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31C-062 27 HIGGINS WAY-LOT 6 BP-2021-1122 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31 C-062 CITY OF NORTHAMPTON Lot: -6 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-2021-1122 Project# JS-2021-001886 Est.Cost:$372000.00 Fee: $1312.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SHAUL PERRY 065400 Lot Size(sq.ft.): Owner: SUN WOOD BUILDERS Zoning: Applicant: SHAUL PERRY AT: 27 HIGGINS WAY - LOT 6 Applicant Address: Phone: Insurance: 84 POTWINE LN (413) 259-1000 WC AMHERSTMA01002 ISSUED ON:4/6/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW SINGLE FAMILY HOUSE 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. I , I TO r '1 • .52 Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 4/6/2021 0:00:00 $1312.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner A `RvLLry PL/ 1& The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: b P 4--i I Z — Date Applied: r r_tii\itth Building Official(Print Name) Signature ��� '! 0/ 1 6 Date y SECTION 1:SITE INFORMATION l.147e6tty A ress: , .---7 1.2 Assessors Map&Parcel Numbers ^� Z tt a a 06 ilit y (x P 1.1a Is this an . c,'tee street?yesX no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: e Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided ' Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private CIZone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1�'ner ecord: / / 1`./Tout erry - jorrwoed roi‘cesi a O/OOot Name(Prin / City,State,ZIP / 8� "o/ Iw vt i�-o# , *3 i 9-/GVO 6 wocc/�/6irrcas t. rfc,,-1 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Constructiot4Existing Building 0 Owner-Occupied 0 Repairs(s) Cl Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work'-:/OO Sc. - l 3 -L t }' si /ear Cjfa, SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building SC3a 000 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ aaQQO 0 Standard City/Town Application Fee i 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $d‘000 2. Other Fees: $ 4.Mechanical (HVAC) $„/�%OQQ List: 5.Mechanical (Fire S -� Suppression) Total All Fees: $ i1 2112 Check No (;heck Amount: Cash Amount: 6.Total Project Cost: S(.. OOQ 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Co true 'on SupervisorSun License(CSL) /t LJ_D , n 56G� .Qrr License Number ,f(/[J Ex ti Date Name of CSL Holier Si/ / List CSL Type(see below) _2) irtc1 ire/ No.a Str et Type Description . �be(6 Alj1 aoo1 U Unrestricted(Buildings up to 35,000 cu.ft.) ��77 �/(/7 (/` 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 gistered Ho I prove t Contractor(HIC) - LW^Ap33 � l.�iyw00d 1Ot9,�Cr ' HIC Registration umber E ira on Date Hipa e or HIC R}�gistrant NameAol/ / l �I et diet SV/`�i' &il� �C.O$T Ile} /"rust, A O/ODot 4,C3 i9/000 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 Issuan e 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(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 contain in this application is true and accurate to the best of my knowledge and understanding. GW/ l 0 Print Owner's or Autho 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 4 ._F._tip'' C�\... i '' Massachusetts ��?�' .L. ',''.e j! H' �. 1"" 4I, ,i`ifi,' DEPARTMENT OF BUILDING INSPECTIONS ;_ g ` aw ' 212 Main Street • Municipal Building 9Li, ,ii" Northampton, MA 01060 ''J ••. ` ' 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: ael Cill ./ / Location of Facility: 'OA( o✓rinlo/Y rd /YarAoirp4 y i( 0/o60 j The debris will be transported by: Name of Hauler: 5AckaPer-t 6vrfrvoocJ' o /d4 c Signature of Applicant: Date: Ot/ The Commonwealth of Massachusetts Department of Industrial Accidents '_ _ 41 Congress Street,Suite 100 _ = Boston,MA 02114-2017 www mass.gov/t is Workers'Compensation Insurance Affidavit:Builders&Contractors/Eketrlcians/Plumbers. TO RE FILET)WITH THE PERMITTING AUTHORITY. Applicant Information - -1(� Please Print Legibly Name(Itusinessf r$anirationtlndividual): 6v#wo0U KJGit'/riCd'S' Address: U�( 20 tly,LtC jattczr_ City/StateJZip1f y %,- M/Y 0/Oat Phone#: f ' 'p ?-/O0O Are yea an employer?Cheek the appropriate boot Type of project(required): t Ian a employer with__ 04 _employees(Hill aadior plan-tins).+ 7.,ew construction 20 I am a sole proprietor or partnership and have no employees working forme in $. 0 Remodeling any capacity.[No wasters"ccanp.insurance required.] 30 I a a homeowner all workwalkers't myself.[No walkers'comp.iusaramce mitered.] 9. El Demolitionm dr 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on osy property_ t will ensure that all cornractora either have workers'compensation insurance or are sole 11 a Electrical repairs or additions proprietors with no employe. 12.0 Plumbing repairs or additions 50 I am a general contractor and I have hired the mb'conrratimrs listed on the attacfhed diem. l3 Roof repairs These subcontractors have employees and have workers'comp.insurance_% 6.0 We art a corporation and its officers have exercised their right of exemption per NCI c. 14. Other I S2.I10).and we have no employees.[No workers'comp.insurance required.] 'Any applicant that cheeks box 01 mint also fill out the section below showing their women'compensation policy inforrnatirw. t Horneowmenr who submit this atridsei t indicating they are doing all watt and then hire outside carMractras must submit a new affidavit indicating such. tContracwni drat cheat this box must attached an additional shay showing the name of the sub-contractua and state whether or not those entities have employees. lithe sub-contraca rs have employees.they attest provide their waiters'comp_policy number_ I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site infer atatiort. Insurance Company Name: Policy#or Self-ins.Lie.#: Wx!z8Oo8ot2��& fOf(A) Expiration Date: t,O'ot/d/ Job Site Address: City/State/Zip:4 J�,,t4't� 0//O/tlo 0 Attach a copy of the workers'compensation policy declaration page(showing the policy number and'expiridion date). Failure to secure coverage as required under MGL c. 152,425A is a criminal violation punishable by a fine up to S 1,500.00 ancVor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage i do hereby certiJ trade/ he and penalties of perjury that the Information provided above lss t'w t e and correct. Signature:0 22 Date: L30/,e/ Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitiLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CltylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A`oRIJ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/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 (HONN Ext). (413)586-0111 laic,No): (413)586-6481 8 North King Street E-MAIL kparker©webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Selective Ins Co of Southeast 39926 INSURED INSURER B: Selective Ins Co of S Carolina 19259 Sunwood Builders,Inc. INSURER C: A.I.M.Mutual/A.I.M. Attn:Shaul Perry ' INSURER D: 84 Potwine Lane ' INSURERE: 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 ADDL SUBR POLICY EFF ' POLICY EXP LTR TYPE OF INSURANCE INSD MD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY 1 EACH OCCURRENCE $ 1,000,000 DAMAGE TO D CLAIMS-MADE n OCCUR PREMISES(EaENToccE ence) $ 500,000 MED EXP(Any one person) $ 15,000 A S239905500 03/04/2020 03/04/2021 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 _ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED x SCHEDULED A910808200 03/04/2020 03/04/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) Medical payments $ 5,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE S239905500 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 [7 N/A VVMZ80080056582020A 05/22/2020 05/22/2021 E.L.EACH ACCIDENT $ 500 000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) 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/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 "/112 . -D vt I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD