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35-271 (6) 165 WEST FARMS RD BP-2020-1086 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35-271 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Deck BUILDING P E R M I T Permit# BP-2020-1086 Project# JS-2020-001832 Est.Cost: $32000.00 Fee:$208.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WILLIAM CHILDS 014572 Lot Size(sg.ft.): 165092.40 Owner: OMASTA JOHN P&FAYE A Zoning: Applicant. WILLIAM CHILDS AT. 165 WEST FARMS RD Applicant Address: Phone: Insurance: 229 WISDOM WAY (413) 247-9269 GREEN FIELDMA01301 ISSUED ON:4/29,12020 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADDITION OF NEW DECKS 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 4/29/2020 0:00:00 $208.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton status of Permit: r • Building Departm6nt Curb Cut/Driveway Permit 212 Main Street ,�+ '�; I � Sewer/Septic Availability . Room 100 -4101� Mater/Well Availability Northampton, MA`0-1060 �1> T o Sets-of Structural Plans phone 413-587-1240 F`6 :41 687-112 4:? lot/Site Plans _.. . Othe "Spec4 APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENW,* R DE OLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be c—o�jmplete)d by office v✓ S c"- �� S f�C( Map r Lot "r 7< Unit /411 c` Zone Overlay District % 0 1 LL Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: V - /cL -t. O ��s A/o_ S" 42-1 � Fo_ 125 Rce/ NNam�e�((Print) Curr�jnt Mailing Address: Signure , Telephone at 2.2 Authorized Agent: to Name /� V"" C.A- c v� �'l i s o� C( "lel C3lc�litq G"� �� cr ame(Print) Current Mailing Address: Signature Telephone ACL L 2 SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted b ermit a licant 1. Building U VU (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) I U 5. Fire Protection 6. Total=(1 +2+3+4+5) 000 --" 1 Check Number / (1, This Section For Official Use Only Building Permit Number: ✓ D 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 Or Doors F I i Accessory Bldg. ❑ Demolition ❑ New Signs [C7] Decks Siding[O] Other[O] Brief Description of Proposed j Work: !! 1(j �j ;o Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative Plans Attached Roll -Sheet Renovating unfinished basement Yes x No sa. If New house and or addition to existing housing complete the following a. Use of building : One Family X _ Two Family __Other b. Number of rooms in each family unit. Number of Bathrooms c. Is there a garage attached? O d. Proposed Square footage of new construction. Dimensions ® 2 ( '�— `f �C 9 e. Number of stories? -- v - k�j a f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance Masscheck Energy Compliance form attached? h. Type of construction P (-'r20Yte 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 property� � � 7 ! 6� as Owner of the subject hereby authorize (4j ! L t G'G to aMtyh in er ive to work authorized by this building permit application. Signature of Owner Date `t L C 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 and enaltieof pe4ur�� • � (rs, (�,� ( W � � C IV Print Name Signature of Owner/Agent Date [SECTION:8 -CONSTRUCTION SERVICE.1 Licensed Construction Supervisor: Not Applicable ❑ ame of License Holder CS _ i License Number Address Expirati Dat Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ VC,t,, LZe-e 6v\c L(.. w r� N— ` t.0 10039D Company Name Registration Number Address Expir tion Me W f L L kc.- C �� I S Telephone_ 1 q 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...... ❑ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reai-ctration Expiration 100320 06/1S/2020 WILLIAM CHILDS W iLUAM R.CHILDS 229 WISDOM WAY GREENFIELD,MA 01301 Undersecretary Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-014572 WILLIAM R CHILDS Expires: 10/31/2021 ` 229 WISDOM WAY GREENFIELD MA 01301 Commissioner _ IdP/Ao6•sseW.MMM vsm Jo OOZE (L& 9)IIeD asuaol s33asnyoessew l s143 Inge uoljeuuoluf ,:I asuaoy s1 s uolIeOOAOJ jol asneo sl apo0 6ulpllnl3 ajejS a4110 uof*Pa 3uajjn3 a ssassod of ajnlle j JauolssltuWO0 Pasolou coeds LO£LO VIN 0131dN33NO uleluoo 1,66)laal algno 00&V qW 6ZZ Sue to s&4PAwa J{ygn liM L ZOZr L E!