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38C-021 (2)
361 SOUTH ST BP-2021-1205 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:38C-021 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2021-1205 Project# JS-2021-002016 Est.Cost: $12797.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WORTHINGTON CONSTRUCTION 069649 Lot Size(sq. ft.): 6141.96 Owner: JOHNSON SALLY J Zoning: URB(100)/ Applicant: WORTHINGTON CONSTRUCTION AT: 361 SOUTH ST Applicant Address: Phone: Insurance: 254 WORTHINGTON ST (413) 883-6171 WC SPRINGFIELDMA01103 ISSUED ON:4/21/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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 UPO VIOLATION OF ANY OF ITS RULES AND REGULATIONS. ,2 . Iota Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 4/21/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner RECEIVE :,� APR 2 Thy Commonwealth of Massachusetts 0 2021 oardu of Building Regulations and Standards FOR MUNICIPALITY \ __ assadhusetts State Building Code,780 CMR USE dt�1(.Di 1 r i._____ NoRTHAt f ;,,;+"Ikpp#ication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 _.—.__ _--. . _r One-or Two-Family Dwelling t t i This Section For Official Use Only Building Permit Number: 4 P-.7/-'/d 0 Date Applied: L .-1Z /ZZ L_ Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Ass ,Map&Parcel Numbers I=� c / , t " 4 it .1,1 eu V 1.Ia is this an accepted street?yes_x 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 l 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 U Private❑ Zone: _ Outside Flood Zone? Municipal El On site disposal system U Check ifyes0 SECTION 2: �P�RjOPERTY OWNERSRRIP1 17,-2.1 Ownert of Recflrd: i �G 'S/ # ill ,6/d CAO Name(Print) City,State,ZIP . S361 �'r f 4J�- ,�- No.and Street Telephone Email Address r SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction CI Existing Building X Owner-Occupied II Repairs(s) C I Alteration(s) LI Addition 0 Demolition ❑ Accessory Bldg.0 Number of Units Other ClxSpecify:Rooffnstallaiion Brief Description of Proposed Work': "Installation of a Asphalt Shingle Rooftop:"Rip-&-Replace Asphalt"Dispose in 30 Yard Dwnpster,Dumped Local TransferStatiotrfLand Fill SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: se�y Official Il (Labor and Materials) _ 1.Building S 1. Building Permit Fee:S Indicate how fee is determined: 2.Electrical $ ©Standard City/Town Application Fee II Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (I-IVAC) $ List 5.Mechanical (Fire Suppression) Total All Fees:he1.1° 6.Total Project Cost: $ 2 s Check No6I Check Amount Cash Amount•. j 379-!, 0 Paid in Full El Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Paul M.Degrav CS-069649 05111/2021 Name of CSL Holder License Number Expiration Date No.and Street: P.O. Box 847Southwick,MA 01077 List CSL Type(see below) "U" Type Description City/Town,State,ZIP U Unrestricted(Buildings up to 35,000 cu.11.) (413)279-9144 R Restricted l&2 Family Dwelling info(w.worthingtonconstructiongroupinc.com M Masonry Telephone Email address RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Insulation D Demolition 5.2 Registered Home Improvement Contractor(HIC) 189-575 03/10/2022 Anthony Matos I Worthington Coast.Group HIC Registration Number Expiration Date Inc. HIC Company Name or HIC Registrant Name info i4 orthingtonconstuctiongroupinc.com 254 Worthington Street Email address No.and Street SprinEfield MA 0110 (413)883-6171 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 "Yes" No .B 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 ente 'og my name below,I hereby attest under the pains and penalties of perjury that all of the information 'o t s appl' '•- • true and accurate to the best of my knowledge and understanding. coal. Anthony Maros Pres. Worthington Const Group Inc _x • • uthorized Agent'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.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" The Commonwealth of Massachusetts Department of Industrial Accidents i �' Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 ww».mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Worthington Construction Group inc. Address:254 Worthington Street City/State/Zip:Springfield MA Phone#: (413) 883-6171 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 5 4. 0 I am a general contractor and I 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. 0 Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' insurance 9. 0 Building addition comp.[No workers' comp. insurance required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.1111Roof repairs insurance required.] T c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required] *My applicant that checks box#1 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: Nortiaurd INS CO Policy#or Self-ins. Lic.#:WOWC063855 Expiration Date:08/05/2021 Job Site Address: X _�'7 SR//if 27 City/State/Zip/,,'j /l,/ 4 e/46 O 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 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. 1 do hereby certify !der the pains and penalties ofperjury that the information provided above is true and correct. Signatur f / //,`"‘//)c:/}-/ Date: 1/4 2-/ Phone i# (413) 8836171 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): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 ElectricaI Inspector 5Elumbing Inspector 6.DOther Contact Person: Phone#: FoofriziwevieefeatA4 e/.."