ins Co 470 Southampton Rd INSURER D: INSURER E: Westfield MA 01085 INSURER F: COVERAGES CERTIFICATE NUMBER: CLI992406953 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDY/YYri POLICY P LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ARENTED CLAIMS- ADE PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 10,000 A L261002596-1 09/04/2019 09/04/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S 2.000,000 POLICY ❑PRO 2.000.000 JE CT LOC PRODUCTS-COMPIOP AGG $ OTHER Employee Benefits $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED BA-91-097539-19-42 04/16/2019 04/16/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED XNON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Medical payments $ 5,000 UMBRELLA LLAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I RETENTION$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N 1,000,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA WCC-500-5019831-2019A U1/Ul/2U19 Ul/U1/2020 E.E.L.EACH ACCIDENT S OFFICER/MEMBMBER EXCLUDED? (Mandatory In NH) EJ-DISEASE-EA EMPLOYEE S 1.000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD/01,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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD M Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 176074 TNT GENERAL CONTRACTING, INC. Expiration: 07/10/2021 470 SOUTHAMPTON RD WESTFIELD,MA 01085 Update Address and Return Card. SCA 1 _, 2011-05117 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Cornoration before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 176074 07/10/2021 1000 Washington Street -Suite 710 TNT GENERAL CONTRACTING,INC. Boston,MA 02 18 WALTER TOMALA %1 ✓'/<� 470 SOUTHAMPTON RD WESTFIELD,MA 01085 Undersecretary Not valo Without-signature � Commonweal+h of r. issachus�tts� Divlsior:of Pro:• ssionai Licens rre Board of Building Regulations and Standards Constructibr, S`ervisor CS-068454 ExPires:08127/2020 WALTER J TOMALA 470 SOUTHAMPTON RD WESTFIELD MA 01085 13 Commissioner l/e— /I--