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43-024 (3) 525 PARK HILL RD BP-2020-0815 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:43 -024 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2020-0815 Proiect# JS-2020-001408 Est.Cost:$180000.00 Fee:$1170.00 PERMISSION IS HEREB Y GRANTED TO: Const.Class: Contractor: License: Use Group: TEAGNO CONSTRUCTION INC 034716 Lot Size(sg.ft.): 29272.32 Owner: POST GEOFFREY B Zoning. Applicant: TEAGNO CONSTRUCTION INC AT: 525 PARK HILL RD Applicant Address: Phone: Insurance: 228 TRIANGLE ST (413) 549-0803 Workers Compensation AMHERSTMA01002 ISSUED ON.]/]712020 0:00:00 TO PERFORM THE FOLLOWING WORK.-INTERIOR 2ND FLOOR RENO NEW SIDING AND 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. Certificate of Occupancy Sivature: FeeType: Date Paid: Amount: Building 1/17/2020 0:00:00 $1170.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner i Department use only City of Northampdon `'— V` Status of Permit: Building Department Curb Cut/Driveway Permit i f 212Main Street I m6 ?p,20Sewer/Septic Availability i ,A, '._ Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans = Other Specify J APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1 SECTION 1 -SITE INFORMATION di ( w `-""' '0 1 J 1.1 Property Address: / (,This section to be completed by office T�wk tml P-G Map i 3 Lot OL11V _Unit /�orr�vM� A Zone Overlay District Elm St. District CB District l I I SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �ecf'�re� h .moo:�' sd.f Pa.�•4--f.<<// � /Uoy�ctays-r�l�vt /f't/� � Name(Print) Current Mailing Address: eTelephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: i Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant Building (a)o (a) Building Permit Fee i 2. Electrical 13, (,oU (b) Estimated Total Cost of Construction from 6 _ 3. Plumbing if 0V p , 00 Building Permit Fee 14. Mechanical(HVAC) O0 5. Fire Protection � Sona 6. Total= 0 +2+3+4+ 5) pO' Check Number oZ C� j This Section For Official Use Only �� 1 Building Permit Number: N '20— Date Issued: J I a fSignature: 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 Rear Building Height 1\P(�kw Bldg. Square Footage % Open Space Footage % (Lot area minus bIdg&paved of Parking Spaces i j- (volume&Location) A. Has aSpecial Permit/Variawnce/Finding ever been issued for/on the site? �� NO �_� DON'T KNOW YES �_�� IF YES, date issued: IF YES: Was the permit recorded atthe Registry ofDeeds? NO �� D ES �~� un / xnuvv / IF YES: enter BookPa8e and/or Document #/ | B. Does the site contain a bnuuk' body ofwater orwetlands? NO DONT KNOW YES IF YES, has permit been orneed Lobeobtained from the Conservation Commission? »�� ~� . Needs to be obtained Obtained Date Issued: | �~� �_� ' . ` �� C. Do any signs exist on the property? YES �_� NO IF YES, describe size, type and location: i D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size' type and location: E. Will the construction activity disturb (clearing, gradingexcavation, orfilling)over 1acre orioitpart ofacommon plan that will disturb over 1acre? YES ��) 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) d Roofing Er Or Doors E' Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding PC Other[0] Brief Description of Proposed n, Work: 2emovaA exjV-rio 2eJ I" rAjd �e cc! t12.A(a,4AVL& V+ lj Alteration of existing bedroom Yes No Adding new bedroom Yes l 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, Fe b-'Pei as Owner of the subject property hereby authorize >011a Id f 1 C' 1 nir (_ to act on my behalf, in all matters relativd to w k authori d by this building permit application. i Sinat r f Own r MgDate- I, t O> 01W doc r'eaq& 1;lc , as Agent hereby declare tVat the statements andAnformation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ON Gv{ 1462 Pr e Sig ature of gent Da SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ rlr - � _ Name of License Holder: /6VtCGI WA H f-, L.5 — 63 LIT License Number �.4s TyZng4 S} J�uti,�rs� u"N' //l d/Olzo 02a Address Expi ation l5ate atur Telephone 9.Reaisterec4ome Improvement Contractor: Not Applicable ❑ 4 !24 �o S�riucf llr�'? C Company Nam Registration Number Z_- c, FV Address Expiration Date Telephone !3 r d 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...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 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: 5-2S Pa,rk- 17V FO's Z /�i'o�-. �wt�i /1?/� (Please print house number and street name) 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: (Company NafneAnd Address) Signatu f 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. TEAGCON-01 LAURA '4�Rif CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDrfYYY) 4/2/2019 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 CONTAMEACT Laura Misseri Phillips Insurance Agency,Inc. PHONE 413 594-5984 F ,No):(413)592-8499 97 Center Street E-MAX AIL IL Ext): ) Chicopee,MA 01013 E-MAIL Appgssq laura@phillipsinsurance.com INSURERS AFFORDING COVERAGE ' NAIC# INSURER A:Ohio Security Insurance Co 24082 INSURED INSURER B:Ohio Casualty 24074 Teagno Construction,Inc. INSURER c:A. I.M.Mutual Ins.Co. 33758 Mr.Donald Teagno 228 Triangle Street INSURER D: Amherst,MA 01002 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADINS POLICY POLICY NUMBER POLICY EFF MMIDD POLICY EXP LIMBS LTR A X COMMERCIAL GENERAL LIABILI Y EACH OCCURRENCE $ 1'000'000 CLAIMS-MADE ❑X OCCUR BKS57750627 4/1/2019 4/1/2020 DAMAGEa( RENTEDn 500,000 MED EXP An one person) 10,000 PERSONAL BADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2'000'000 X POLICY❑X JECTPRO F—] LOCPRODUCTS-COMP/OP AGG 2,000,000 $ OTHER: COMBINED SINGLE LIMIT $ 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BAS57750627 4/1/2019 4/1/2020 BODILY INJURY Per emon $ OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ �( HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAR CLAIMS-MADE US057750627 4/1/2019 4/1/2020 AGGREGATE $ 1'000'000 FJ DED I X I RETENTION$ 10,000 C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITYY/N WMZ8006223012018A 4/1/2019 4/1/2020 1,000,000 E.L.EACH ACCIDENT ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N/A .1 ,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mon space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Inspection Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Amherst Ins p ACCORDANCE WITH THE POLICY PROVISIONS. 4 Boltwood Avenue Amherst Amherst,MA 01002 AUTHORIZED REPRESENTATIVE I ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD \ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 U` www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual)-�pQ_.,:, Address: City/State/Zip: Phone #: 1-113-54�- Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with employees(full and/or part-time).* 7. E]New construction 2.L I am a sole proprietor or partnership and have no employees working for me in $. 10 Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 10E]Building addition 4.[:]1 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 I LE]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions ti.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ repairs re airs These sub-contractors have employees and have workers'comp.insurance.t t,.❑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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: -A-S M k-y?V N\ � �Q Policy#or Self-ins.Lic.#: Expiration Date: -/-o'>")p _ Job Site Address: �r�rJ \P►c� .�\ City/State/Zip: ��Ser,�c_o.�V�A p1Woa 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 hereb erti Punder the pains and penalties of perjury that the information provided above is true and correct Signature: l:�� Date: / Phone#: y/� � r-r— 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#: