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32A-201 (22) 51 PHILLIPS PL BP-2020-0511 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A-201 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPAIR BUILDING PERMIT Permit# BP-2020-0511 Proiect# JS-2020-000869 Est.Cost:$4500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DICKY MATOS 105917 Lot Size(sy. ft.): 11891.88 Owner: CARSWELL CAMERON Zoning: URC(100)/ Applicant: DICKY MATOS AT. 51 PHILLIPS PL Applicant Address: Phone: Insurance: 3 GLEN ST (413) 530-5335 WC HOLYOKEMA01040 ISSUED ON.1012412019 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIRS TO DECK 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: Roui;h 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 11'aid: Amount: Building 10/24/2019 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner r Department use only <' City of Northamptp(t`,� Status of Permit: Building Depart/ ,6Tt`�` O� urb Cut/Driveway Permit lu. ~ o. C:. 212 Main Stt%je ;/ `L %Se/wee/Septic Availability tl P Room �/,i ' ��� titer/Well Availability 2►, NOrthampt 010 two Sets of Structural Plans phone 413-587-1 40 F 4187-1 J\�2 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, PAIR, ATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION v —2-0-511 1.1 Property Address: This section to be completed by office 5► h'l I I ips V)a.c, Map �a Lot Af Unit N o<,VOCknj>, O(1 I Mh 0)C)(QC) Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: T(Effl,(X(.,A NA) P1 Name(Print) Current Mailing Address• Telephone Signature 2.2 Authorized A ent: &4en s� Nam nt), Cur re t Mai' g Address: SLinat6re Telephone i SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building j� (,I() (a)Building Permit Fee 2. Electrical (// J (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) ► y/� 5. Fire Protection IIIJJJ"" 6. Total = (1 +2 + 3+4+ 5) O Check Number This Section For Official Use Only Building Permit Number: DateIssued: Signature: Id.Zy 2()1 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E3 Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [ Siding [01 Other[ Brief Descripti o ro ose { Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. if Newhouse 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, 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 as Owner/Authorized Agent hereby declare th t thd 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. S Pime, r' , 2_ S re of Owner/Age Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constructi n Supervisor: Not Applicable ❑ Name of License Holder: License Number 01- d 0-7/-ZA Adre s ` ExpiraG Date 0 i�v ^ nture Telephone 9.Re istered Home Improvement Contractor: ; ::,.., _ Not Applicable ❑ Companv Name b Registra ion Number d U. O 10 26 Z D r s Iz Expiratio Date 'LAI 4M4� Telephone )3 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 buildU permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts �sr E, DEPARTMENT OF BUILDING INSPECTIONS a 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.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: H1 Est. Cost: ,op Address of Work: Sfid 1A o4ho10 1� 0 Date of Permit Application: b 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: zbIOU )61p2oy- Tate Contract r ame 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 i M City of Northampton °' Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building w Northampton, MA 01060 �siY•- Y��^� 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: / 6/A (Please pfint house tuber and street name) Is to be disposed of at: 61f"'�w,4Q (P ease print name and location of faci y) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Kr) 0- ,2- I C? "atureof t Appl' ant 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 I Congress Street, Suite 100 Boston,MA 02114-2017 s www mass.gov/dia NVorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): NaJ�ssKd Address:_ 1 5/ City/State/Zip:A4C l) hone#: �� `�30 S��3� Are you an employer?Che4thie,/ppropriatebox: Type of project(required): I.�m a employer withemployees(full and/or part-time).* 7. E]New construction 2.❑I am a sole proprietor rship 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.]t 10E] Building addition 4.n I am 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 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp.insurance.: p 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: rlK3a-11 Policy#or Self-ins.Lic.#: 8.3 2 Expiration Date: ZAQ Job Site Address: = I Z/idj �/� City/State/Zip: b&4, 47Q. Attach a copy of the workers'compensiftion 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 cern u er the pains and p a 'es o perjury that the information provided above is truce and correct. Signature: avkAj Date: Phone#: 3U S 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#: .. 3 Glen St an Holyoke, Ma 01040 413-530-5335 - M� CS105917 HIC-166207 Date Oct 20, 2019 + ! ' CT- 0639705 P.O. Terms Bill To Cameron Carswell Ship Via 51 Phillips Place Northampton, Ma 01060 Ship Date cameroncarswell @ yahoo.com Qty Description Unit Ext 1 GENERAL FRAMING 4,500.00 4,500.00 Price is for Labor Only ----- ----------- Total (1) $4,500.00 Si ature Page 1 of 1 ACOROa 70,2122/2019 (MM/DDM YY) `� CERTIFICATE OF LIABILITY INSURANCE 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 ACT NAME: Heather Fleury CHI Insurance Agency,Inc. PHONE, -2685 536-2685 AX NII: (413)532-0889 416 Main Street E-MAIL hfleu chia en ADDRESS: ry@ g cyCOm INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01040 INSURER A, ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B Dicky Matos dba DMR Roofing INSURER C: 3 Glen Street INSURER D: INSURER E: Holyoke MA 01040 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ � I CLAIMS-MADE C OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ ~~ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONPER AND EMPLOYERS'LIABILITY X STATUTE ER ANY A OFFICER/MEM ER EXCLUDED?ECUTIVE YIN N/A UB1 K836443 02/12/2019 02/12/2020 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate issued as evidence of insurance. 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 �;omfnonwealth of"✓lassarhu5 t-� Division of Professional Licensu e Board of.BaildtngRequrations ant Stanaarns Construction Supervisor ; xpires: 03/30/2J20 DICKY MATOS - 3 GLEN STREET HOLYOKE MA 01040 COMMISSIOner y� ()ifice of ConsumOr A"Mairs and Business Regulation One Ash,bUY-ton Place- SUNS 1801 masa 02108 Home Improv3m(gnt Contractor PsglebMon DICKY iMiATOS Type: Individuai S GLEN ST. Regisbilon: 166207 HOLYOKE,MAA 01040 E50ration: 05/06/2020 ICA 1 ab 2t)M 0511� Gradate Address and Retuum Card. Trrrrrrvenicvll��+, `i 11... 01ftF�Y°'E�III�PR���nees ReaW�fon NTRA&OR "A" u�()c98silrr8bun vWidl Vor Undividual use oroy 1992p7 AGO f(consumer rfai s and Business ness O ulation DICKY MAT05 a�e Ashburton Race-Suite 1301 az Stan,IWA 02108 DICKY MATOS 3 GLEN ST. HOLYOKE,MA 01040 Undersecretary AM Wgft t s0—gn8 Vq