36-213 (14) 33 BIRCH LN BP-2021-0113
GIS#: COMMONWEALTH OF MASSACHUSETTS
Maa:Block:36-213 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 RENO BUILDING PERMIT
Permit# BP-2021-0113
Proiect# JS-2021-000206
Est.Cost: $27500.00
Fee:$178.75 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DAVID A HARDY CONTRACTOR 043898
Lot Size(sq. ft.): 213008.40 Owner. KUCHINSKAS SHARI
zoning: Applicant: DAVID A HARDY CONTRACTOR
AT. 33 BIRCH LN
Applicant Address: Phone: Insurance:
PO BOX 1468 (413) 527-2655 WC
EASTHAMPTONMA01027 ISSUED ON.7/29/2020 0:00.00
TO PERFORM THE FOLLOWING WORK:KITCHEN 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:
FeeTyne: Date Paid: Amount:
Building 7/29/2020 0:00:00 $178.75
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
lax The Commonwealth of Massachusetts
Vi
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
I This Section For Official Use Only
uildin it Number: Date Applied:
J
n
Buildin O cial(Print Name) Signature . Dat
SECTION 1:SITE INFORMATION
1.1 Pr2perty Address: 1.2 Ass ssors Map&Parcel Numbe s
C 4"e Flo�,tce `Llil
1.1 a Is this an accepted street?Y es no ap Number Parte umbe-r
eP
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
cS�herrl /% kuckliiyk!�3 FlOrcAcf 6 (r -7—
Name(Print) City,State,ZIP
'36 of/rid 1ev,e A e r-r 1 VC& 40
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': —let i e � I ii u
.n
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ , J 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $
13 Standard City/Town Application Fee
O d •GO ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 576C6, Go 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:
Check No _Check Amoun t
6.Total Project Cost: $P :Olt,w ❑Paid in Full ❑Outstanding Balance Due:
17,6•75
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C5 `6ta -QT- //
61 (`!o � 5/ License Number Expiration Date
Name of CSL older�J—�' `-
1 n List CSL Type(see below)
�f
no K�X�C� Type Description
No.and Street
( �� / Q U Unrestricted(Buildingsu to 35,000 cu.ft.
L"Vo �'K.Q 4" 7D R Restricted 1&2 Family Dwelling
City/Town,State,Zur M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Lf(3` 6)-dYct-7 [ Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 15:.7 F yo A,lo 1R.%_
[1 ISA/ C C HIC Registration Number Expiration Date
lie 141 1 9 IC Company ame or strant Name ��Q
`( leo = D ff D412by S 0d,e
No.and S et mail address
Cit /Town,Stat,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
S
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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L
1,as Owner of the subject property,hereby authorize G�Id is I (k � e& �'�uCl1CPN U./--
to act on my behalf,in all matters relative to work authorized by this building permit dpplication.
Print Owner's Name(Electronic-Si g-natfire) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain this application is true and accurate to the best of my knowledge and understanding.
7 —),\g dig - AO oto
Print Owner's or Authorized A nt's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mgg.gov/oca Information on the Construction Supervisor License can be found at www.mass.g_ov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
!
Office of Investigations
Lafayette City Center
` 2Avenue de Lafayette, Boston,MA 02111-1750
t
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): DAVID A. HARDY, CONTRACTOR, LLC
Address: P.O. BOX 1468
City/State/Zip: EASTHAMPTON, MA 01027 Phone #:413-527-2655
Are you an employer? Check the appropriate box: Type of project(required):
1. ■❑ I am a employer with 3 4. ❑ I am a general contractor and 1 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P h'• 9. F] Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.[J Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
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.
Insurance Company Name: FARM FAMILY CASUALTY INSURANCE COMPANY
Policy#or Self-ins. Lic. #: 2001 W8463 Expiration Date: 07/02/2021
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. 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 cert y der the pains a nalties of perjury that the information provided above is true and correct.
Si nature: Date: 7
Phone#: 413-527-2655
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
1❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50PIumbing
Inspector 6.❑Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) name(s), address(es)and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center, 2 Avenue de Lafayette
Boston, MA 02111-1750
Tel. (617) 727-4900 or 1-877-MASSAFE
Revised 7-2019 Fax (617) 727-7749
www.mass.gov/dia
Farm Family Casualty
Insurance Companya
9 I . An?mercan National Con-�pany
NATIONAL
344 ROUTE 9W I GLENMONT,NY 12077-2910
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE
NCCI COMPANY NO, 16721
JOSHUA E NADEAU
POLICY NO. 2001W8463 246 NONOTUCK AVE
EFFECTIVE 07/02/2020 CHICOPEE MA,01013-2500
TRANSACTION TYPE Renew
FEIN# 20-8235541 413-203-5180
ITEM 1.INSURED INSURED AND MAILING ADDRESS:
DAVID A HARDY CONTRACTOR LLC
PO Box 1468
EASTHAMPTON,MA 01027-5468
THE INSURED IS LLC
Workplaces covered by this policy:
ST WP NO. ADDRESS OF WORKPLACE RTG.BUR NO. INTRASTATE NO.
MA 1 116 PLEASANT ST STE 332
EASTHAMPTON MA 01027-2756
ITEM 2.POLICY PERIOD I
The policy period is from 07-02-2020 to 07-02-202112:01 A.M.Standard Time at the insured's mailing address.
ITEM 3.COVERAGE
A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the state listed here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.The limits of our
liability under Part Two are:
Bodily Injury By Accident Bodily Injury By Disease Bodily Injury By Disease
$500,000 each accident $500,000 policy limit $500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here: All states except the states
designated in item 3.A. of the information page and ND,OH,WA,and WY
0
0
m
D. This policy includes these endorsements and schedules: N
WC00000lA0319 WCOOOOO000115 WC0001150120 WC0003150985 WC0004040484 WC000406A0795
a
WC0004140790 WC000422B0115 WC2003010484 WC200302A0908 WC200303D0810 WC2004011190
WC2004030191 WC2004050601 WC200601A0708 WC2006041102
0
0
0
0
Copyright 1987 National Council on Compensation Insurance
PROCESSED 2020-05-28
WC000001A
Edition 03-19
2001WS463
Construction Debris Affidavit
(for all demolition and renovation work)
In accordance with the provisions of MGL c4O, $ 54,a condition of Building Permit
Number is that the debris resulting from this work shall be disposed of in a
property licensed waste disposal facility as defined by MGL c 111, �150A.
The debris will be disposed of in: _
Valley Regional Recycling &.Transfer Facility, Northampton
LOCATION OF FACILITY
The debris will be transported by:
David A. Hardy, Contractor, LLC
NAME OF HAULER
SIGNATURE OF APPLICANT
) — g4
DATE
g CommonwreaRh of Massachusetts
Division of professional Licensure
Board of Building Regulations and Standards
Co nstruet%Adpervisor
CS-043898Expires: 11/12/2021
DAVID A HARDY
4 COOK ROAD
SOUTHAMPTON MA 01073 #,
Commissioner f
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
159840 06/02/2022 100hingto Street -Suite 710
DAVID A.HARDY,CONTRACTOR LLC B ston, A 1 8
DAVID HARDY
4 COOK RD.
SOUTHAMPTON,MA 01073 Undersecretary Not valid without signature
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