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24A-120 (5) 34 CALVIN TER BP-2020-0917 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24A- 120 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPAIR BUILDING PERMIT Permit# BP-2020-0917 Project# JS-2020-001559 Est.Cost: $18000.00 Fee: $117.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg.ft.): 8494.20 Owner: STULTZ RICHARD Zoning: URA(100)/ Applicant STULTZ RICHARD AT. 34 CALVIN TER Applicant Address: Phone: Insurance: 34 CALVIN TERRACE NORTHAMPTON MAO 1060 ISSUED ON:2/12/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR ROTTEN SILL AND RIM JOISTS, REPAIR WATER DAMAGED AREA 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: iDriveway Final: Final: Final: Rough Frame: Cas: 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: FeeType: Date Paid: Amount: Building 2/12/2020 0:00:00 $117.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner N _ ___ Department use only ' City of Nort�ampREG E I V of ermit Building DeparteFn1 Cu C riveway Permit 212 Maintre t S /S Availability Room j00 F E B 1 2 2020 Wa er/NwVe I AvailabI r Northampton,!MA 01060 TVVISets f Structural Plans T phone 413-587-1240 fax Site ns DFPT OF 6UILDING INSPE TI I NORTHAMPTON.SAA of other Spe ify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map . Lot /-20 Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record• _ Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2 o o C� (a) Building Permit Fee . 2. Electrical (b) Estimated Total Cost of Q (? Construction from 6 3. Plumbing �_ Building Permit Fee 7 4. Mechanical(HVAC) �� 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only 7 Date Building Permit Number: Issued: Signature: V1 C-0 Building Commissioner/inspector of Buildings / Date Z� '—K EMAIL ADD ESS (REQ IRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [a] Decks [a Siding[a] Other[a] Brief Description of Proposed Work: <C d c. r ry r 'c ' (.�• i�� �i�G/ t c r t Alteration of existing bedroom / Yes No Adding new bedroom Yes No LJ Attached Narrative Renovating unfinished basement Yes 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 CitySewer 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 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 Da e SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑// C ID Company Name /IV / / / Registration Numbe 6 A 4;,-0 Address Expirati n Dat L 6cnj.� Y J r Ji I / 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.*ailure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... ❑ s J SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alter ati s) Roofing EJOr Doors Accov ry Bldg. ❑ Demolition ❑ New Signs [O] Deck Q Siding [O] Other[0] Brief Aription of ProposedWork Alteration o xisting bedroom Yes No Adding new be om Yes No �J Attached Nar tive Renovating unfi ed basement Yes No Plans Attache oil -Sheet 6a. If New houl and or addition to existina housing, m tete the followin : a. Use of building : e Family Two Family Other b. Number of rooms in ch family unit: Nu er of Bathrooms c. Is there a garage attach . d. Proposed Square footage o w 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 weAPrivaete No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor k. Will building conform to the Buildis? Yes No . I. Septic Tank City Sewer City water Supply SECTION 7a-OWNER AUTHORIZATION TO BE COMPLE D WHEN OWNERS AGENT OR CONTRACTOR A LIES FOR BUILDI PERMIT I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relativ to work authorized by this bui 'ng permit application. Signature of Owner to 1, ? as Owner/Authorized Agent hereby declare that the state nts and information on the foregoing app ation are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalti of perjury. Print Name -2,L11 Signature of Owner/Agent Date City of Northampton / Massachusetts � 5, �`•� y "J4 DEPARTMENT OF BUZLDZNG ZNSPECTZONS ° 212 Main Street • Municipal Building Northampton, MA 01060 �3yj •• 11, 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 be registered Type of Work: YP r Est. Cost:�T �t U Address of Work: 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: �7 / Date Contracto ame 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 �y DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 ijti:jY :>>< 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: (Ple a print napfie and loc tion of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Sign ture 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 Massachusetts Department 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. Applicant Information Please Print Lep-ibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): I.E]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. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 10❑Building addition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will rX 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.❑ repairs re airs . 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. tContractors 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. Ido hereby certify unde 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#: CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDlYYYY) 02/10/2020 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: House CW NE FAX Regina Jasak Independent Insurance Inc PAH (413)3155775 No,Ext: (413)315-5775 (AIC,No): (855)278-6332 P O Box 543 ADDRESS: INSURER(S)AFFORDING COVERAGE MAIC# Ludlow MA 01056 INSURERA: Concord Group INSURED INSURER B: Quincy Mutual Paul Bradish d/b/a Handy Hubby INSURER c: Aim Miutual INSURER D: 44 Willow St INSURER E: FLORENCE MA 01062 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 SUOR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIOD MMlDDIYYYY LIMITS © COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ❑ CLAIMS-MADE rM OCCUR PREMISES(EK.Z=.).) $ 50,000 ❑ MED EXP(Any one person) $ 5,000 A ❑ 20021000 09/14/2019 09/14/2020 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 F POLICY — JEC7alOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 ❑ ANY AUT-O BODILY INJURY(Per person) $ OWNED © SCHEDULED BODILY INJURY(Per accident) $ AFV207668 B ❑ AUTOS ONLY AUTOS 09/14/2019 09/14/2020 ❑ HIRED NON-OWNED PKUHLK I Y UAMAUE $ AUTOS ONLY ❑ AUTOS ONLY (Per accident) ❑ ❑ $ ❑ UMBRELLA LAB ❑ OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑ CLAIMS-MADE AGGREGATE $ ❑ DED ❑1 RFTFN I ION $ $ ORKERS COMPENSATION N ❑ TH- ND EMPLOYERS'LIABILITY STATUTE NY PROPRIETOR,'PAR I NER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 C FFICER/MEMBER EXCLUDED? D NIA, Issued under Separate Cover 09/14/2019 09/14/2020 Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 f yes,descnbe under ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/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 Rick Scultz ACCORDANCE WITH THE POLICY PROVISIONS. 34 Calvin Terrace AUTHORIZED REPRESENTATIVE Northampton MA 01060 (�1988-20leACORV CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Aco CERTIFICATE OF LIABILITY INSURANCE DATE IMN/DDIYVY1� 1 02/10/2020 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: Regina Jasak REGINA JASAK INDEPENDENT INSURANCE INC is"c°.Ne.Eft E-MAIL ADDRESS: regina@reginajasak.com P O BOX 543 INSURER(S)AFFORMG COVERAGE NAIL• LUDLOW MA 01056 INSURER A. AIM MUTUAL INS CO 33758 INSURED INSURER B• _ HANDY HUBBY LLC INSURER C: INSURER D. I P O BOX 543 INSURER E, LUDLOW MA 01056 INSURERF: COVERAGES CERTIFICATE NUMBER: 503935 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. ■ISR nPEOFN8tD/1lICE ADDLSUBR INSD vivo POLICY NUMBER POLICYEFFPOLICY EXP LI�h3 LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMDAMAGE TO RENTEU_ OCCUR PREMISES Ea ococcurrence $ MED EXP one person) $ N/A PERSONAL b ADV PLIURY $ GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ,ECT F LOC PRODUCTS-COMPIOP AGG $ POLICY❑ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Par accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION TAME ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE YIN E.L EACH ACCIDENT $ 100,000 A OFFICEWMEMBERExcwDED? I WAI NIA NIA AWC40070357262019A 09/14/2019 09/142020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Rick Scultz ACCORDANCE WITH THE POLICY PROVISIONS. 34 Calvin Terrace AUTHORIZED REPRESENTATIVE Northampton MA 01060 C Daniel M.C�rri_ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD