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24D-145 (2) 1n � I File#BP-2020-0735 }-�O w APPLICANT/CONTACT PERSON DICKY MATOS ADDRESS/PHONE 3 GLEN ST HOLYOKE (413)530-5335 PROPERTY LOCATION 225 STATE ST MAP 24D PARCEL 145 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION.CHECKLIST E OSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction:_DEMO AND REMOVAL OF SH New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/Statement or License 105917 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 _ L..,�Demolition Delaly n4n zlv--,� i��I11 Signature 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. 0 Department use only City of Norirham C C I /C tatus f Permit: Building Depart C V urb CLit/Driveway Permit < 212 Male{Stle tE ewer/3epticAvailability ( Room j100 r 3019 Water ell Availability Northampton,;MA 10 o S sof Structural Plans Phone 413-587-1240 Fax L413-587-197 oUsit Plans DEPT OF GUII.DING INSPFCTI NS NORTHAMPTON.".". �` `��Other SIP APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMIL�DWE`LLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office ��i..) SJ &'t lllt JI—i—ee.1— Map � qf) Lot / �� Unit 611 &0 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name \ Current Mailing Address: rY yJ_ 2 7/ G Telephone gnature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to k e Official Use Only completeq_bLpermit applica it 1. Building � � �il. JC.' (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) / 30 5. Fire Protection ' 6. Total = (1 +2 +3 +4 + 5) Check Number �? This Section For Official Use Onl 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 he filled in by 13uilding Department Lot Size s Frontage Setbacks Front r-----� Side L: R:� L: R: y Rear l3uilding Height r � � r-• -1 I3ldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) e #ot'llarking Spaces 7 Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NOQ DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW n YES Q 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 Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO IF YES, describe size, type and location: 1 E. Will the construction activity disturb (clearing, grading, gxcavation,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 ❑ Or Doors Accessory Bldg. ❑ Demolition New Signs [0] Decks [E3 Siding [p] Other[p] Brief De�iption of Propposed Work: / d)" San a_-J e eyaJAC / ��f�/�/S •l.r Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If WW hoyise and or eddit on to exist—Ina housing.complete the fottowina: 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 aut ize to act o y behalf, in all 7mars relative to work authorized by this building permit application. /Z •/Z• Of caner Date I, as Owner/Authorized Agent hereby declare 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. Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ,rye Not AA�pplliicable�0 Name of License Holder: ,)l L Y /'!R � C� J /v��l/ License Number Aklye e r,)2130 ba,,)=e Addr Expiratio Date 5 -533 S Signature Telep one 9.Realstered;Man*ImplinVOMMt,Contractor. Not Applicable ❑ 020'7 Company Name Registration Number, en �S�• la Deo' Address Expirati Date 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....... x No...... ❑ City of Northampton Massachusetts , DEPARTMENT OF BUILDING INSPECTIONS 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 he registered Type of Work: Est.Cost: -/7 54 d o Address of Work: V-- M,,Yom,d.,�9S•^, ln,4 O/dy Date of Permit Application: 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: 1.2 ,13/, 9 aay lya)O�s 16& a617 Datc 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 Massachusetts DEPARTMENT OF BUILDING INSPECTIONS �. T� 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: (Please print house number and street name) Is to be disposed of at: ca— -ella 7014, /ylufn`Sl f1;61�d�p/ (Please print name and Ibcation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of mit Ap icant 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. Ls The Commonwealth of Massachusetts Department of Industrial Accidents UV_ 1 Congress Street,Suite 100 Boston,MA 02114-2017 wwwmass.gov/dia orkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lead)IN Name (Business/Organization/Individual): ID/ Address:---.. cs/ - City/State/Zip: z d la Phone #: rr ;' 'S33S Are you an employer?Check the appropriate box: L f project(required): 1.O I am a employer with T employees(full and/or part-time).* New construction 2.D I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doingall work myself t y• Demolition y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property.e I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.QOther 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box til 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: / 1'1 C--(> Policy#or Self-ins.Lic.#: 146 1 x\ ks& Expiration Date: Job Site Address:�o�cS �� �Ot' ari.0 f1,rn,!jj City/State/Zip: Attach a copy of the workers'compensation policy dee aration 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 certtf er the pains and ena s o perjury that the information provided above is true rind correct. Signature: Date: /� Phone#: 3S 3 3 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 25. Plumbing Inspector 6.Other Contact Person: Phone#: A`,oRo® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/22/2019 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 CONTACT NAME: Heather Fleury CHI Insurance Agency, Inc. PHONE (413)536-2685 ac No): (413)532-0889 416 Main Street E-MAIL hfleu g y ADDRESS: ry Q@chla enc .com INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01040 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED 4 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 ADDL SUER —TPOLICY EFF POLICY EXP L TYPE OF INSURANCEIN-RD WVD POLICY NUMBER MMIDD MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE a OCCUR AAA To RENTED PREMISES Ea occurrence $ �---� MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY E PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO Ea accident OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LAB I OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X I SPER TATUTE ERH AND EMPLOYERS'LIABILITY Y/N -ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? ❑ NIA UB1K836443 02/12/2019 02/12/2020 (Mandatory in NH)and E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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(2016103) The ACORD name and logo are registered marks of ACORD ' Commonwealth of Massachusetts AM ' > Division of.Professtonal Licensure Board of Building Regulations and Standards Construction,Supervisitir CS_�05g�' Expires. 03/30/2020 DICKY MATOS 3 GLEN STREET HOLYOKE MA 01040 Ccmmissloner ✓ Office of Consumer Affairs and Business Regulation One Ashburto-i Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor R6gistration Type: Individual DICKY MATOS Registration: 166207 3 GLEN ST. Expiration: 05/06/2020 HOLYOKE, MA 01040 SCA 1 0 20M-05/17 Update Address and Return Card. ������nriraavrnPrr�lli n�^r'�r,;arr•��urrlf Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Recistration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Offi:e of Consumer Affairs and Business Regulation 166207 05/06/2020 One Ashburton Place-Suite 1301 DICKY MATOS Boston,MA 02108 DICKY MATOS .0 Com. 3 GLEN ST. C ^ HOLYOKE,MA 01040 Undersecretary Not valid without signature 3 Glen St Holyoke, Ma 01040 413-530-5335 0 CS105917 HIC-166207 Date Dec 10, 2019 dkiRILSOWN., CT- 0639705 P.O. Terms Bill To Forge Property Management Ship Via 225 State Street Ship Date Northampton, MA 01060 cameroncarswell @yahoo.com Qty Description Unit Ext 1 Demolition 4,750.00 4,750.00 Demolition of Barn located at: 225 State Street Northampton, MA 01060 Total(1) $4,750.00 - - 'y Si --natu 7g natu� Ute`\- ---- - Page 1 of 1