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38C-044 (6) 26 SOUTH PARK TER BP-2020-0558 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38C-044 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Bath reno BUILDING PERMIT Permit# BP-2020-0558 Proiect# JS-2020-000632 Est.Cost:$10500.00 Fee: $68.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CHRISTOPHER ROMAINE 088577 Lot Size(s(l.ft.): 12283.92 Owner: MARTUNES PETER PAUL Zoning: URB(100)/ Applicant: CHRISTOPHER ROMAINE AT. 26 SOUTH PARK TER Applicant Address: Phone: Insurance: 100 LEONARD ST (781) 710-2474 WC NortonMA02766 ISSUED ON.111512019 0:00:00 TO PERFORM THE FOLLOWING WORK.-BATH RENO 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: FeeTvpe: Date Paid: Amount: Building 11/5/2019 0:00:00 $68.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ©OL--Zc% Department use only fir City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit �. 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability �. Northampton, MA 01060 ructural Plans - phone 413-587-1240 Fax 13- Plan Other S ecify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENEtTqR LI H A NE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION NS 1.1 Property Address: ab '50.'V% NORTHAMPTON,MAoi jt s s ' n to be completed by office �/p( 7LZ/Ntovn �R Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Pe>er 1'77Qr161r7eS Name(Print) CufrTnt Mailing Address: q13- Telephone Signature 2.2 Authorized Agent: C�A_7s L Name(Print) Current Mailing Address: 791, -762-- Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2 foo " (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of �Q v' Construction from 6 3. Plumbing Sd.0 ary Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total=(1 +2+3+4_+5) '—"Jo • di> Check Number This Section For Official Use Only Building Permit Numb Date Issued: Signature., /- Building Commissioner/Inspector of Buildings Date CLi(r.S @ APRr'-7 P�f1 �io(r►�� corn 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 © DONT KNOW ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW � YES 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 Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained 0 , 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 © NO 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 0 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 [E:I] Decks [Q Siding [[:3] Other[p] Brief Description of Proposed Work: Ae -- coo-GvrP �� i��..� r���°✓.Cu fly �hs�g�/� ),y loYN7r4r7'_e7_ 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, , 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 I, �J, as Owner/Authorized Aged-hereby— are that the 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.. Gi",s Print Nam c v Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction /Supervisor: Not AApppllicable ❑ c `} Name of License Holder: ( /7ri570�h�1 /� �c� i�'l.Q w �0 0 License Number ioo � ,¢,d sz fLy,-yore 195V9 Qa-7L,6 9 /1,3 Address Expiration Date -7e ) ' 7 / 0 - ZY-7Y Signature Telephone 9.Reaistered Home Improvement Contractor: Not Applicable ❑ f �Z3/i9 Company Name Registration Number Address / Expiration Date /&,-) Lw lewd SZ /VA OYTCN l'�� 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 building permit. Signed Affidavit Attached Yes....... J!J�- No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS a ° 212 Main Street •Municipal Building << 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: -_� C_ (Please print house number and street name) Is to be disposed of at: �5 GvwlnC)l� �,� Som 04 /71/01 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signa ure 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. The Commonwealth of Massackusefts 02 Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/OrganizatioorAndividual): `{ / j i j={ 11� �{p�yre oil Address: aZ City/State/Zip: 4�4 4:W/ Phone #: Are you an employer?Check the appropriate boa: Type of project(required): 1:a]ll am a employer with_employees(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. E'Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[—]l am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.❑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. Plumbing repairs or additions 5.