�}�in��ljan�suo0 ZL5bLO-So JoslAJ8 tS U(4U�% 1suo0 spjepuelS pue suopeln6ab 6ulplmg 10 pleog amsua3lI leuolssalOJd 10 uolslnlp I ? suasngoesseW jo ylleamuowwoo tielajoaSjapun a' M p111RA 104061.0 Vw'C11313N338E) OOSI M 6ZZ 3" V!71M SLLZO VIN'U011111911-10 VYVj;11M U046 1 OOOL `� a 01,LS yaw uoljeln6e1:i ssaulsng Pug s - t3j a aq :oj ujnja�Pl102 � �%OH /(lug sjle9v jawnsuo0 to aoWO , • City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS Y 212 Main Street • Municipal Building v� Northampton, MA 01060 ssyW .j, 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 17 Type of Work: /- U i 6 612- _ -Ole C� LIZ-_ Est. Cost:- J ^^ -4 Address of Work:_C(��j Date of Permit Application: I hereby certify that: Registration is not required for the following rea.on(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 EN'ITRING INTO CONTRAC'T'S WITH UNREGISTERED CONTRACTORS OR SUBC'ONTRAC'TORS FOR APPLI( %BLE HOME IMPROVEMEN'r WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE :ARBITRATION PROGRAM OR GtIARANTV FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS .ALSO ASSUME"THE RESPONSIBILITF,S FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXTPAGE FOR MORE INFORMATION. Signed under the penalties of perjure: I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice. I hereby apply Ibr a building permit as the owner of the above property: Date Owner Name and Signature - City of Northampton 1, Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 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 /�-cj t.c% e` -t rid w"' S A C� (Please print house number and street name) Is to be disposed of at: (Please print name and location f facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) -atv& Signature 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 ' M www.masv.gov/dia liorkers'Compensation Insurance Affidavit: Builders/C'ontractors/Electricians/Plumbers. TO BE FILED WITII'I'IIE 11"ERMITTING AUTHORITN. Applicant Information Please Print Lelziblv Name (13usincss/()rganiiation/Indi\i(iva1): Address: City/State/Zip:____ _ _ Phone #: Are you an employer'Check the appropriate box: Type of project(required): I.❑1 am it employer with enyilm cc,Hull and/or part-time)." 7. ❑New construction 2.N 1 am a sole proprietor or partnership and have no employees working kir me in 8. Remodeling any capacity.1 No workcrs'romp msuranre rryuircd.1 3.[]l am a homeowner doing all mirk ms self 1 Vo workers'rump InsLlranri e(luired 1, 9. ❑Demolition 4.O 1 am,' ncr and will he hiring contractors to conduct all work on mm prupertX. I will 10 ❑ Building addition ensure that all contractorseither hacc workers compensation nnsumncrui err title 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-cont ractoi:s listed on the anuched sheet. 'I'hcsc sub-contractors hacc emplosccs and hair%%orkers comp unsur:uire 13.❑Roof repairs 6.F-1 We area corporation and its officers hacc exercised their right of excmpuon per M(il.c. 14.[&Other V 152.§1(4).and wr have no employees lNo workers comp insurance reymred Anyapplicant that checks hox ill must a11,0 fill out the section helm% ,ho��ut,�!nrir\�urkers'compensation pulic\ inlbrmauon. I lomeowners who suhntit this aff•idac n indicating tile\are doing all\\ork and ibrn hire outside contractors must suhntit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showini_the name of the sub-contractors and state w hether or not those entities have employees. Ifthe sub-contractors have emplo\ees.thrk must provide(heir wttrken romp.policy number. I am an emplirtyer that is providing workers'compensation insurunc•e for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. 9: _ 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 wel l as civil penalties in the tbrm of a STOP WORK ORDER and a line 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 herehv eertiji'under 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 hr 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 S. Plumbing Inspector G.Other Contact Person: Phone#• ,4c R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 04/22/2020 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 HOUSe NAME: King&Cushman Inc. PHONE (413)584-5610 FAX 41 P.O.Box 447 A/C No Ext: AIC,No: ( 3)584-9322 E-MAIL 176 King Street ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURERA: Ohio Security Insurance Co. 24082 INSURED INSURER B: William R Childs INSURER C 229 Wisdom Way INSURER D: INSURER E: Greenfield MA 01301 INSURER F COVERAGES CERTIFICATE NUMBER: CL2042203700 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. INSRAUUL POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ CLAIMS-MADE PREMISES Ea occurrence $ 300,000 A BKS58380659 MED EXP(Any one person) $ 15,000 03/09/2020 03/09/2021 1,000,000 PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICYPRO- JECT ❑Loc 2,000,000 PRODUCTS-COMP/ $ Fa OTHER: Experience Mod Factor for 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO Ea accident OWNED SCHBODILY INJURY(Per person) $ EDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOSON LY ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 ©1988-2015 ACORD CORPORATION. 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