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31C-061 CONTRACTOR CHANGE Con friac U(\ 23 HIGGINS WAY-LOT 5 BP-2019-1413 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31C-061 CITY OF NORTHAMPTON Lot:- PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:New Single Family House BUILDING PERMIT Permit# BP-2019-1413 Project# JS-2019-002285 Est.Cost:$371750.00 Fee: $1640.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SHAUL PERRY 065400 Lot Size(sq. ft.): Owner: SHAUL PERRY Zoning: Applicant: SUNWOOD BUILDERS AT: 23 HIGGINS WAY - LOT 5 Applicant Address: Phone: Insurance: 84 POTWINE LANE (413) 259-1000 WC AMHERSTMA01002 ISSUED ON:7/24/21)19 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT NEW SFH WITH ATTACHED TWO CAR GARAGE 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 sign<,tn , ' i FeeType: Date Paid: Amount: Building 7/24/2019 0:00:00 $1640.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner is The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR `Y�_ Massachusetts State Building Code,780 CMR MUNICIPALITY _„ USE _ y Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2010 6 One-or Two-Family Dwelling 1111 o o (�Q n This Section For Official Use Only o_ m a Building Permit Number: 6 -► 1 el4I3 Date Appli : o z 1.1-1zo 3da) U m Building Official(Print Name) Signature ate Q 0 cr SECTION 1:SITE INFORMATION o CC ot Lu 1.1 Pro r rd;psi 1.2 Assessors Map&Parcel Numbers n V 1 ( 1.1 a Is this an accepted stfeet?yes)( 5fritio 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 wne ' Record r'l«.f 7 .r ec / 00r/wood 1Cr Ali O/Gcoi Name(Pri / ity,State,ZIP / 8 l n/W,IYd fc. 4/3/'9/A� Sv,rwoode,coocast eJ No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number f U 'ts Other eci :—/5 4, Brief Descrip 'on of Propos iork2: SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees/ Check No?_2heck Amount: L Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: ..,e c,- 6inLia, C,Fz, Chi an -e, SECTION 5: CONSTRUCTION SERVICES 5.1 Co true on Supervisor License(CSL) G LI_D ,�n 5 o j .rr License Number �Shc Ex ratio Date Name of CSL Hol er ) / n / List CSL Type(see below) (�/ N2iLr / �� / Type Description 4 O/oo U Unrestricted(Buildingsupto3000cuft.) Cit�own,State,Zit' CJ R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 gistered Hoige Ipprovep►�t Contractor(HIC) Off wood v. crs /Q�30 aOf HIC Registration umber Ex era on Date HIC pa to or HIC Rygistrant Name / / 1 No. S et frioired Ao,rfei ejew0eOr &Co/VICO..1 /le .remes V. D/OO� �/,t _ i9/00O Email address City/Town,State,ZIP /(-J 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 Issuan a 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date 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 contaalin in this application is true and accurate to the best of my knowledge and understanding. ") ali-r O Print Owner's or zed Agent's Name(Electronic Signature) ate // 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 �? � • j � c Iits ,{_ DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building � .Cb Northampton, MA 01060 s ';-• O. 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 150A. The debris will be disposed of in: call of Facility: Main D O�oi',� Location ac ty Main/0/'! rci Aljairp iOlf /rG�f The debris will be transported by: Name of Hauler: 5401 Pert evorvood Avidcrif Signature of Applicant: Date: Ot/ -- The Commonwealth of Massachusetts Department of Industrial Accidents - u 1 Congress Street,Suite 100 Boston.MA 02114-2017 www mass.gov/dia 11 or•kers'Compensation Insurance Affidavit:BuildersiContractors/Ekctricians/Plumbers. TO BE 111.1:1)%1'111-111E PER5IIT•1IN(:AUTN0RITII. Applicant Information —_/ Please Print legibly Name(Business)(k ani7ation'Individual): SorrWOor Address: Uifo7'w, _T City/State/Zip:Ai/Aei-Stt M/`I O/Ct Phone#: -pelt? 1000 Are y au an eu.pkn er!Clerk the appropriate hos. Type of of project(required): 1 l am a emphwcr with /� en�lleyce (folk and,in trot-tiro[)a 7. New construction 201 am a sole proprietor or patnerslrip and lose no employees working fur ne en g. Remodeling airy capacity.[No workers'comp.immature n-quires[.] 9. ❑Demolition 3 I am a Im orwwnr cluing all wink myself INu workers'comp.insurance required.) 10 Q Building addition 4f:I I am a h nicowneu and will be hiring contractor,to eundrud all work urn my poverty_ I will cream:that all cwr11 w10r>either terse workers'cum nmattun insurance or are sole i 1.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions S01 am a&la to al aonuaetor and I lose hired the sub-contractors listed on the attached sheet_ 130 Roof repairs These suhtmtractors lose employees and base workers'comp.insurance., 6.0 We art aeorp uratiun and its otTrecrs base eats-erred them tight of ascription per NCI c_ 14.o Ot)tc`I 1SZ 11(4),and we have nu employees.INu workers'cutrr_insurance required.' •Any applicant Pm darks boa#1 mini also fill out the section below>huwing then limier,'comp.-maim policy informing& tiwncuwaen who submit this drain it indicating they are doing all work and then hire outside contractors mom submit a ttawatlidasii nadirs-aline such 'C ontra:kmrs that check this hoc must attached an additional shirt sbussing the name of the mb-connacturs and sale whether ar sot those entities base employees. If the sub-contracwrs have employes.they must preside their worker;coaw policy number.. I am an employer that Is providing workers'compensation insurance for my employirrs. Below Ls the policy and job site information. • �/uJ ? ,rcwrcc./ Insurance Cotnpany Name: -- Policy#or Self-ins.Lie.#:y✓iv/Z5OO8OO5& 9dO/QA) ___-- Expiration Date: (deep/Oft Job Site Address: os /r , A/0/j40/7p1C 'r CitytState Zip_4ry ,61/r!/J' o,oso Attach a copy of the wont npensati policy declare on page(showing the police number ant espiraJion date). Failure to secure,coverage as required under MGL c. 152,§25A is a tximinal violation punishable by a tine 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 tine of up to 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of InveAigations of the DIA for insurance coverage verttic:tlit) . I do hereby eerti/i untie the p . and penalties of perjuy that the information provided' ppCJ aboveb1 is true and correct Signature: 22 Dat ly e: O��/ PExutc ��V 9'/d0 //aa Official use only. Do not write in this area,to be completed by city or town official. Cite or Town: Permit/License# Issuing Authority(circle one): I.Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector 6.Other Contact Person: Phone!t: ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/02/2020 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 Kathy Parker NAME: Webber&Grinnell PAHONN EMI: (413)586-0111 FAX No): (413)586-6481 8 North King Street EDDRIL kparker@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC N Northampton MA 01060 INSURER A: Selective Ins Co of Southeast 39926 INSURED INSURER B: Selective Ins Co of S Carolina 19259 Sunwood Builders,Inc. INSURERC: A.I.M.Mutual/A.I.M. Attn:Shaul Perry INSURER D: 84 Potwine Lane INSURER E: Amherst MA 01002 INSURER F: COVERAGES CERTIFICATE NUMBER: CL203512689 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 ADDCSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD MID _(MM/DD/YYYY)1(MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $ 500,000 — MED EXP(Any one person) $ 15,000 A S239905500 03/04/2020 03/04/2021 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO i BODILY INJURY(Per person) $ B OWNED s,/ SCHEDULED A910808200 03/04/2020 03/04/2021 BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY X AUTOS ONLY (Per accident) Medical payments $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADES239905500 03/04/2020 03/04/2021 AGGREGATE $ 1,000,000 DED X RETENTION$ 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER , C ANY PROPRIETOR/PARTNER/EXECUTIVE N/A WMZ80080056582020A 05/22/2020 05/22/2021 E.L.EACH ACCIDENT $ 500 000 OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 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 City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 240 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 'J/1 y\nP I �I ©1988-2015 ACORD CORPORATION. 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