[]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.1 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. L , Insurance Company Name: ®',tl�t qCf S-1.S eD�/TV of Policy#or Self-ins.Lic.#: W C-11 0/b a 3 10 D l Expiration Date: 6 Job Site Address: A& "y � /� ity/State/Zip:,.,&//4/4.FPZk7 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 under the pains and penalties of perjury that the information provided above is true and correct. Si Date: ��� Phone#: 8/- �w - �4 V 7 y 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#: pharmacistsPharmacists Mutual Insurance Company - bh-A rYlutlJal NCCI Carrier Code No. # 17604 800.247.5930 or 515.295.2461 TOMORROW. IMAGINE THAT. P.O. Box 370, 808 Highway 18 West, Algona, Iowa 50511-0370 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INFORMATION 1.NAMED INSURED AND MAILING ADDRESS CUSTOMER NUMBER 0100017636 HEALTHWIS25 WALPOLE PA HOME CORP POLICY NUMBER WCV 016236101 25 WALPOLE PARK S WALPOLE MA 02081-2522 Previous Policy Number WCV 0162361 2.POLICY PERIOD 06-01-19 TO 06-01-20 12 01 A.M.local Time at the described location TRANSACTIONf 1. :.:.........:............::: .. . . AMENDED DECLARATION Effective: 06/01/19 DELETE ADDL INTEREST FEIN# Risk ID# Entity of Insured U.I.# 824136063 CORPORATION See Schedule Other workplaces not shown above: SEE EXTENSION OF INFORMATION PAGE 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part THREE of the policy applies to the states,if any,listed here: ALLSTATES EXCEPT NORTH DAKOTA,OHIO,WASHINGTON, WYOMING,AND STATES DESIGNATED IN ITEM 3.A. D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates, and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 500 AMENDED Total Estimated Premium $ 4,435 Authorized Representative GAILT.WOLFE,CISR,API 3020 WC 99 06 00(11/18) Date Printed: 05/21/19 INSURED COPY Page 2 of 5 T CUSTOMERNUMBER: 0100017636 � o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/21/19 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 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 NQNjgCT PHARMACISTS MUTUAL INSURANCE COMPANY PA)8%.Ed):800-247-5930 1r No): 808 HIGHWAY 18 WEST, PO BOX 370 - SS: - ALGONA, IA 50511-0370 -- _ INSURER(S)AFFORDING COVERAGE __ NAIL r INSURERA:Pharmacists Mutual Insurance Com any 13714 INSURED INSURER B: HEALTHWISE AT HOME CORP INSURER C:D: 25 WALPOLE PARKS INSURER WALPOLE MA 02081-2522 INSURER E: 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 SHOW MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY BOP 0163460 01 06/01/2019 06/01/2020 EACHOCCURRENCE $ 1, 000,000 CLAIMS-MADE F-1v I OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) S 50, 000 MED EXP(Any one person) S 5, 000 GEN'LAGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY s INCLUDED POLICY PRO-JECT LOC GENERAL AGGREGATE S 3,000,000 —{IPRODUCTS-COMP/OP AGG S 2 000 000 OTHER WATER LEGAL LIABILITY Is S0,006 AUTOMOBILE LIABILITY ��ppMBIN D SINGLE LIMIT (ta accident) $ BODILY INJURY ANY AUTO (Per person) S------------ ALL OWNED H SCHEDULED BODILY INJURY S------------ AUTOS AUTOS (Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) S ------------ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS S I WORKERS COMPENSATION AND PER OH EMPLOYERS'LIABILITY STATUTE E ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? - -- f(Mandatory In NH) Y/N EL DISEASE-EA EMPLOYEE $ - t yes,describe under DESCRIPTIONS OF OPERATIONS bel E-L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) See Remarks for Location Schedule CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE FOR EVIDENCE ONLY EXPIATIN DATE THEREOF,WI HRTHEOPOLIICY PROVISIONS.ENO RICEIBEDy'OLIBE DELIVERED BE LINE ACCORDANCE BEFORE THE AUTHORIZED REPRESENTATIVE GAIL T. WOLFE, CISR, API __ Page 1 of 1 0 1988-2015 ACORD CORPORATION. All rights reserved. Division of Professional Licensure i` Board of BuildingRegulations and Standards 9 Office of Consumer Affairs&Business Regulation Construction Supervisor HOME IMPROVEMENT CONTRACTOR j TYPE: Individual CS-088577 Expires:09/13/2021 Registration Expiration 173119 10/30/2020 CHRISTOPHER ROMAINE CHRISTOPHER ROMAINE 100 LEONARD ST NORTON MA 02766 1 1� CHRISTOPHER M.ROMAINE 100 LEONARD ST , NORTON,MA 02766 Commissioner Undersecretary PE MA RT U ab So UT. Pafr 3 s8 8 3 v s ! P a' o 19 o s E 0 R R o 0 rpt 1- A- y 0 � t tie NJ v 0 t AP