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25C-170 (3) 38 ORCHARD ST BP-2020-1140 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C- 170 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING; WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:demolition BUILDING PERMIT, Permit# BP-2020-1140 Proiect# JS-2020-001910 Est.Cost: $40000.00 Fee: $280.00 PERMISSION IS HEREB Y GRANTED TO. Const.Class: Contractor: License: Use Group: TOSHI KASHIMA 060134 Lot Size(sg. ft.): 7710.12 Owner: COSTELLO ROBERT D toning. URB(100)/ Applicant: TOSHI KASHIMA AT. 38 ORCHARD ST Applicant Address: Phone: In strrance: 15 UNION ST (413) 774-5402 __ WC GREEN FIELDMA01301 ISSUED ON:5/21/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-DEMO OF INTERIOR FIRE & WATER DAMAGE 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 5/21/2020 0:00:00 $280.00 212 Main Street, Phone(4 13)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Versionl.7 Commercial Building Pernut May 15, 2000 { Department use only z City of Northampton Status of Permit: 'n y Building Department Curb Cut/Driveway Permit - I C i 212 Main Street Sewer/Septic Availability n` Room 100 Water/Well Availability Z t Lp z'1 t.�'� Northampton, MA 01060 Two Sets of Structural Plans r., I P o m o p Ong 413-587-1240 Fax 413-587-1272 Plot/Site Plans g a Other Specify API,LId OTV TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 38 Orchard Street Map A Sc Lot / 70 Unit Northampton MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Robert Costello 137A Franklin Street, Arlington MA 01474 Name(Print) Current Mailing Address: c� //�� yy, (413) 387-8464 Signature e1 e � YN�f\-SRI I�^ Telephone 2.2 Authorized Agent: Quality Cleaning and Restoration 72 Montague City Road, Greenfield MA 01301 Name(Print) Current Mailing Address: (413) 774-7737 Signature �-� - - �_ Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building y O, DUv { ae�+o (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 48L/ 5. Fire Protection 6. Total= (1 +2+3+4+ 5) 04 Check Number This Section For Official Use Only Building Permit Number Date r/ 1(? Issued Sig tures 0 But ing Commissioner/Inspector of 135Wings Date Version 1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs 0 Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑ Brief Description Demo of interior fire and water damaged drywall, floor, cabinets Of Proposed Work: SECTION 5 -USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business ❑ 2A ❑ E Educational ❑ 213 I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential Q R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) _.._.._.__,....__._ __. _._..,..'-- 1St St 2nd 2nd 3 rd 3rd 4m 4th Total Area(sf) -��- Total Proposed New Construction (sf) Total Height(ft) Total Height ft 7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone[-] Municipal ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ® No SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Robert Costello as Owner of the subject property hereby authorize Quality Cleaning and Restoration to act on my behalf, in all matters relative to work authorized by this building permit application. 05/08/2020 Signature of Owner Date Quality Cleaning and Restoration 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. Christopher Philipsen Print Nam ----- 05/08/2020 Signature of Owner/Agent Date SECTION 12 -CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Toshi Kashima CS-060134 License Number 15 Union Street, Greenfield MA 01301 11/04/2020 Address ' Expiration Date ft— U�'1rrk ST (413) 522-1713 Signatul!&� —�� Telephone SECTION 13 -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 0 No DATE(MM/DD/YYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE `� 1 04/03/2020 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 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 NAME: Michelle Bettencourt A H RIST INSURANCE AGENCY INC IAIC No.Ext): ( )PHONE 413 863-4373 FAX No: _ EMAIL ll h icee ADDRESS: MiChelle@ahrist.com P O BOX 391 _ 1NSURER[SZAFFORDINGCOVE RAG E NAIC0 TURNER FALLS MA 01376 INSURERA: LIBERTY MUTUAL_ FIRE INS CO 23035 INSURED INSURER B: TOSHIHARU KASHIMA INSURER C: INSURER D_: 15 UNION STREET INSURERE: GREENFIELD MA 01301 INSURER F: COVERAGES CERTIFICATE NUMBER: 521073 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'TYPE OF INSURANCE ; POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY I MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE El OCCUR PREMISES Ea occurrence) $ _ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY D PROJECT D LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WAND EMPLOYERS'LIABILITY ORKERS COMPENSATION /� STATUTE ERH ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A WC231S376057020 03/23/2020 03/23/2021 (Mandatoryin NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Quality Restoration ACCORDANCE WITH THE POLICY PROVISIONS. 72 Montague City Rd AUTHORIZED REPRESENTATIVE . QJ Greenfield MA 01301 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 313 OCClhacc S}- The debris will be transported by: The debris will be received by: Building permit number: Name of Permit ApplicantCleaner o. Date Signature of Permit Applicant QUALITY 72 Montague City Rd Greenfield, MA 01301 Restoration 413.774.7737 FIRE WATER STORM Fed Tax ID #45-4127163 Claim: Robert Costello Insurance Company: Address: 38 Orchard Street, Northampton, MA, USA Local Insurance Agency: Home Phone: 4133878464 Adjuster: Business Phone: Adjuster Email: Date of Loss: May 8, 2020 Policy No.: Client Email: rdcostello@aol.com Claim No.: Costello Type of Loss: Fire Deductible: WORK AUTHORIZATION AND DIRECTION TO PAY I agree to hire Quality Cleaning and Restoration ("Quality")for cleaning, restoration and remediation services. I authorize Quality to enter my property and to complete the work as deemed appropriate by Quality. I represent that I am the owner of the house or property which has been damaged. I further represent that the damaged property has appropriate insurance coverage to cover the loss or damage which is the subject of Quality's work. I authorize and instruct my insurance company to pay Quality directly for its work in connection with this loss or damage, or, include Quality as a co-payee on checks for payment. I assign to Quality my right to recover payment under applicable insurance for Quality's work. I authorize Quality to send this contract to the insurance company for Quality to obtain payment directly from the insurer. If the insurance company pays me, despite my authorization and instruction to pay Quality directly, I agree to pay Quality within five (5) business days after receipt of the insurance payment. I authorize Quality to supply information about this loss or claim to the insurer, as well as a report of services provided by Quality. I understand that I am hiring Quality and I am responsible for full payment for Quality's work and services, regardless of insurance. I am responsible for paying any insurance deductible or charges not covered by insurance, or not paid by an insurer for any reason. I understand there is no guarantee that in all circumstances items or property can be restored to their condition prior to the loss or damage. Quality will try in its good faith discretion to ensure that its charges for services will be the amount authorized and paid by available insurance, not including any deductible, client-ordered change orders, or unforeseen damage presently hidden. However, Quality does not and cannot promise this. Where insurance is not available, or insufficient, Quality will charge its customary rates, which are available upon request. Late charges of 18% per annum shall be charged on late payment and I shall be obligated to pay Quality's reasonable attorneys'fees necessary for collection. I also agree that, in the event Quality is not paid within 30 days of completing its work, at its option, Quality shall have a lien on my property where the work was done. —j� May 8, 2020 Owner: Date