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38D-043 (2) ��v v I-.w— / k—)UV — Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability L . Room 100 Water/Well Availability ' Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ► SECTION 1 -SITE INFORMATION Q P ( "� f (0C/ 1.1 Property Address: This section to be completed by office 3 �� Iv V Map_ ) Lot Q�-5 _Unit A� `AA M A Zone Overlay District lElm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print Curr nt Mailingdrgss �/I 3X1(3 36 Telephone Signature 2.2 Authorize Agent: 1 �a A ESL n w, r L'( — jo LO Name(P' Current Mailing Address: 7=4--� LO-3 &qS-? 39 Signature Telephone r SECTION 3-E6 TIMATED 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=(1 +2+ 3+4.+5) OR 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) 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 f� DON'T KNOW © YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 1P YES O IF YES: enter Book Page and/or Document#, i B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW )&, YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO (� IF YES, describe size, type and location: L 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 © NO l IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: c f Not Applicable ❑ Name of License Holder: License Number Add ess Expiration Date ignatur Telephone 9. Registered Home Improvement Contractor: / Not Applicable ❑ Company Name Registration Number Address Expiration Date 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement windows Alteration(s) Roofing Or Doors tw Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [0] Other[Co Brief Des ri ion of Proposedf k 1 n t 1 Work: ' o I 1 K u 111 S ►` 2�� Y I�Pv Alteration of exTsting bedroom Yes No Adding new bedroom Yes Nee ,,, Attached Narrative I Renovating unfinished basement Yeso Plans Attached Roll -Sheet 6a. If New house and or additiolh to existing housing, complete the following: a. Use of building : One Family o 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, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby declare that the statements and informati on the foregoing a lication ar t( and ac ate, to the best of my knowledge and belief. IV- Signed under the pains and pe alties of perjury. +h� 1 l CL44 Print Name �} �32 � ner/ nt Date City of Northampton r•�'`¢ Massachusetts r ;} DEPARTMENT OF BUILDING INSPECTIONS Z �' / 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: 31-/ P61►r iv W (Please print house number and street name) Is to be disposed of at: (Please print name and location' facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) /'Y a re 7o/fermitApplicant or Owne 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 r Department of Industrial Accidents s I Congress Street,Suite 100 e Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): l �v9 wvt (J l i C 1 Address: C�e4P`�� City/State/Zip: `et� � Phone #: Are you an employer?Check the approp .ate box: Type of project(required): I jaI am a employer with cC� employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.[—]l 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 arc sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.0 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.t � I 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14 Other C,/�L 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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. t Insurance Company Name: A ('Q Fes{^r t Policy#or Self-ins. Lic.#: I�O A R P Expiration Date: 2 Job Site Address: �y #o o w otle— City/State/Zip: O✓, vj 1 L Attach a copy of the workers'compensation policy declaration page(showing the policy number and expir ion 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 hereby certify underthe pains-an rtes of per' that mation provided above is true and correct. Si a Date: Q Phone#: 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#: Wea f J A DAll home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, Vrovial must be registered with the Commonwealth of Massachusetts. low Inquiries about registration and status should be made to the AN/A11L1@lgOQ1BWAtf Director. Home Improvement Contract Registration, One alodrbnewm..�e...�. Ashburton Place,Room 1301,Boston,MA 02108(617)727-8598 375 Chicopee St. Chicopee,MA 01013 z, Phones:(413)883-3802 1413)331-4357 Fax:(413)331-4358 1-011call Pay more,but you can't buY bete :IA "'cL.54 1u :T Lie#a5 5a47 www.AllianceHomeinc.com N ���- Z3-�iS3� BMITT D�'O: Phone: f Cell• 3'° 2" XZ .` Email: ACA We hby subm specification nd estimates for work to be performed and materials b :6�� ` f d f4 AZ4r M_45'` tiul Leit, .4 aN OA MA4sem' •, mayt Madoo Jr r tr w ❑ Aluminum Trim ❑Alliance Trim ❑Flat Coil [:]PVC Coil ❑G8 Coll Color: E]Corners Color: ❑WINDOWS Grids: S ElNO ❑Flat r-1Contour [:]Colonial E]Diamond E]Other: O'How many? D/H,� PIC_ El2LS ❑3LS_ ElCSmt [12 Lt/CSmt ❑3Lt/Cs mt_ ❑AWN ❑HOP ElBOW(4 or 5 lines) ❑Bay Full Screen:❑YES 0 NO ❑Wood grain Interior: Color: Exterior Color:❑YES Z�MO Color: Mull:❑YES � ❑How many? Dass Option: Type:. limaTech ❑ClI aTech TK2 ❑ClimaTech TG2 E311�TRY DOOR;,�ES ❑NO ofype: '' ❑Stjle: ri tel' Z _ ❑STORM DOOR:❑YES ❑NO ❑Type: ❑Style: If ❑Material Location: Q aSte Disposal: c: WORK SCHEDULE Propq ed 5tart an eomplean Schedule-The following schedule will be adhered to unless cirwjTstances nd the con ctor's control arise: _. / Date when contractor will begin contracted work. 46 pate when contracted work will be substantially completed. Contracted work may not be In until both parties have received a fully executed copy of the contract,and the three day rescission period has expired.The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor including,but not limited to strikes,Acts of God,shortages of materials,accidents,and all other delays beyond its control,shall not be considered as violations ofthis Agreement. WARRANTY r All materials have�/ =fyy Warranty or as otherwise specified by manufacturer.Labor and workmanship have a warranty of one full year from the date of installation. