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31A-248 (6) 50 DRYADS GREEN ST BP-2020-0842 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:3 1 A-248 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: Bath reno BUILDING PERMIT Permit# BP-2020-0842 Project# JS-2020-001451 Est.Cost: $16464.00 Fee:$107.00 PERMISSION IS HEREB Y GRANTED TO: Const.Class: Contractor: License: Use Group: WILLIAM LABOMBARD 114593 Lot Size(sq. ft.): 5009.40 Owner: MILLER RON Zoning_URB(100)/ Applicant. WILLIAM LABOMBARD AT. 50 DRYADS GREEN ST Applicant Address: Phone: Insurance: 12A PARKER AVE (413) 687-7946 O WC NORTH FIELDMA01360 ISSUED ON:1/27/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE TUB WITH TILE SHOWER 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 Si«naturc: FeeType: Date Paid: Amount: Building 1/27/20200:00:00 $107.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton--)' f Status of Permit: .,f Building Department ~� orb Cut/Driveway Permit ,A 212 Main Street' S`.*?ySeptigAvailability Room 100Wad JAN NVell vailability Northampton, MA 01060 2 3 20 Two ets Structural Plans -' phone 413-587-1240 Fax - - 87-1272 20 Plo Site ans ^n�rr%rr Ot er Sp city APPLICATION TO CONSTRUCT,ALTER,REPAIR,R ,ti 'fEFOLI H A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Prouertv Address: This section to be completed by office s v prICAJS �r15 /� Map �1A Lot Unit / er4"J,,,i0)0,1 Zone Overlay District l 1 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:A Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized A ent: VI'll,'(4/I Z C1 �v/-7 6 W!� Alel Name(Print) Current Mailing Address: a136a i Signature V Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building P q (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of d Construction from 6 3. Plumbing I� a0 Building Permit Fee '1 4. Mechanical(HVAC) 5. Fire Protection 1� 6. Total=(1 +2+3+4+5) , Check Number n ,/This Section For Official Use Only Building Permit Number: C7 P 0 - /.)" Date Issued: Signature: —t'�'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 [: F Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[Q Brief Description of Proposed 7 ( Q Work: 7-()k E'CPT�ca_d w��1 / i�l t )Asda.✓ll " re Pla<ed n Zx1,�n.y!�- n6)'A'^9 0,x vrel( Dkv Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes 2C No Plans Attached Roll -Sheet 6a. If New house and or addition to existina 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT (•!4 1, 4 / -1- as Owner of the subject property hereby authorize to act n my behalf, in all matters relattW to work authorized by this building permit application. P ' i 122 1 2v Signatu of Owner Dat I, .l r •6:✓!� ��''�*�� as Owner/Authorized Agent hereby declare that thg 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 wner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction�Supervisor: Not Applicable ❑ Name of License Holder: Y V I�� Gtr G-C,&1,,74A&1 JW�`/ License Number Addre s 7 Expiration Date 07— 7q-tlG Q444,1, Telephone 9.Re istered Home Improvement Contractor: Not Applicable ❑ . ll- 1440M iwo D,0.9'17 Company Name Registra °n Number P � vim: -�V o Addrest Expiration Date Telephone of ig7�y46 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 r Massachusetts DEPARTDENT OF BUILDING INSPECTIONS z 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: 57-0 b 4 j (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 fro (Company Name and Address) -.0 Signat a Applicant o wner 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 a I 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. Applicant Information Please Print Le ibl c Name (Business/Organization/Individual): u 61c_ U Address: /3: o2+z 2d City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).' 7. E]New construction 2.IJ 1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workerscomp.insurance required.] 9. Demolition 3.f_1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 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 1 LM 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. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 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: �/ L �'�f i C CR r V(e; '' Policy#or Self-ins.Lic.#: �G G '5-j5765_0;11W_-220R xpiration Date: f� &!-- _-.2 , Job Site Address: ' `� y al A (6ct�e 1 City/State/Zip:/✓dh` ►��d/� 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 tine 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 u der t pains and penald pe ' that th information provided above is true and correct Si ature: Date: Phone#: ell? 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#: AC40 CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DDIYYYY) 11/4/2019 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 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: Adina Edgett Webber 6 Grinnell PHONE (413)586-0111 FAX (413)586-6481C N t: AIC No B North King Street E-MAIL ADDRESS: g sreerang aed ett@bbd rinnell.com INSURERS AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A:Evanston/BRECK INSURED INSURER B:Citation 40274 Aging In Place Builders, Inc. INSURER C:Associated Employers Insurance 11104 Attn: Jeff LaBombard INSURER D: 203 Birnam Road INSURER E: Northfield MA 01360-9526 INSURER F: COVERAGES CERTIFICATE NUMBER:Exp 10/20 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/DDIYYYY MMIDDNYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A ❑X OCCUR DAMAGE TO RENTED 100,000 PREMIS CLAIMS-MADE ES Ea occurrence $ 3EW1473 10/28/2019 10/28/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 JECTX POLICY 0 PRO, F LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea ccident $ 1,000,000 a B ANYAUTO BODILY INJURY(Per person) $ ALL OWNED EX SCHEDULED BCDR51 10/28/2019 10/28/2020 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident Uninsured motorist BI split limit $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LLAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WCC50050211662019A X PEROTH- AND EMPLOYERS'LIABILITY 1,/N STATUTE ER ANYPROPRIETOR/PARTNERIEXECUTIVE Jeffrey LaBombard, Nlchael E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? Y❑N I A C (Mandatory in NH) LaBombard, and William 10/28/2019 10/26/2020 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below LaBombard are excluded. 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 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 p� W Grinnell, CPCU, CIC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) O"k*Ot n-At Affairs &Susbwas Regulation HOME IMPROVEMENT CClf+rITR,ACTOR TYPar„ IndK46ul 11459 WILLIAM W. L.ABOMBAP0 WtLLIl+M'#'j. LA,OMBAR,0 12 A PARKER AVE VCI+RTH -FLC, MA Q1wo U rid W ret ary Convmnwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Con struCtibn "Supervisor CS-060247 Expires: 06/06/2020 WILLIAM W LABOMBARD - 12 A PARKER ST „ NORTHFIELD MA 01360 Commissioner