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05-056 (4) 453 AUDUBON RD BP-2020-1070 GIS#: COMMONWEALTH OF MASSACHUSETTS MV.Block:05-056 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-2020-1070 Project# JS-2020-001815 Est.Cost: $30000.00 Fee: $195.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: K&N CONSTRUCTION SERVICE LLC 101634 Lot Size(sq.ft.): 194277.60 Owner: GORDON JOEL P Zoning: RR(100)/WSP(100)/WP(53)/ Applicant. K&N CONSTRUCTION SERVICE LLC AT. 453 AUDUBON RD Applicant Address: Phone: Insurance: 52 NORTH ST (774) 545-6684 WC GRAFTONMA01519 ISSUED ON:4/23/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-HOME HEATER RELEASE & CONSTRUCTION SERVICE TO REMEDIATE RESTORATION 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 -4/23/2020 0:00:00 $195.00 '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: Building Department Curb Cut/Driveway Permit 212 Main Street APR 2 Seler/Septic Availability �= ( Room 100 2 2��) Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans -_ '' ZJther Specify r, APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address. _ Map Lot Unit 453 Audubon Road Northampton, MA. Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: I Joel Gordon 453 Audubon Road Northampton, MA Name(Print) \ Current Mailing Address: 413-320-2092 '—�Id) Telephone Signature 2.2 Authorized Agent: K&N Construction Service LLC 52 North Street Grafton, MA. 01519 l�enn et� Q�\S\� Name(Print) f�- l 774-545-6684 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 30,000. (a) Building Permit Fee 195.00 2. Electrical NSA (b) Estimated Total Cost of 30,000. Construction from 6 3. Plumbing NSA Building Permit Fee 4. Mechanical(HVAC) NSA 195.00 5. Fire Protection 6. Total =0 +2 +3 +4+5) 30,000. Check Number 1759 This Section For Official Use Only �f 0 Date - Building Permit Number: A�i' Issued: � 7� Signature: Building Commissioner/Inspector of Buildings Date Ken@kn-constructionsvc.com ( Contractor) 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 Side L:- R: L: R:7-7 u 0 Rear 0 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 Q DON'T KNOW Q YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW Q YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? All interior work, Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 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 O NO Q 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) Roofing Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other[0] Brief Description of Proposed Home heater release and construction service to remediate restoration. Work: Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X 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 Joel Gordon I, , as Owner of the subject property K&N Constructs Service LLC/Kenneth Nadolski hereby authorize to act on my behalf, in all m ers re i e to work authorized by this building permit application. ^� �► Signature of Owner Date Kenneth Nadolski/K&N Construction Service LLC I, 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. Kenneth Nadolski Print Name 04/14/2020 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Kenneth NadolSkl License Number 52 North Street Grafton, MA. 01519 CS-101634 Address Expiration Date 50/30/2020 Signature Telephone "" AL. 774-545-6684 442 Registered Home Improvement Contractor: Not Applicable ❑ Kenneth Nadolski Company Name Registration Number K&N Construction Service LLC 188316 Address Expiration Date 52 North Street Grafton, MA. 01519 Telephone 774-545-6684 07/17/2021 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....... x:.- No...... ❑ City of Northampton -•'' Massachusetts �. S ' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building yJ6 D .. O Northampton, MA 01060 rsVh `�o 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: Masonry, Excavation. Est. Cost: 30,000. Address of Work: 453 Audubon Road Northampton, MA. 01060 Date of Permit Application: 04/14/2020 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: Kenneth Nadolski/K&N Construction Service LLC 188316 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a b ' ding rmi th ner of the above property: 1 Date Owner Name and Si nat re City of Northampton Massachusetts U DEPARTMENT OF BUILDING INSPECTIONS212 Main Street •Municipal BuildingNorthampton, 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: 453 Audubon Road Northampton, MA. 01060 (Please print house number and street name) Is to be disposed of at: UMM Hauling Inc. Millbury, MA 01527 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: K&N Construction Service LLC /UMM Hauling Inc. (Company Name and Address) 4e', co T4;t� Sig a ure 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 w„ www mass.gov/dia \N"i-kers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual):K&N Construction Service LLC/Kenneth Nadolski Address:52 North St City/State/Zip:Grafton, MA 01519 Phone#:508-839-4405 Are Nou an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4 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. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.n I am a homeowner doing all work myself.[No workers'comp,insurance required.]f 10 ❑Building addition 4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 1 1.❑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. p ❑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. 14.10 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 thepolicy and job site information. Insurance Company Name:Associated Employers Insurance Policy#or Self-ins.Lic.#:WCC50050165472018A Expiration Date:10/20/2020 Job Site Address:453 Audubon Road City/State/Zip:Northampton, MA 01060 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 herebyfy and r the pains a d e alties of perjure,that the information provi e r ve is true and correct. Signature. Date: II// �r(� Phone#:774-545-6684 Official use only. Do not write in this area,to be completed hp 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#: / 1 ® DATE IMM/DD/YYYY) ACROCERTIFICATE OF LIABILITY INSURANCE 4/8/2020 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: LeeAnn Watterson Gaudette Insurance Agency, Inc. PHONE FAX 1 Plummers Corner ac No Ext: 508-266-6441 Alc No):508-234-8121 Whitinsville MA 01588 ADDRESS: lwatterson@gaudefte-insurance.com INSURERS AFFORDING COVERAGE NAIC# _ INSURER A:Lloyds'of London _ INSURED KNCONST-01 INSURER B:Commerce Insurance Company 34754 K&N Construction Service LLC 52 North Street INSURERC:Associated Employers Insurance Grafton MA 01519 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1254325175 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAALLIABILITY I EN0000203503 11/13/2019 11/13/2020 EACH OCCURRENCE $1,000,000 DA NTED CLAIMS-MADE h] OCCUR PREM MISEESOEa o [XI $100,000 MED EXP(Any one person) $25,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 _ POLICY Z JEI° F LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER $ A I AUTOMOBILE LIABILITY FCS018 3/30/2020 3/30/2021 COMBINED SINGLE LIMIT $1a ,000,000 _ COMBINED _ ANY AUTO BODILY INJURY(Per person) $ OWNEDX SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION VVCC50050165472018A 10/20/2019 10/20/2020 X AND EMPLOYERS'LIABILITY Y/N STATUTE ER _. ANYPROPRIETOR/PARTNER/EXECUTIVE F_N] N/A E.L.EACH ACCIDENT $1,000,000 _ OFFICER/MEM BER EXCLU E (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ***Workers Compensation Information*** Sole Proprietors, Partners,Officers and Others Coverage Endorsement:Kenneth Nadolski is covered. 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. City of Northampton 212 Main Street Northampton MA 01060 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:LLC Registration Expiration 188316 07/17/2021 K&N CONSTRUCTION SERVICE LLC KENNETH NADOLSKi � 52 NORTH ST GRAFTON,MA 01519 Undersecretary