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16D-032 (6) 58 LILLY ST BP-2021-1235 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16D-032 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-2021-1235 Project# JS-2021-002057 Est.Cost: $19430.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MAJOR HOME IMPROVEMENTS 103054 Lot Size(sq.ft.): 23304.60 Owner: COOK DANIEL Zoning: URB(88)/WP(44)/URA(12)/ Applicant: MAJOR HOME IMPROVEMENTS AT: 58 LILLY ST Applicant Address: Phone: Insurance: 19 HUNTER SLOPE (781) 913-6405 WC WESTFIELDMA01085 ISSUED ON:4/27/2021 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 UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy signature - > . '1 • FeeType: Date Paid: Amount: Building 4/27/20210:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 4, C.'‘� The Commonwealth of Massachusetts 4/°A 1 e Board of Building Regulations and Standards 3 FOR Massachusetts State Building Code, 780;01 1Z, <90(2 UNICIPALITY • USE Building Permit Application To Construct, Repair, Renovate'C i>Petpolish ai R(ksed Mar 2011 One- or Two-Family Dwelling `",o<�Fer�' �T This Section For Official Use Only osOoys I Building Permit Number: 491-'a,!-.P 36- Date Applied: -'` . , Building Official(Print Name) Signature e SECTION 1: SITE INFORMATION 1.1 Property Address 1.2 As a sor ap& Parcel Numb r) LA. 11 y t5 fi'-eel- 1.1 a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq II) Frontage(it) 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 OWNERSHIP1 1 2. �Ct,r)ei r^ 4 cor rtow ce ( It'L'1 01 C`6 Name(Print) City, State,ZIP .se ally klfiQ � y -2,) c.. b-9 -63g3 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building tr Owner-Occupied 0 Repairs(s) a Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: ,,v-,_ Brief Description of Proposed yl'ork2: S-ki 13 .Q_( (S� ,1 _L_ .Yt__ . ,.Ld1_ ____T SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1 9, 4 3 Co 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $,�s: _ / Check Novi 36 Check Amount: Cash Amount: 6.Total Project Cost: $1 C t (F 'D 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) J V a J I r 1. 1hr1, ,kh ct,) CikLLI License Number Expiration Date Name of CSL Holder ( List CSL Type(see below) J ) s (fl O Type Description No.and Street i L d ,t t i or O �� U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP !"� R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding r �)6 36G�6 /� �,�' iced() SF Solid Fuel Burning Appliances i c i r) Insulation [ Telephone Email ad ess D Demolition 5.2 Registered Home Improvement Contractor(HIC) 157)x`C �3/. NL /1 a c iQ b o - me- ��em 5 HIC Registration`C Number Expiration Date HIC om N e or HIC Re r t N kr N'. _ Email ad ess C� 1 and)s Stet-h LLd o(c�a'S ),).6 36 -6cxi 6 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 [I' 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 I( )Ci/)C JLU,k. to act on my behalf,in all matters relative to work authorized by this building permit application. 6631( I 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 contained in this application is true and accurate to the best of my knowledge and understanding. / I / q-70/ Print Owner's or Authorized 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" ,sikSr.r.o.. -, The Commonwealth of.11assuchusetts Departinent of industrial.-Iccitlents R9 -::°', AI 1 Congress Street,Suite 100 ,,s.r• , , „.," -50-- Boston, .31A 02114-2017 w ovw.mass.gov/din t Waiters'Compensa Ilion Insurance.1flidavit: Builders/Contractors/Electricians/Plumbers. To BE C11.11)will!'UBE PERNWITINt;Al'IllORITV. Applicant Information Please Print Legibly Name I BusinessiOrgatimationfIndividuall: 411. 1.1c ...11 itClitt. tiltP1--0 -iiitid—) Address: ce9X , 4227/--- C'ity/StatetZip : 'kid A 0(0 - Ph one# (3)6 ‘ -60-(-(‘ an employ rr!Check fir appropriate hot: Type of project(required): i D I.:1111 a employtx with_ , entpkleo.(lull nntl'or pnel,timel.. 7. 0 New construction ..::.:I am 4 suk propntiot of palinerihir.and base is,employees woviang tia me in H. 0 Remodeling any Voracity.(NO workers'comp.insuranvx required" 9. 0 Demolition ljI am a homeowner Joins all work myself.(No workos'1:012tp insurance roluinall' lc)0 Building addition 4 D I am a homeowner and will be hiring contractors lu conduct all sv ork on nriy property. I will CIESUIV that all coigns:tors either have soaker's'compensation insurantx ot are sole II 0 Electrical repairs or additions • propnetots with no empliiyees. I am a iNnetili contractor andhave I kited die subeeunti actors listed on the attached sheet.1,,T ese sub-contractors haxe employom and have workers'eornr.insurance.: I la Plumbing repairs or additions l 3 1111 Root repairs _ 14.0 Other ba we are a corporation and its officers have exercised their nilln 11t%Atavism per MICiL c. _____ !SI f 1(4),rein we have no employees.[No workers'comp.insuranee requital *Any apt,licarH i thai i4iOcks box gi IIII1S1 al.ei fill our[ire;ecnon belou stun%my them workers compensation policy information. *Homeowners who submit this affitlav it indicating they arc doing all w ork and then hue outside comae tors must submit a new affidavit indicating suck contractors that check this box must attached an additional sheet show nip the 1111M42 of the sub-contractors and Male%belief or not those entities have employ rev It tlx sax-contractors have viirploy ces.they must Nov idc Men mmkers'%.-omp robe) nuitik.: Itt I am an employer that is providing worAers•compensation insurance formy employees. Below is the policy and job site inlOrmation. lriNurance Company Name: _ Policy it or Self-ins.Lie.#: Expiration Date:_ _________ Job Site Address: „ City/StateZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required wider MC.B.,c. 152, ' 25A is a erimUial violation puni.Aiable by a Fine up to SI.59(L00 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 (la, against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coveratc i critic...Won. I do hereby certify under the pains and penalties of perjury that the inlOrmation provided above is true and correct. --- _____..... $ignature: 1).-11,: If/ti( k-r Phone#: 4/),) - :3 —1()(44 Official use only. Do not write in this area, to he completed by city or town official City or Town: Perinitilicense# — Issuing Authority (circle one): I. Board of Health 2. Building I/epartinent 3.Cityfrowa Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton Massachusetts t 'W DEPARTMENT OF BUILDING INSPECTIONS � �f 212 Main Street • Municipal Building ��, Northampton, MA 01060 ,HtivK� 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: SEA( 1 /yU,\Ci ,C) ) (_,J The debris will be transported by: Name of Hauler: ()(S A N C LtrZ /Q-c cy cl arc // Signature of Applicant( Date: 7.4 oL ( { { Commonwealth of Massachusetts IPDivision of Professional Licensure Board of Building Regulations and Standards Consist<uetthi 1St5pervisor CS-103054 Expires: 08/2412022 VASILIE M KUKHARCHUACr;. 19 HUNTERS SLOPE ''� ; C WESTFIELD MA 01085 Commissioner �j= �� �i. ati;+c11a, Office of Consumer C�ffair�s&eusfness Riegul ion HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 150841 05103/2022 VASILIE KUKHARCHUK D/B/A MAJOR HOME IMPROVEMENTS VASLIE M.KUKHAREHUK 19 HUNTERS SLOPE WESTFIELD,MA 01085 Undersecretary • 1 ATE OF CON \ECTICUT DEPARIUF\TOF(i):\'r :IL:R PROTF_CTIO:V Timm IMPROVEMENT CONTRACTOR VASILIE KUS IARCHUK 19 Hunters Slope Westfield,MA 01085 MAJOR HOME IMPROVEMENTS Registration# Effective Expiration 1 HIC.0611632 12/01/2020 11/30/2021 SIGNED 1 { Ac RO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �.r►' 06/11/2020 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 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: Christina Penna BERKSHIRE INSURANCE GROUP INC HONo.Exn: (413)447-3519 FAX (A/C. ADDRESS: cpenna@berkshireinsurancegroup.com 43 East St INSURER(S)AFFORDING COVERAGE NAIC# PITTSFIELD MA 01201 INSURERA: LM INS CORP 33600 INSURED INSURER B: MILET INC INSURERC: DBA MAJOR HOME IMPROVEMENTS INSURERD: 19 HUNTERS SLOPE INSURER E: _ WESTFIELD MA 01085 INSURER F: COVERAGES CERTIFICATE NUMBER: 542989 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 I 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 LTR LSD WWVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT 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 $ AUTOS AUTOS ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH PEATUTE AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A WC531S360160050 06/09/2020 06/09/2021 (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/LOCATIONS/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 Major Home Improvement ACCORDANCE WITH THE POLICY PROVISIONS. 19 Hunter Slope AUTHORIZED REPRESENTATIVE C� Westfield MA 01085 Daniel M.Cr oro y,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 ACc R17 CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) `...� ^ 05/06/2020 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 David R Jarry Neill&Neill Insurance Agency Inc PHONE 413-732-4137 FAX 413-731-6629 662 Riverdale Street {AlC,No,Extk (A/C,No): West Springfield, MA 01089 E-MAIL ADDRESS: dj@neillandneill.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Northfield Insurance NOR INSURED Mile':`., Inc.dba Major Home Improvements INSURERS: 19 Hunters Slope Westfield,MA 01085 INSURER C: INSURER D: 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. h1OT VITHSTANDING 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 ADDLISUER LTR TYPE OF INSURANCE INSD II WVD POLICY NUMBER POLICY EFF POLICY EXP {MMlDD/YYYY) (MMlDDlYYYY) LIMBS A ✓ COMMERCIAL GENERAL LIABILITY WS424227 '04/29/2020 b4/29/2021 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) 5 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE ILAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY P F JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ 1$ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAE CLAIMS-MADE AGGREGATE $ DED RETENTION$ j $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS LIABILITY Y/N STATUTE 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 $ � I 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESE' ATI'E ibio II B f* > rA WO Ihit iNIIVI cm .,1 01100 ',10 ONSI NiiI