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32C-126 (7) 36 FRUIT ST BP-2020-1213 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C- 126 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: KITCHEN&BATH RENO BUILDING PERMIT Permit# BP-2020-1213 Project# JS-2020-002044 Est.Cost: $24000.00 Fee: $156.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: STEPHEN D ROSS 079160 Lot Size(sg.ft.): 7318.08 Owner: BECKMAN ROBERT C Zoning. URC000)/ Applicant. STEPHEN D ROSS AT. 36 FRUIT ST Applicant Address: Phone: Insurance: 36 SERVICE CENTER RD (413) 584-1224 (� NORTHAMPTON MA01 060 ISSUED ON.6/9/2020 0.00:00 TO PERFORM THE FOLLOWING WORK.-KITCHEN AND BATH RENO 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 6/9/2020 0:00:00 $156.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only Yr, City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit �, `� 212 Main Street Sewer/Septic Availability 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 1.1 Property Address: This section to be completed by office Map 1AC— Lot 1 2fj Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Curnre�nt Ma11 v Address: 7 r /V e✓ G 2: L Telephone Signature 2.2 Authorized Agent: Name(Prild Current Mailing Address: na e Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building Gam) �� (a) Building Permit Fee 2. Electrical LUQ (b) Estimated Total Cost of Construction from 6 3. Plumbing f, �� Building Permit Fee 4. Mechanical(HVAC) P., 5. Fire Protection 6. Total=0 +2 +3+4+5) 2 p JO Check Number n-� This Section For Official Use 0l Building Permit Number: ,JJ/ () 121,3 Issued: ed: Signature: 8,z 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 Side L: R: L: R: Rear Building Height Bldg. Square Footage % 'Qpen Space Footage % (Lot a ved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO (:>/ DON'T KNOW 0 YES o IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO �DON'T KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , 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 0 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 Q NO 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 Alterations) Ea Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding [O] Other[l3] Brief Descript of Proposy-d / `/ /' I��r Work: -c.�-+c c� � t Alteration of existing bedroom Yes No Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes // 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 construct' n. Dimensions e. Number of orie ? f. Method of heating.• Fireplaces or Woodstoves Number of each g. Ene4ConservationIia e. asscheck Energy Compliance form attached? h. TypeLconstruction i. Is co 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 . 1. 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 1, �C��_�� �-L K,ism_.-,l—L as Owner of the subject property hereby authorize to act on my behalf, in all matte relative to work authorized by this building permit application. Signature of Owner Date as Owner/Authorized Agerr ereby d are that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the p ins and penalties of perjury. flL-cy—j I- C,-:)- Pri gnature f Owner/Agent 6ate The Commonwealth of Massachusetts _ Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 ..'� www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aimlicant Information Please Print Legibly Name (Business/Organization/Individual): Address: ✓`z'J �� —✓ City/State/Zip: v ��*^- �- AIV Phone #: Are you an emplo ?Check the appropriate box: Type of project(required): 1.�1 am, mployer with employees(full and/or part-time).* 7. [] New construction 2. in a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.O I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4f�I am a homeowner and will he hiring contractors to conduct all work on my property. I will 10[] Building addition ensure that all contractors either have workers'compensation insurance or are sole l 1.E]Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance., 13.E]Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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. 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: Policy#or Self-ins.Lic. #: 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 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 certi er t penalties of perjury that the information provi77;�; r a and correct. F Si nature Date: 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#: A�o�Ro® CERTIFICATE OF LIABILITY INSURANCE DATE /DDIYYYY) 03//0404/2020 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 Patrick Gooden NAME: Webber&Grinnell PAHONN Ext (413)586-0111 FAX No): (413)586-6481 8 North King Street E-MAIL pgooden@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: West American/Liberty 44393 INSURED INSURER B: A.I.M.Mutual/A.I.M. Stephen Ross INSURER C: Attn:Kim Clairemont INSURER D: 36 Service Center Road INSURER E: Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 7/20 Master 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 CONTRACTOR 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 POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 15,000 A BKW58371793 03/01/2020 03/01/2021 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY � PRO ❑ LOC [PRODUCTS $ 2,000,000 JECT OTHER: I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED 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 LAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILYIN ITY STATUTE ER B ANYPROPRIR/PARTNER/EXECUTIVE NIA WMZ80080065462019A 07/01/2019 07/01/2020 E.L EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in Ni E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 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 Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction SuDe isor: Not Applicable 0 ^ Name of License Holder: License Number .3G S'tr re Address -AID 14r V4&b Expiration Date Signature Telephone Not Applicable 0 Moo- -&J m c, 07 pan, ame Registration Numbee Address Expiration Date no, Telephorek/L*�-1�22� IS 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. LSigned Affidavit Attached Yes....... 13 No...... [I ew The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner,Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-ve."reriod shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Buildingt,Official,that he/she shall be responsible for allsuch work Performed under the bufldine permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS ` 212 Main Street *Municipal Buildingti 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: (Please print house number and street name) Is to be disposed of at: e/�d' ('C!2n (Plea a print name a6d location of fa lity) Or will be disposed of in a dumpster onsite rented or leased from: (C mpany me and Address) Sin re 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. City of Northampton f � Massachusetts E DEPARTMENT OF BUILDING INSPECTIONS x 212 Main Street • Municipal Building vti a� 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 co oration or LLC, that entity be registered Type of Work: L ��t /Lil C`Q� Est. Cost• Address of Work: Date of Permit Application: �C Z 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: Date Contractor 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