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from the above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. PAYMENTS We propose hereby to furnish material gd labor-complete in acc dance with Payments to be made as follows: Z - C;; a§qve specification for the um of: ,/ ► rl/ %($ upon signing Contract; Iti .....dollars %($ upon delivery of materials; (!,i 7 %($ )upon job completion; C, Name of Salesman %($ •�q shall be made forthwith upon comp Edon work under this contract. Authorized Signature The customer hereby understands and agrees to pay finance charge of 1.546 per month(or annual percentage rate of 18%)on the outstanding nce not pald within 30 days after cornpletl.n of work.All payments received after 30 days after completion of work shall be applied first to unpaid finance charges and then to outstanding balances.In the event of default,customer hereby understands and agrees to pay,In addition to the outstanding Indebtedness,all costs associated with collection including reasonable attorney's fees. Acceptance of Proposal:I have read both sides of this document and accept the prices,specification and conditions stated.l understand that upon signing,this proposal becomes a binding contract.You are authorized to do work as specified.Payments will be made as outlined above.You,the Buyer,may cancel this transaction at any time prior to midnight of the 3rd business day after the date of this transaction.Cancellation must be done in writing. DO NOT SIGN THIS CONTRACT XTIEANY BLANK SPACEES. k1A(Signatur ate l Signature Date"" NOTICE OF CANCELLATION:YOU MAY NCEL THIS TRANSACTION,WITHOUT ANY PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE.IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACTOR SALE,AND ANY NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED.TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE,OR SEND A TELEGRAM TO:ALLIANCE HOME IMPROVEMENT,INC.,375 CHICOPEE ST„CHICOPEE,MA 01013 _(Date.Sunday and holidays excluded) I HEREBY CANCEL THIS TRANSACTION _._ ._ (Buyers Signature) ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/2019 ) ACORL7 03/11/2019 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 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). PRODUCERNTACT David Jarry Neill&Neill Insurance Agency Inc PHONE FAX 662 Riverdale Street 413-732 4137 A/C.No): 413-731-6629 West Springfield, MA 01089 ADDRESS: dj@neillins.com INSURERS AFFORDING COVERAGE NAIC# INSURER A: State Auto Insurance Companies STA INSURED Alliance Home Improvement, Inc INSURER B: SAFETY INSURANCE COMPANY 39454 Sergiy SuprunchukAdia Insurance Com A0235 375 Chicopee Street INSURER C: caCompany Chicopee, MA 0 10 13 INSURER D: 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 ADDL SUBR POLICY NUMBER MMIDDYEFF/YYYY MM/DDIIYYYY LICY EXP LIMITS LTR A GENERAL LIABILITY PBP2689283 03/12/2019 03/12/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE V OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ B AUTOMOBILE LIABILITY 6226463 12/04/2018 12/04/2019 COMEaaccidentBINED SINGLE LIMIT 1 000 000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per aocitlent $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED I RETENTION$ $ C WORKERS COMPENSATION MAARP300625 12/05/2018 12/05/2019 WC STATU- OTH- AND EMPLOYERS'LIABILITY FIR ANY PROPRIETOR/PARTNER/EXECUTIVE a NIA E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ Ifyes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE IS FOR PROOF OF INSURANCE PURPOSES ONLY CERTIFICATE HOLDER CANCELLATION Alliance Home Improvement, Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Sergiy Suprunchuk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 375 Chicopee Street ACCORDANCE WIT^E POLICY PROVISIONS. Chicopee, MA 01013 AUTHORIZED REPRESE TI l t ©1988-2010 ACORD CO ORATIO . I ights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD . %/r� t�r�r��r���rii�irf°rr/// i�. ��ir�.•1rri�iiir-//.i Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration .. Type: Corporation ALLIANCE HOME IMPROVEMENT,INC i s , Registration: 154218 375 CHICOPEE ST Expiration: 02/19/2021 CHICOPEE,MA 01013 5 h Update Address and Return Card. ;CAI A 2OM-0&17 .//� %'�•iiuiiriinvvi///1 ��,r/�rr-�.Iitr�tr �./L� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Renis ration Expire Ion Office of Consumer Affairs and Business Regulation 154218 02/1912021 1000 Washington Street-Suite 710 ALLIANCE HOME IMPROVEMENT,INC L—A A 02118 SERGIYSUPRUNCHUK ,4? C�(�X�a--- 375 CHICOPEE ST CHICOPEE,MA 01013 Undersecretary N t valicriwithout signature Colml MW441th of Messmouse is . Ohflelon of PMkoalonal Lkensm BMW of MAdlnq a and lUndiirds Cone� P,�`�7�rvlsor `' fF C8404327 �pJr":i111Y/Z010 t Vic CFfICOt�!!MA s,� Commisdoner L/""