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31B-134 (6) 122 STATE ST BP-2020-0955 GIS#: COMMONWEALTH OF MASSACHUSETTS MQ:Block:3 1 B- 134 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: KITCHEN RENO BUILDING P E RM I T Permit# BP-2020-0955 Project# JS-2020-001625 Est. Cost: $13000.00 Fee: $84.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JIM R BOYLE 107689 Lot Size(s(l.ft.): 4007.52 Owner: BUDHRAJA VIKRAM Zoning: URC(100)/ Applicant: JIM R BOYLE AT: 122 STATE ST Applicant Address: Phone: Insurance: P O BOX 241 (413) 586-8010 WC HADLEYMA01035 ISSUED ON.212412020 0:00:00 TO PERFORM THE FOLLOWING WORK.-KITCHEN RENO. 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 signature: FeeType: Date Paid: Amount: Building 2/24/2020 0:00:00 $84.50 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1. .. 1 r _ Department use only City of Northampton =usPermit: Building DepartmentDriveway Permit , _ 212 Main Street ��� Se / etic Availability ROOM 100 24 Water/W II Availability Northampton, MA 01060q,� �/ o S s of Structural Plans phone 413-587-1240 Fax 413-5 �f Plot/ ate Plus h r Speby g APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE O MOLI H A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office �• Map �` � Lot _Unit Zone Overlay District Elm St.District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1-8m Name(Print) tl{e�(lai,(ingn e : l �,�^ Teleepphone 11 ��(( Signature 2.2 Authorized Agent: '` 1_- 'l I n _& a�lC PP� d' `.�JiQir1 cl li Po ?spy, �, 1 I I� QLAC) Name(Print) Current Mailing Address: . &klp ((41 6- Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building `$I C) OCC _ (a) Building Permit Fee 2. Electrical $ i iS� _ (b) Estimated Total Cost of Construction from 6 3. Plumbing I 'SCO — Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2 + 3 +4 + 5) 000 Check Number This Section For Official Use Only LQ v�b�b� Building Permit Number: c7 f DateIssued: Signature: L. (' 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 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [0] Other[EI] Brief De�sscription of Proposed work:Ketno>f d- cep Oce_ \Ai"en Cc_6ne�5 �, t00n-��R21 ►� Imo°W,ndaC� Alteration of existing bedroom Yes _No Adding new bedroom Yes X 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, V 1 K Cam m aas Owner of the subject property ` /� \ hereby authorize kkVC 1Pi1 to act on my behalf, in all matters I ive au .-by this bui g permit application.I� c� I 30aC) Signature of Owner VDate 1 Cpr,k 1� (—" as Owner/Authorized Agent hereby declare that a statements and information on the foregoing application re true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name N'%N-N � a a ► Fav Signature wner/Agent Date SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable EIName of License Holder: u M \ 1(-og 1 License Number �uS5�1y � . Pr �a)dx Q gmiJl ; 1N� a �a DLS ) a0ID1 Address 00,35 Expiration Date i 5 to -35 i ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ I L e pt's LLL \ 3354 Company Name T—� T Registration Number \ � 1 QuS&C- 1 S f 00 box ALAI , -I'radleu. ma � 0\ I Ialoao Address 010133 Expiration Date Telephon '-t 13) 5(A'6, 0 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...... ❑ Itchen KXchen.CO"t5,Er vei4yvCente - GAZETT GAZETT W1111 NN 117 Rww,17�StreetBestofoncepts P.o.^8241H01 E H01 E a2ot8DREAM m DESIGN m DELIVER 7 fadte/y, MA 01035-0241 I I AI A""ED�D BUSIMFS3 CONSTRUCTION SUPERVISORS LICENSE Recognized by the Commonwealth of Massachusetts as a Supervisor. Superior knowledge of Massachusetts laws and code are mandatory. Testing and years of experience are required to receive this license. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Consti%;&%AJ visor CS-107689 ' OKpires: 10/25/2021 JIM R BOYL� J. PO BOX 241 3 HADLEY MA 0,1035 �C Commissioner License #-CS 107689 HOME IMPROVEMENT CONTRACTORS LICENSE Required for remodeling existing property. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:LLC Registration Expiration 193350 10!10/2020 KITCHEN CONCEPTS&DESIiA CENTER LLC JIM R.BOYLE 117 RUSSELL STREET HADLEY,MA 01035 Undersecretary License #-180308 All licensing information can be obtained through government agencies. Insurance coverage binders and references are furnished upon request. Office: (413)586-3506 • Fax: (413)586-8051 0 Email: design@kitchen-concepts.net The Commonwealth of Massachusetts Z 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 PERMITTING AUTHORITY. Amplicant Information Please Print Leizibl Name (Business/Organization/Individual): S-'+V I i hna Trp- Address: I �► 9 X d 1 l City/State/Zi 01635-- Phone#: `7 3 '59 IO -yo/0 Are you an employer?Check the appropriate box: Type of project(required): 1.KI am a employer with Q _employees(full and/or part-time).* 7. E]New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. S Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.E]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10E]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.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof 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 I / 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 CompanyName: �' ot-Vwfe Policy#or Self ins. Lic.#: Expiration Date: Cid Job Site Address:)aa &a � Pe4 City/State/Zip: �A, 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. l do here rtify under the pqi s and penalties of perjury that the information provided above is true and correct. SigRature: r ' Date: Phone#: LA 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#: .4Co CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) _J 02/03/2020 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 pollcy(les)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 NAME T Barbara Van MDurik Finck&Perras Insurance Agency Inc. PHO .No Ext; /413.527.5520 AX No (413)527.5970 6 Campus Lane E-MAIL bvanmounk@finckandpcn as com ADDRESS INSURER(S)AFFORDING COVERAGE NAIC N Easthampton MA 01027 INSURER A Main Street America Assr Cc 29939 INSURED INSURER 8: NGM Insurance Company 14788 ASAP PAINTING INC INSURER C: PO BOX 241 INSURER O INSURER E: HADLEY MA 01035-0241 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2012104677 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 A POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD(YYYY MWE)DIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 CLAIMS-MADE FXI OCCUR PREMISES Ea occurrence 5 500,000 MED EXP(Any one person/ S 10.000 A MPB49466 05105/2019 05/05/2020 PERSONAL&ADV INJURY $ 500,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 1,000,000 X JECT PRODUCTS $POLICY F-1 PRO 1,000,000 OTHER Individual Risk Mod Prem s AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea wx den/ ANY AUTO BODILY INJURY(Per person) s 100,000 B OWNED XSCHEDULED M9849466 06120/2019 06/20/2020 BODILY INJURY(Per accident) s 300,000 AUTOS ONLY AUTOS HIRED XNON-OWNED PROPERTY DAMAGE S 100,000 AUTOS ONLY AUTOS ONLY Per accident HNTBI s UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE s DED RETENTION 5 S WORKERS COMPENSATIONv PER OTH- AND EMPLOYERS'LIABILITY Y/N /� STATUTE I ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT s 100,000 B OFFICERIMEMBEREXCLUDED? a NIA VVCB49466 01/31/2020 01/31!2021 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 100,000 )(yes,descnbe under DESCRIPTION OF OPERATIONS below I I I .L DISEASE-POLICY LIMIT s 500,000 _t -_ T 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ASAP Painting,Inc ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS x 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 dis7sed of t Va' 0 Dla� (Plea print ame'and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) %fn 9- &I � ' 62 Signalure of Permit A plica 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. City of Northampton • r" Massachusetts + ,A + 1� DEPARTMENT OF BUILDING INSPECTIONS ' 212 Main Street • Municipal Building 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:_1 �% �('n �krnod!u Est. Cost: a 1 Address of Work: Date of Permit Application: b i 121 Da V 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 4gent of the.owners 3) C'en,ler, LLC "C'oncoM5 1­0 i CZ,- -7 108 Date Contractor NanW 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 GAIETY GAZET GAZETE GAIETY Itchen Kitchen Concepts&Design Center,LLC houzz P.O.Box 241 NUI E HUI FbilhronceptsBHadley,MA 01035-0241 _ «G 1- DREAM®DESIGN•DELIVER FINALIS W I N N IN BUSINESS February 21, 2020 Attn: Building Department City of Northampton 212 Main Street, Room 100 Northampton, MA 01060 Subject: Building Permit 122 State Street To Whom It May Concern: Enclosed please find our Building Permit Application and payment for a kitchen remodel at 122 State Street. Please contact me at (413) 586-3506 with any questions. Thank you, Luann L. Brown Executive Administrative Assistant :llb • Office: (413)586-3506 0 Fax: (413)586-8051 0 Email: design@kitchen-concepts.net