‘-eze,Weeelee'c-ie/f, Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston,Maseiachusetts 02118 Home irnproverneatCbutractor Registration �. : Type: Corporation 'i ,` gistfation: 189575 WORTHINGTON CONSTRUCTION GROt " E a gistr"11:. 03/t0J2022 254 WORTHINGTON STREET SPRINGFIELD,MA 01103 i F x_ Update Address and Return Card. SCR 1 * 171-$114Af i Dints at Consumer Malts&Dusinge Rapuiauon HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Cornoratin i,atnre the expiration date. It found return to: 8agIst ldien LIIWURIER Office of Consumer Affairs and Business Regulation :182;575 03!10120-'�' :000 Washington Shoat-Suite 710 WORTHINGTON CONSTRUCTION GROUP INC. . Alston,MA . 111 ANTHONY R.trtAias 4! ►fir 254 WORTHINGTON meet ip,w.wr r!;sj .' SPRINGFIELD.AAA Ot 103 Ot valid with ut signature Commonwealth ot',14 ..tcIsu et' �` Division of Professional Ucensure Board of Building Regulations and Standards :ons#�f '5f!'t:p,rvisor CS-069649 Tres;05/114021 PAUL M DEGRAY - " POBX847 - ,' SOUTHWICK MA 01071 Commissioner itr «�— Direct Payment Request WORTHINGTON FEIN N 82-1034609 CONSTRUCTION GROUP CS#-069649 www.WorthingtonCon structionGroupinc.corn 413.279.9144 MA 1860.270.0409 CT 800.386.0179 Toll Free Work Authorization and 254 WORTHINGTON STREET SPRINGFIELD, MA 01103 Insured name and billing address rri-/ /trAta /I / Property Address: 1 ec l4I In alit 3S686,5-7f __ Insurance C mpany 'ame: Agent Name: )/ The general scope of this work and the Contract Price is set forth in the estimate of Worthington Construction Group Inc..,which is incorporated into this agreement. Work will commence on y�22— 2 I and the estimated completion date is 5-//I 21 which may be extended for delays beyond the control of Worthi ton C nstruction Group Inc. / In consideration of the agreement of Worthington Construction Group Inc.to provide services required to preserve and protect the personal and/or real property which I own,control,or lease. I) 1/We hereby assign to Worthington Construction Group Inc.all my rights,title,and interest in and to a portion of all the insurance benefits or proceeds to which I/We may be entitled,and assign any and all claims which 1/We may have against my insurer,to the extent of the amount of the bill for professional services rendered to me and/or my property referenced above;and I/We hereby grant a lien to Worthington Construction Group Inc.on any insurance benefits or proceeds that may be due to me.1/We further acknowledge and agree that said assignment may not be revoked retroactively,and may only be revoked by giving a written notice by certified mail or hand delivery to Worthington Construction Group Inc.within 3 days of the signed date of this contract. 2.) I/We hereby authorize and direct the payment of such insurance benefits or proceeds directly to Worthington Construction Group Inc.and direct the above referenced insurance company to pay Worthington Construction Group Inc.such �/ sums as may be due upon receipt of statement for services rendered. fT _ me at or my prone ronta wu III IIlit Id 4.) 1/We hereby request and authorize my insurance company to furnish Worthington c construction group ink with any and all information,including without limitation,payment information and estimates with regard to work required to preserve and protect the personal and/or real property which I/We own,control,or lease. 5.) Any individual or entity shall be entitled to relay on the original and/or photocopy of this document as if it were an original. 6.) It is understood that the estimate is subject to the approval of the adjust or or the representative of the insurance carrier. 7.) I/We acknowledge that all movable items of significant value have been removed from the premise or destroyed as follows: g.) 1/We further understand that any and all deductibles and/or betterment from our insurance carrier shall be due and payable by us at the completion of services rendered.If payment is not received within 30 days of invoice,a delinquent payment penalty will be erged at 18%anal rate. Q�em nu, wunTisTef n-ff�Feagrce pay reasonable alto n C • L cou I e . 10.) All contractors and subcontractors must be registered by the state and any inquiries relating to a registration should be directed to the state.Owners'rights are set forth in M.G.L.c.142.A. Do not sign this document if there are any blank spaces /j Intending to be legally bound,l/We sign this day of h// Zo 2-1 Awner's Printed2 e and Signature SQ( t d 7 0�I Owner's Printed ne and Signature Date 712 r,i5;46-.Y4— /I Y(2( k orth'n n ro resenlative Printed Name and Signature to Note:If a mildewcide has been applied by a tank sprayer,avoid going into the affected area for at least one(1)hour after application L 1 City of Northampton OaYMAMYTO.:. .y... 4% " Massachusetts 'es sc� 4 ; "CG DEPARTMENT OF BUILDING INSPECTIONS ‘& `► r' 212 Main Street • Municipal Building pa� J;Northampton, MA 01060 ry ... ...0 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: 14 9-72i147 e-yL, The debris will be transported by: Name of Hauler: JI2 M7 �%f��'T� /1? /x 4 - _ Signature of Applicant: Date: Vi'1