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38B-029 (3) I - 123 SOUTH ST BP-2020-0779 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-029 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT. Permit# BP-2020-0779 Proiect# JS-2020-001351 Est.Cost: $7800.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JOSEPH KENNEDY 055440 Lot Size(ss .ft.): Owner: BERMAN SUSAN Zoning URC(100)/ Applicant: JOSEPH KENNEDY AT. 123 SOUTH ST Applicant Address: Phone: Insurance: 38 HARKNESS AVE (413) 525-1735 O Workers Compensation EAST LONGMEADOWMA01028 ISSUED ON:1/7/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-KITCHEN UPDATES AND STORM WINDOWS 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. I Certificate of Occupancy Signature: FeeTvpe: Date Paid: Amount: Building 1/7/2020 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only 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 Two Sets of Structural Plans "<1 phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans fill 1 1 -- APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OO F kMILY DWELLING SECTION 1 -SITE INFORMATION JAN - 6 2019 1.1 Property Address: This section to be omp eted by office �� ` ( —DEPT.OF GUILDINr It�PFTIONS Unit r`— ap ���oT���,�,,,�� �tJJC. 1 Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 01060 Name(Print) Current Mailing Address: Telephone 2.2 Authorized Agent: o C t ki -?g 4"Iq Au'p Nae(Print) Current Mailing Address: I FT;v A V2 2 jc c t , c,cr�a 36aZ-7?�rG Si ature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building O (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing � 6 ® Building Permit Fee 4. Mechanical (HVAC) �"U 5. Fire Protection O L 6. Total=(1 +2+3+4+5) -] S'Oc% Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: 6P- r�o-- '7 7 7 ZOZU Building Com Imissioner/Inspector of Buildings Date o e- -) @ 00 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:__ __-7 0 Rear Building Height Bldg. Square Footage % J Open Space Footage % Q (Lot area minus bldg&paved parking) #of Parking Spaces r 1 Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW ( YES O r_. IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW (ar YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © 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 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 O 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 E] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [p] Other[a Brief D scription of Proposed ���' l w K r Sr4lCru.+ wQ�O(.VS' IUSK��f Alteration of existing bedroom Yes ><' NO No Adding new bedroom Yes P� 4�� 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, V C( L \(.� « as Owner of the subject property hereby authorize to act on my be f, in all matters re ve to work authorized by t s building permit application. 1/ Signature of:Nvnef Date I — ����� as Owner/Authorized Agent hereby declare th the statements and inforplation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under theains an penalties of perjury. ( �- Pri Name Sig ture of Owne/Agent Date SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: i License Number A dress Expiration Date --, 'k d ? 76 r reTelephone r 9. Re istered Home Improvement Contractor: Not Applicable ❑ C �v� C ci LA<;i--b,( -(�v 17 f a a Comoany Name Registration Number 3 L' &- --P <:; -- q - ) 0a o Address Expiration Date LA 0( wl V a 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....... No...... ❑ DATE(MMIDIVYYYY` CERTIFICATE OF LIABILITY INSURANCE 06,13,2019 "1 'Ei CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS IRTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 14::I.OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED Ft-PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER Ilc ies must have ADDITIONAL on INSURED provisions or be endorsed. lA1PQRTANT: If the certfficate holder is an ADDITIONAL INSURED,the po Yl ) If Sl1BROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement 1.11i:>certificate does not confer rights to the certificate holder in lieu of such endorsem Jerrt(sR Leahy,Jr. a.aqucrrtE' (413)788 6492 PHonE (413)788-8393 A1C,No: rallce+Realty,Inc. ac No ext: ADDRESS: lleany�leanyandtxown.com s,wren Street,Suite 1 NAIC a INSURER(S)AFFORDING COVERAGE 21792 MA 01118-2009 INSURER A: ATLANTIC CASUALTY �;p,ngfield STAR INSURANCE CO 18023 I_;_..... INSURER 0: r�;,16tFD r�on,jyervices INSURERC: !8 HarknesINSURER s Avenue D 3 �. INSURER E: MA 01028 INSURER f East Longmeadow/ REVISION NUMBER: CERTIFICATE NUMBER: OVERAGES CL196130?226OD IIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI tIDIC FICATE NOTWMAY ITHSTANDING G AN YRPERTAIN.REQUIREMENT, (TERM OR C CEOAFFDORDED BY THE POLITION OF ANY ICIIES DESCRIBED ACT OR OTHER DHEREINOES SUBJECT TO ALL THENT WITH RESPECT TO TERMS, :cCLUS10NS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIIMSS POLICY NUMBERMMIDD LIMITS 1000000 t TYPE OF INSURANCE IVSD VNO F_ACH OCCURRENCE S , , COMMERCIAL GENERAL LIABILITY S 50,000 PREMISES Ea occurrence CLAMS-MADE 17 OCCURS 10,000 MED EXP(Any ane person) 04/0112019 0410112020 PERSONALBADVINJURY S 1,000,000 L261002306 GENERAL AGGREGATE S 2,000.000 GEITL AGGREGATE LIMIT APPLIES PER' 2,000,000 pRODUCTS•COMP/OPAGG S POLICY ❑PRO - LOC Employee Benefits S COMBINED SINGLE LIMIT g OTHER Ea accident) AUTOMOBILE LIABILITY BODILY IN9JP,Y(Per person) S ANY AUTO BODILY INJURY(Per accident) S OWNED SCHEDULED PROPERTY DAMAGE S _ AUTOS ONLY AUTOS Pet aocoerd HIRED NON-OWNED S AUTOS ONLY AUTOS ONLY i EACY.00CURP.ENCE S UMBRELLA LIAB I OCCUR AGGREGATE S EXCESS LtAB CLAIMS-MADE $ PER 0TH• DED RETENTION S STATUTE ER YIN �� .2 E L EACH ACCIDENT S 1,000,000 ANY PROPRIETOR(PARTNERIEXEC 1,000,000 i3 E-EA EMPLOYEE S OFFICERIMEMBER EXCLUDED') 1,000,000 (Mandatory In NH) E.L DISEASE-POLICY LIMIT S it yes.describe under _ DESCRIPTION OF OPERATIONS belay t nESCR1PTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addltl0nal Ramsrka Schedule,mdy be attached N mom aWce is required) 4 CANCELLATION CERTIFlCATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TION DATE THEREOF,NOTICE WILL BE DELIVERED IN CORDAN WITH THE POLICY PROVISIONS. UTHORIZED REP ENTATIVE ©1988-2015 ACORD CORPORATION. Ail rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation CHARISTA CONSTRUCTION SERVICES, INC. Registration: 171982 PO BOX 706/38 HARKNESS AVE Expiration: 05/09/2020 1, E.LONGMEADOW,MA 01028 Update Address and Return Card. SCA 1 20M-05/1' / %i� �rnrz.yraayaarv��l�ro -,'F�crlauJt/Y - Office of Consumer Afairs Busine's's" Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 171982 05/09/2020 One Ashburton Place-Suite 1301 CHARISTA CONSTRUCTION SERVICES,INC. Boston,MA 02108 4NOt JOSEPH KENNEDYPO BOX 706/38 HARKNESS AVE E.LONGMEADOW,MA 01028 Undersecretary v id W hout signatur Commonwealth of Massachusetts. Division of Protessioriai f_icens;re 'Board of Building Regulations and Standards Conelvol11 topgrvisor CS-05544 JOSEPH A KENNEDY 18 FOREST ST �'C PO BOX 1356 BONDSVILLE MA 01009 ��� Commissioner The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations =� 600 Washington Street MA 02111 �t 4" , Boston '' www MA Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeiblv Name(Business/Organization/Individual): Lou,i S4 Cc to k!6 (,I Address: 3 L4JLtt a s � ko LIL • ' City/State/Zip: M-61, Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.Tam a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Wemodeling ship and have no employees These sub-contractors have g, EJ Demolition working for me in any capacity. employees and have workers' insurance.+ 9. E] Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[I Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13•0 Other 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. / G Insurance Company Name: !�^ _` �U (lr e Policy#or Self-ins.Lic.#: l/`�l D (p ? Expiration Date: a c a a Job Site Address: L d :� 4 jQ A ' N()rt! Y�ity/State/Zip: l,Ut.LI 01 V I6 0 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebyertify under a pains enalties of perjury that the information provided a ove is true and correct. �1 Si ature: Date: �'- Ctr Phone#: 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#: City of Northampton Massachusetts c {' ' DEPARTMENT OF BUILDING INSPECTIONS yv az 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: "'4 P � ( lease print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: r "c,epo (Company Name and Address) \ (Y i Sign re of Per it Applica�it or Owner D If, or 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 ulDepartment of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aimlicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.Q I 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. ❑Demolition 3.n I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Q 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. 6Q 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 Homeowner,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.#: Expiration Date: Job Site Address: City/State/Zip: 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. Signature: Date: Phone#: 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#: