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24A-130 (5) 33 PROSPECT AVE BP-2021-1136 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24A- 130 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Bath reno BUILDING PERMIT Permit# BP-2021-1136 Project# JS-2021-001909 Est.Cost: $30000.00 Fee: $180.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 7143.84 Owner: BENJAMIN MARA Zoning: URA(100)/ Applicant: BENJAMIN MARA AT: 33 PROSPECT AVE Applicant Address: Phone: Insurance: 33 PROSPECT AVE (212) 666-9232 () NORTHAMPTONMA01060 ISSUED ON:4/7/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:BATH R E N O 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: ' ' r ' ' FeeTvpe: Date Paid: Amount: Building 4/7/2021 0:00:00 $180.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 1------ -___QICit-t- S, The Commonwealth of Massachusetts Board of Building Regulations and Standard APR ' 6 FOR lcti Massachusetts State Building Code, 780 C1�I 20�/ 1 CIPALITY TO l USE Building Permit Application To Construct, Repair, Renovate"&k 0[#rolis ra Re►lisedMar 2011 One-or Two-Family Dwelling t�'.F,���7L��IoNs LL vv This Section For Official Use Only �'� Buildin Permit Number: &" -1/"//,,3(/ Date Applied: )46-.V)1,-) (21) .5 .1/ Li-ta-Zd1 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numb s 33 erc ct Ave No titomp%i tMa, 0ic?bu /A /3a 1.la Is this an accepted street?yes Y 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'o Record: v N k" M O 6 0 k a s > Name(Print) ' City,State,ZIP No.and Street Telephone Email Address) tic°IAA— SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building[l( Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': (:f}, IYtih1 ge lir&i SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ (XV-00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 000'CO 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ l-fO,Qo.x) 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fee th Q� Check No. Check Amount: / O 6. Total Project Cost: $ 303 -Cb ❑ Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL"Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Z zy H&rt/ w KS D BA HIC Registration Number Expi a on Date HIC Company Name or LII,C Registrant Name 70 1-crx' ('4witt 4t biiw tYlAtrics &-ru I-cct14 No.and&refit Email address Leveret- / - (?Ion{ 113-76y-Dy City/Town,State,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 ❑ 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(Electroi c 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 contained in this ap lication is true and accurate to the best of my knowledge and understanding. it',tt v 7 cZ I Print Owner's or th• - A ;gent's Name(Electronic Signature) Date NOTES: 1. An Owner who o•tains 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 v wv.mass.gov/oca Information on the Construction Supervisor License can be found at «.mass.quo /cips 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) 70$9/.41t. (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks!porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 41.r••‘;', The Commonwealth of Massachusetts 1)epartment of Industrial Accidents 1 Congress Street,Suite 100 1.4 .3: Boston,:%1 1 02114-2017 www.muss gov/dia 11uikers' ('onipcusation Insurance.%ffida%it: BuildersK'ontractorsiEkctricianst'Plumbers. '11)BE FILED NAB"1II1. Pf NMITON(;Al''hIIURI'11. Atrnlicant Information Mt Please Print Legibly' / 1 Name 1LiustncssCkganlraucwr ittdtr ll�lal►: GL`G�, islal'1�,ir'1 i n Address: 33 ve, CltylStateiZip:/bent tti oil MGt. 0{p o Ph0ne#: I-9-1 2 66,6- 23 2 Are sou an e1e l rr?Cheek the appropriate hot: Type of project(required): ICI I ano a cmptuycr atih employees ikoll and Of part-trine,.' 7. : J New construction n 2.0I am a sole proprietor or partnership and have no employ ez-%a Olt rnc Ilia me m '$. etnodeling m a capacity..[No aorktT, eying.irtourance regaured.I IL IIGG!! 9. ❑Demolition ICJ I am a honavarocr doing all work sayself.!No workers'comp_insurance required"" 100 Building addition 4. I am a honuvwner and call be hiring cnoIradurs to conduct all wcad.on my property_ I will ensure that all co ntrrtora either bow aurkcrs"compensation insurance u arc sole II.dElectrio:al repairs or additions proprietors w nth no employees_ 12. Plumbing repairs or additions <in I am a general contractor and I base hued doe mob-contractor%hstcyl on the attached sheet. 130 Roof repairs Thor subtiuntracturs to/a employees and hams worker;curtail.uuanonce. 6.0 wc an:a corporation and its officers hav a cAtne"laed(heir ngrht of ex...mptaert per kit rL c_ 14.0 Other -- I It4t.and we have rioeropluyccs.[No o others'comp.insurance required.' 'An% appticart that chocks hoA al mum also tits out the season betua show one then aorl era culnpcmatwnpolits rrtierrnation. 'Il.rrr000 ncra a hu%ubmnit tins affidavit uid o:a.tutu they arc doing all work and then bir:uubrde corstractoradattsi subtotal a nea afitdavii indicating arch. 'Contractors that eheet,this tint must attawited an ad.htoonal ahood shun mg the n:une of the sub-contractors and slate abetter ur not those►unties bast employer+. It the anb-eoutraeruta INtc enrr{1Io►eca.obey nnrat prusode then 'rtorkera comup_policy manber.. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Mann: Policy#or Self-ins.Lie.#: _ _ Expiration Date: — Job Site Address: CityiState 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 andOr 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_ copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer fr u the as and penalties of perjury that the information provided above is true and correct Signature: Date:. / 5/2- Phone#: ti-Llt“P `2-31— Official use only. Do not write in thi.t area,to he c•umplcted b►'cite'or town official ('itv or Town: Permitil.icense# Issuing Authority;(cirek one): I. Board of Health 2.Building Department 3.('it.,i.nsn Clerk 4.Ekctrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton `>>i r�s1ir�. ' ' `,, s/ j 1�f� ti Massachusetts ti \w )�{`;► DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building sv�, CDC Northampton, MA 01060 •P.siii..,ii_s`1, 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: Location of Facility: Republic, Servicee The debris will be transported by: Name of Hauler: Re3bi;c Semi-lc 5 it ----- Signature of Applicant: � Date: (21( OV2o21 City of Northampton -0m1,,r0��� sv .S Massachusetts �' f ~fit { i.a; !' DEPARTMENT OF BUILDING INSPECTIONS ti 212 Main Street • Municipal Building J •L' ' .-� Northampton, MA 01060 4. ‘ HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, tAA A (insert full legal name), born (insert month,day, year), hereby Apose and state the following: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns 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-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this S day of 41 , 20 z (Sign ture) Proec-- Curre • . ., Toik+ \ 41010 _ i S�,oWPt '� ; rani IV' - _4room rbOli dose-f 7—.1' 1 : 13(47'i, i(.)k-1 . 1 • a 1vj11c L'14J Ac -1-e‘,- ... Toile* • . . _... giper __ EIoSe4 14� f i - -_ :mot i ACC)121:21 DATE(MM/DD/VYVY( CERTIFICATE OF LIABILITY INSURANCE 0405,2021 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). PRODUCER CONTACT Susan Fleury CIC CISR CPIA NAME: King&Cushman Inc. PHON No,Eat): (413)584-5610 FAX No): (413)584-9322 P.O.Box 447 E-MAIL sfleury@kingcushman.com ADDRESS: 176 King Street INSURER(S)AFFORDING COVERAGE NAIC p Northampton MA 01061 INSURER A: The Concord Group INSURED INSURER B Daniel O'Dell,DBA:Handyworks INSURER C 470 Long Plain Road INSURER D: INSURER E: Leverett MA 01054 INSURER F: COVERAGES CERTIFICATE NUMBER: CL214504182 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ED CLAIMS-MADE X OCCUR PREMISESO(Ea occu rence) $ 50,000 _ MED EXP(Any one person) $ 10,000 A 20041227 04/01/2021 04/01/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: Employee Benefits AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO 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 UAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE n N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ II 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Mara Benjamin ACCORDANCE WITH THE POLICY PROVISIONS. 33 Prospect Ave AUTHORIZED REPRESENTATIVE Northampton MA 01060 � ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD