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35-057 (4) 955 RYAN RD BP-2021-1047 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35-057 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit# BP-2021-1047 Project# JS-2021-001781 Est.Cost: Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JAMES WALLING 105507 Lot Size(so. ft.): 17380.44 Owner: MARTIN MIKE Zoning: Applicant: JAMES WALLING AT: 955 RYAN RD Applicant Address: Phone: Insurance: 62 SUMMER ST (978) 880-8772 BARREMA01005 ISSUED ON:3/23/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL CHIMNEY SYSTEM FOR WOODSTOVE 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. ;6149\AAK- 311 Certificate of Occupancy Signature: FeeTvpe: Date Paid: Amount: Building 3/23/2021 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner /INN<0 * 14 The Commonwealth of Massachusetts *'99 ice'`<-�, 116bit I Board of Building Regulations and§tandars,\ c�� �' CI ITY Massachusetts State Building Code, 78()C1*."6, c'p�J USA" Building Permit Application To Construct,Repair,Renovate lish a ised,klar 2011 One-or Two-Family Dwelling •4i, i c.� vnc,� �•^ e /f This Section For Official Use Only °bb o4s Building P rmit Number: I I " on- /0q7 Date Applied: ti CWO ( 17 -/ 3 Z3 202I Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1cfr rty,Addre ` 1.2 As ors Map&Parcel Numbers ,7 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: - ThIkg_ r rfcx) f +hrkitnp+On,ma oID Li-Q Name(Print) City, State,ZIP 955 (Nail l Rd- C&tl3 .1 —`�L 2S . i�aplq t 1 -70c_nr icask��f No.and StreetTelephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other Specify: Brief Description of Proposed Work2: IIS iv�a - c u1 y O C psi`4'l$ LOCYYA SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 3iss u,o0 I. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee ce 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 0 2. Other Fees: $ 4.Mechanical (HVAC) $ 0 List: 5.Mechanical (Fire $ Total All Fees: Sat Suppression) Check No. (IA 17tCheck Amount: kJash Amount: 6. Total Project Cost: $ 3160..00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 105501 I l't Zo22 Jar S � tykr License Number Ex biraticn Date Name of CSL Hol er No. ` - opS-4.- PO '`-�L O List CSL Type(see below) No.and Street Type Description Sntki-Y ( � �/y�'4 O 107 4/ U Unrestricted(Buildings up to 35,000 Cu.ft.) Y 1 ( V r ' l `-( R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry J �i f esa f -`,� uvwv y�C 1 V ick s(CG O1 RC Roofing Covering a �V Window and Siding Solid Fuel Burning Appliances 64 1 3)ci 3 uj 14_l“CP I Insulation Telephone Email address D Demolition 5.2 Registered Home,Immprovement Contractor(HIC) lria�t LI 9 21 ccr-C d U U �t�S HIC Registration stration Number Expiration to HIC Comp Name or HIC Re s ant e Q77 a� inAkr V Cci nd( (eeTktedi1 Britt) Net v_y 6 iV l� (/1I,3)1 (s_7eiz o Email address tr✓La-St (0 City/Town,Stake,ZIP ! Telephone SECTION 6: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 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize c-1 y' di l ray ay �V L-ct S v• to act on my behalf,in all matters relative to work authorized by this building permit app ication. ()Ilk (r n 31 a1)66:3?I Print Owners Name(Electronic Signature) ate SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. TSc vs LOall Li 3) . /(2 i Print Owner's or Authorized Agent's Name(Eleic 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.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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" City of Northampton Massachusetts w: :� DEPARTMENT OF BUILDING INSPECTIONSs1/4 212 Main Street • Municipal Building ti, Northampton, MA 01060 sf , v10 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 1S0A. The debris will be disposed of in: Location of Facility: r&77 , GA r �►� �� 00 k The debris will be transported by: Name of Hauler: Op L'..0 &ft} LtCAS Signature of Applicant: _ Date: 3f4.zap The Commonwealth of Massachusetts Department of Industrial Accidents _ I Congress Street,Suite 100 s'••�" Bosh, MA 02114-2017 14'wis:mass.gov/den ')ureters'Compensation Insurance Affidavit:BuildersiCantractorsIEkctricinnsfPlumbrrs. it)BE E 11.E_D V1 r114 I PERNIrrr,N(;AUTHORITY. Applicant Information Please Print l.ct thh Name(auxin ( nimuonin►t,idua i: c-i�� G.4e. CJ'\Lrvrnf e/ Se.( � a S Address: a-77 aa\ cc City/State/Zip: L► s'e,le 6\ 0 ' Phone#: (y k3)q 3( 7 y(-P Are pa s•employes/Clerk the appreprhoe bse Type of project(required): tint am a employer with U) employees(fll and+err part-time I! 7. ©New construction 20 lam a sole prupriekw or punne,ship and haw no enrploy►es working in me m $. Remodeling any'e�{ueaty.['_ru woxkLn'carp.ireu mace required] 9. D Demolition 30 I am a Iionwuwner. doing all wink mpselt[Nu norkrra`cunap_imunaa c naluiriai_]' 4.01 am a haiun, wnia and w aasai ill be hiring mantrrs to a,aadnet all work on my property. brill 10 a Building addition era,arc that all contractors either have swarm'comp orrati In rcauran=air are yule 11.C]Electrical repairs or additions prnprkt.n with no employees. 12.0 Plumbing repairs or additions 50 I am a gerund contractor and I have hire the sob-contractors lined m the attached sheet_ 13.1Roof repairs Thew sub-contractors have eirgloyees and have worker(corp.ii unnae.: Otha 6.0 W e ate a corporation and its officers have exercised their right of exemption per MGL t_ 14` h lm n e y 13't 14 4).and we ba c no ev>,aluyees.[No woakeni"comp_insurance required] r e• t rS "Any applicant that checks bare#I most also fall out the station below showing their waxers'compensation policy infrrmatioe. I h nneow nee who subunit this affidavit indicating they are doing all wank and then hire ur6i&cariracturs mint submit a new affadavii sunk :Contractors that check din box must attached an additional sheet show irir the name(lithe su-cuimactarn and mak whether or nut those doilies helve cinpluyre^s_ It the sub-eotersckira'Roe cagiluyeca.they mon pru.idc then 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 Natne: Itia.V e to r S Policy#Of Self=ins.Lic.#:7PJ u ba Go a3 f to Expiration Date_ 51 ►a I as Job Site Address: q 55 Q GL.r\ 1 d CityIStatel71p:Tho ''p Attack a copy of the workers' peasation policy declaration page(showing the policy asrber and es oo date).C)1640 Failure to secure coverage as required under MGL c. 152,j25A 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 state neat may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cent' a the and penalties of perjuy than the information provided above is trete and correct. Signature: A y., Date: 31 0 I c20a i Phone Ale: C I ( ?) ( LG ` rig CO OfJicial use only- Do not write in this area,to be completed by city or town officiaL City or Toutn: Pernik/License# Issuing luthurit,, (circle one): I.Board of Ilealth 2.Building Department 3.('ii'T1'min Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts • gi Division of Professional Ucensure Board of Building Regulations and Standards • ConstructiottStipeiVisor Specialty CSSL-105507 Expires:01/19/2022 JAMES J WAILING 40 HIGH STREET P.O.BOX 40 _r • SOUTH BARRE-MA 01074 =. •10-' . r..r Commissioner / i-'G--- • P CJo/??i??ia1?Co2adei ot-c a-4e,{ex0 •G4P .5. Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration • Type: Corporation FIRESAFE CHIMNEY SERVICES INC • - Registration: 182449 277 PALMER RD UNIT 2C • Expiration: 06/25/2021 WARE,MA 01082 • • • Update Address and Return Card. MA 1 i3 2061.05117 .1:1 e 5.5/lI/rIeWle ilAf/`:/ieen i'jr,, i m .. 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: Reoistratiori ,- Expiration. Office of Consumer Affairs and Business Regulation 182449 06/25/2021 1000 Washington Street -Suite 710 FIRESAFE CHIMNEY SERVICES INC Boston,MA 02118 JAMES WALLINGJFI 277 PALMER RD UNIT 2C �/c%--rofl•'s/. _ WARE,MA 01082 Undersecretaryali ithot�t signature FIRECHI-01 JPIERCE ACORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/2/2021 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). CONTACT PRODUCER NAME: Brabo Insurance Agency PHONE 508 830-3800 FAX 65 Cordage Park Circle (A/C,No,Ext):(508) (NC,No):(508)746-1540 Plymouth,MA 02360 E-MAILADDRESS:info@braboinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Northfield Insurance Company INSURED INSURER B: Firesafe Chimney Services Inc. INSURER C: 277 Palmer Rd INSURER D: Ware,MA 01082 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 POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYY) IMM/DDIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR WS420788 7/15/2020 7/15/2021 PREMISDAMAGEES(TOEa RENTEDoccurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[ PRO-JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: CMBINED $ AUTOMOBILE LIABILITY Ea accident)SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $- OWNED SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY _ NON-OWNED ONLYY PROPERTY DAMAGE (Per ccident) $ _ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y/N LSTATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Street Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �-.� DATE(MM/DD/YYYY) A(lv/ CERTIFICATE OF LIABILITY INSURANCE 03/02/2021 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: Jessica Pierce BRABO INSURANCE (n"c°.No.Ext►: (508)830-3800 (NC.No): ADDRESS: jpierce©braboinsurance.com 65 Cordage Park Circle INSURER(8)AFFORDING COVERAGE NAICI Plymouth MA 02360 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: FIRESAFE CHIMNEY SERVICES INC INSURER C: INSURER D 277 PALMER ROAD INSURERE: WARE MA 01082 INSURER F: COVERAGES CERTIFICATE NUMBER: 627695 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 EFF POLICY EXP W MI LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET 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) $ NON-OWNED AUTOS N PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION v PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER A OFFICER/MEMBERAN EXCLU EXCLUDED?ECUTIVE Y® N/A N/A 7PJUBOG03354620 05/12/2020 05/12/2021 E.L.EACH ACCIDENT $ 100,000 (Mandatory in 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 1 LOCATIONS I 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/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton Puchalski Municipal Bldg ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD