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36-144 (5) 316 BROOKSIDE CIR BP-2020-0951 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 144 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2020-0951 Proiect# JS-2020-001622 Est.Cost: $2200.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DEVON SMITH - DAC HANDYMAN SERVICES 087345 Lot Size(sg ft.): 17162.64 Owner: FRANCIS JANICE zoniniz: Applicant: DEVON SMITH - DAC HANDYMAN SERVICES AT. 316 BROOKSIDE CIR Applicant Address: Phone: Insurance: 340 NIASMITH ST (678) 927-1953 Liability SPRINGFIELDMA01104 ISSUED ON:212412020 0:00:00 TO PERFORM THE FOLLOWING WORK:ROO F I N G - 11 SQ POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring 1).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 Sip-nature: FeeType: Date Paid: Amount: Building 2/24/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner �' � �� s 1 r �. Department use only City of Northampton u`` Status of Permit: Building Department F ,` fl�Cut/Driveway Permit `W 212 Main Street FB �. P)k ptic Availability Room 106F-'T I?41Wa r/Well vailability Northampton, MA Q't �Qc�Q T Set f Structural Plans ' phone 413-587-1240 Fax 41 2 lot/Si Plans Othe Specify s APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVA O D OLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office co o �-� Map Lot 1 �� Unit alb �3ks� � C� Zone Overlay District .1 °`��'e c VLq �A CJI Q h Z Elm St.District Cs District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: ` for Q n tR, VVt u C'oo utUGZ Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized A ent: r f J (­:It `S14 O �t S n� � i'�Ci - rKlo�� NCurrent Mailing Address: te��l : P7 -gay -tis 3 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =0 +2+ 3+4 + 5) o? Check Number oZ This Section For Official Use Only Building Permit Number: �p�dt� « � 'i Date Issued: Signature: 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 `IV Or Doors 0 I (--- Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [[] Siding [p] Other[p] Brief Description of Proposed ff Work: ( � 6 Alteration of existing bedroom Yes No Adding new bedroom Yes _4/4::' 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, t) { ✓(�.✓L(' . as Owner of the subject property hereby authorize r' U✓I C to a a ers re _ authorized by this building permit appli DA,�-'( Z--, Signat re of Owner Date �14 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. Jg nderthe paian penalties of perjury. .7 / ns fnf-A fl Signature o ner/Agent Date SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of LicenseHold r:�Lguc)P,) ( M7 L4 b _ License Number 01 LO7W Ad s Expir tion bate n ure Telephone 9. Registered Home ImprovementContractor: Not Applicable ❑ 7;:�f (C Sb (6 h Iq Comnanv Name _ Registration Number Aism I 1-� S ©cl/0q Address Expi ation Oate ��G (► T(�f YT D) O`� 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...... ❑ 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: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Re 'stry of Deeds? NO © DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW VN YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , 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 ® NO E) 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 © NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Massachusetts r DEPARTMENT OF BUILDING INSPECTIONS y 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: S� �\ku� (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: 4igure mpany Name and Address) f Permit Applicant or Owner D to 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 f Department of Industrial Accidents 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 PERNUTTING AUTHORITY. Aimlicant Information Please Print Le 'bl Name(Business/Organization/Individual): Address: %q_V tJ4�Snn11_� ST City/State/Zip: � 1,elj M, 11- _011 C,tPhone #: C�7 `L00 1 h.3 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. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑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.E]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. 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 thepolicy and job site information. /� _ Insurance Company Name: 1-t l S�1 A&4 SLC!f Policy#or Self-ins.Lic.#: pDExpiration Date: �� (ace_, O<Job Site Address: <,,C-e I f 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 ag ' the vio or. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cove a ve ' Ica on. I dob h un er the pains and penalties of perjury that the information provided above is true and correct. Si na Date: 0)4,1,a,V1g a Phone#: --C)J?— 1953 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 6 " Massachusetts A w ; DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building yeti C�� 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 be registered Type of Work: Est. Cost: Address of Work: X31 �7 ` �ti��k S i Ci CSX a Ce . 04 C, D L 06 2— Date Date of Permit Application:q�`�r) 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: o • \\ Sml�fZ Lel 7 Datl 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 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration all Type: Individual Registration: 161174 DAC HANDYMAN SERVICESti d Expiration: 09/28/2020 340 NAISMITH ST SPRINGFIELD,MA 01109 � r Update Address and Return Card. SCA 1 ca 20M-05/17 office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE-Individual before the expiration date. If found return to: Reaistratian Expiration Office of Consumer Affairs and Business Regulation 161174 09/28/2020 l000 Washin ton Street-Suite 710 DAC HANDYMAN SERVICES Boston,MA it 8 I DEVON M.SMITH 340 NAISMITH ST of valid without signature SPRINGFIELD,MA 01104 Undersecretary Commonwealth of Massachusetts �f Division of Professional Licensure Y Board of Building Regulations and Standards Construct!6r l§Qpervisor CS-087345 Expires: 01/07/2022 DEVON SMITH 340 NAISMITH STREET SPRINGFIELD MA 01104 Commissioner -�� DACHAND-01 S K ACORO DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 7115/2019 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 fi2opCT First American Insurance Agencyac°N ,Ext; 413 592$118 Fac PO Box 14T N.):(413)592-0995 Chicopee,MA 01021 RMISSd INSURERIS)AFFORDING COVERAGE NAIC0 INSURERA:Hudson Insurance Company INSURED INSURER 8: DAC Handy Man Services INSURER C: Devon Smith DBA 340 Naismith Street INSURER 0: Springfield,MA 01104 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 DDL SUBR, POLICY NUMBER POLICY EFF POUCY EXP LIMITS LTRNIL 3M A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE �OCCUR HBD100034826 811/2019 8/1/2020 DAMAGE TO RENTED 100,000 MED EXP An one n 5,000 PERSONAL&ADV INJURY 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY❑zef F-1 LOC PRODUCTS-COMPIOPAGO 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO _ BODILY INJURY Per erson $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY BODILY INJURY Per accident $ AMS ONLY AOIlTOS ONLY 1%Or aRjY AMAGE — UMBRELLA LIAR HOCCUR EACH OCCURRENCE E EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y 1 N A LITE ER ANY PROPRIETORIPARTNERIEXECUTIVE L J E.L.EACH ACCIDENT OFFISER/MEMBER EXCLUDED? N 1A (Mandatory In H) E.L.DISEASE-EA EMPLOYEE S It dew"e under SL�RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LI DESCRIPTION OF OPERATIONS/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 Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988 2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD