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30B-078 (7) ,:rN,SO&/+7-10 Al Department use only City of Northampton Status of Permit: y . Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability J ( Room 100 Water/Well Availability 1 ` Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 F ns r Specify APPLICATION TO CONSTRUCT,ALTER REP IR,RENOVATE OR DEM LISH A ONE OR TWO FAMILY DWELLING NOV 3 Q 7 rt P- /�-oS r SECTION 1 -SITE INFORMATION 1.1 Property Address. DEPT of BUILNG SPECTIO his se t� o be completed by office DII NORTHAMrlON MA010601 iviap Lot �7� Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: A\��. V�;rCY) wg Name(Print) Current in Addr s: i0y 1 ` Telephone Signature 2.2 Authorized Agent: M�OC3,��1F.r o Name(Print) Current Mailing Address: Signature (a4phne SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. BuildingqM cC� (a) Building Permit Fee 2. Electrical W (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee �Q V 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) �� Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 4,117 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 tilled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L:`_—] R:= 0 F ___, Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved J parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW © YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO © DON'T KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO 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 0 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 O 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 Accessory Bldg. ❑ Demolition ❑ New Signs [OL D Decks M Siding[01 Other[ Brief Description of Proposed Work:PA—VkC Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes )1No 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, N``ct �� , as Owner of the subject property p hereby authorize -Tom to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, an as 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. Y Print Name i Signature er/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Supervisor: yNot Applicable ❑ Name of License Holder:'� y �" A3LAt1 ML,5 : L License Number . -V Address Expiration Date eat Telepho e 9.Registered Home Improvement Contractor: Not Applicable ❑ ICn I.C-4a Company Nalm—eJRegistration Number Address Expira ion Date Telephone ��1 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...... ❑ City of Northampton _ l� • '" ` Massachusetts DEPARTMWT OF BUILDING INSPECTIONS ]b 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: Zn ,�� O� Est.Cost:U_� Address of Work:1AA 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 ALSP ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT E NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: �g 12Oi Exa�a l . ITC�m �' mStF.►� 1� 1�Q Date Co ctor 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 City of Northampton � Massachusetts A W \' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 ssNjy ��^,c 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: lyy MC-'Yal- . (Please print house number and street name) Is to be disposed of at: - %t(:A w )�� 'AA R-C-� \tI6 ,MA Q\kOtA . print name and location of facility) (Please P Y) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Z� Sig ure of 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. 16-�ACERTIFICATE OF LIABILITY INSURANCE F DATE(MM/OD(YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CATE THE POLICIES HOLDER. THIS 8,2,2018 ERTIFIC CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED TE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING BY ORDER REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. INSR(S), AUTHORIZED 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 The Dowd Agencies, LLC NAME: Ma Conroy 14 Bobala Road PHONE413 538-7444 FAx Holyoke MA 01040 E-MAIL AIC No: ADDRESS: CROOUCER D - ENELL INSURED INSURERS AFFORDING COVERAGE NAIC N Energia, LLC INSURER A:Evanston Insurance Company- 242 om an 35378 242 Suffolk Street INSURER 13:Commerce Insurance Company 34754 Holyoke MA 01040 INsuRER c:StarStone National Insurance Company 25496 INSURER D:Guard Insurance Group 8281 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 1131630225 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 S BR LTR TYPE OF INSURANCE POLICY EFF POLICY EXP POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY 2064466 7!112018 7/1/2019 X EACH OCCURRENCE S 1.000,000 COMMERCIAL GENERAL LIABILITY DAMA EN PREMISES Ea occurrence 550,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $1.000 PERSONAL 8 ADV INJURY S1,000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2.000,000 POLICY X PRO- LOC PRODUCTS-COMP/OP AGG S 2.000,ODO B TOMOBILE LIABILITY S AU BHQPBJ 7/1/2018 7/1/2019 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1.000.000 ALL OWNED AUTOS BODILY INJURY(Per person) $ X SCHEDULED AUTOS BODILY INJURY(Per accident) S X HIRED AUTOS PROPERTY DAMAGE 5 X NON-OWNED AUTOS (Per accident) 5 C X UMBRELLA LIABX OCCUR 75750H780ALI 5 7/1/2018 EXCESS LIAR 7/1/2019 EACH OCCURRENCE CLAIMS-MADE $1,000.000 DEDUCTIBLE AGGREGATE $1,000.000 RETENTION S $ 0 WORKERS COMPENSATION ENWC952172 S AND EMPLOYERS'LIABILITY 7/1/2018 7!1/2019 X WC STAUTTU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory In NH) If es,describe untler E.L.DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE A80VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. To Whom It May Concern AUTHORIZED REPRESENTATIVE --TI988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD commonwealth of Massachusetts Division of Professional Licensure Board Of BUllding Regulations and Standards Construction Supervisor CS-092540 Expires: 09/02/2019 THOMAS B ROSSMASSI ER 7 100 MAIN STREET HATFIELI)MA 01038 Commissioner Ofrice Or Consumer Affairs&Bus Hess Regulation NOME License or registration valid for individul use only IMPROVEMENT CONTRACTOR ttegistration: 165169 VExpiration: before the expiration date, if found return to: 1/11/2018 LLC Type' Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 ENERGIA LLC `�0 Boston,MA 02116 THOMAS ROSSMASSLER j 242 SUFFOLK STREET HOLYOKE. MA 01040 Undersecretary - 1 Not valid tivithout signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le ibl Name (Business/Organization/individual):_ EIIeCCIIa, LLC Address: 242 Suffolk St. City/State/Zip: Holyoke, MA 01040 Phone #: 413-322-3111 Are you an employer?Check the appropriate box: [2. .VI am a employer with 4. �] I am a general contractor and I 7E] ect(required): employees(full and/or part-time).* have hired the sub-contractors onstruction ❑ I am a sole proprietor or partner- listed on the attached sheet. elingship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' . emolition [No workers' comp, insurance comp. insurance.$ 9. ❑ Building addition 3required.] 5. [I We are a corporation and its 10-El Electrical repairs or additions .E] I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL 11.[] Plumbing repairs or additions insurance required.] t C. 152, §1(4),and we have no 12.[] Roof repairs employees. [No workers' 13.[1 Other 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: Guard Insurance Group Policy#or Self-ins.Lic.#: ENWC952172 Expiration Date: 7/01/2019 Job Site Address:r ` k City/State/Zip:_T CY��� �MA,Q��Z Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimina fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties l penalties of a in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify der the pains and penalties of perjury that the information:provided above 's true an correct. Si azure: Date: 2 Pho a#: 13-322-3111 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#: RISE ENGINEERING' OWNER AUTHORIZATION FORM 1, Alice Rich (Owner's Name) owner of the property located at: 144 Federal Street (Property Address) Florence, MA 01062 (Property Address) hereby authorize C:-A/6 Q—Zz— (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. XOner-'s-��Siganature Date RISE Engineering,a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335 www.RiSEengineering.com