18C-075 781 BRIDGE RD BP-2021-1284
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C-075 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit# BP-2021-1284
Project# JS-2021-002130
Est. Cost:$7000.00
Fee:$30.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JONATHAN HILCHEY 107356
Lot Size(sq.ft.): 47916.00 Owner: VAGET AMANDINE
Zoning: URB(100)/ Applicant: JONATHAN HILCHEY
AT: 781 BRIDGE RD
Applicant Address: Phone: /assurance:
51 RATTLE HILL RD (413) 726-4375 WC
SOUTHAMPTONMA01073 ISSUED ON:5/4/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMO WOOD DECK
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.
II "
.
Certificate of Occupancy signatul ; � � .
FeeType: Date Paid: Amount:
Building 5/4/2021 0:00:00 $30.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
VC%A\
4 c •
y
The Commonwealth of Massachus ym&, (-0 FbR
Board of Building Regulations and Stan..+ =e%
l Massachusetts State Building Code, 780 C o,��tis• MU,NTCIPALTTY
."
i,q 66, 4 USE
Building Permit Application To Construct,Repair,Renovate Or :v,;0, + a evised Mar 2011
One-or Two Family Dwelling s
This Section For Official Use Only
Buildin Permit Number: /0;te A lied:
KLv 5-14
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2/ears Map&Parcel Num ers�
781 Bridge Rd Ci
1.1a Is this an accepted street'?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(MG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal*'On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: Northampton,MA 01060
Name(Print) City,State,ZIP
413-320-0502 Amandine19834Iyahoo.fr
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition . Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': Demolish and remove existing wooden deck to allow for concrete patio
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated ' Official Use Only
(Labor and Materials)
1.Building l00000 1. Building Permit Fee:$ 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: $/ ` ,r
Check No. 11119 Check Amount: 70
6.Total Project Cost: $ 7000.00 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
HAMp
5\
-✓", Massachusetts t Af x- <<
a
x-� • 41DEPARTMENT OF BUILDING INSPECTIONS . 4."ll 212 Main Street • Municipal Building �`. PD
~.tea' Northampton, MA 01060 r'kj 1:J
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS, RENOVATIONS, ROOF MOUNTED SOLAR, ETC.
1. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
2. One set of plans and specifications of proposed work (Digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new/replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code —all new construction (Gut/Rehab) requires a HERS Rater Affidavit
10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
ran cat R� ,
.�,
leI ricittfd1
House-
Deek 4o 6� p
oe, �f
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
I ' CS- iO1.' w 9 -167 -Doa
Zo o e1}VAS C q License Number Expiration Date
Name of CSL Holder 1 , r ,
S I (� -*1 e �`\ ` List CSL Type(see below)
No.and S t �} 1 J Type Description
�� i,� �{ ^i �` U Unrestricted(Buildings up to 35,000 cu.ft:)
�V t ►"� Ail A v j Q� R Restricted 1&2 Family Dwelling
City�Iown,State,ZIP M Masonry
RC Roofmg Covering
WS Window and Siding
�J i SF Solid Fuel Burning Appliances
1 70k1-II 7 j Oc &.. &p(oae(\- 0410.COM I Insulation
Telephone 'Email address / " D Demolition
5.2 R stered Holy prove ent Contractor IC) Uq'1tN
8ja
1 � }.�� '/ I Q
r1CACl rl R► C met 1p `d -� 5414(' HIC umber LtDate
HOLC C Nam WC Re i ant Name
t -1a :11 CSQkkke (tl� ) akod (
No.and Street Em il
SOd4hc 0n fit 61073 `113 -7e)69"117S-
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 a 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.
A-rn\C/ \\/ _r)5/94/
Print Owner's Name(Electronic Si'.ture) 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.
Print Owner's or Authorized A t'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
w«'w.mass.gov/oca Information on the Construction Supervisor License can be found at NvwVw.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"
.r._... The Commonwealth of Massachusettsm.-.- --
it MEMO -- Department of Industrial Accidents
n =1���
• ri 1 Congress Street.Suite 100
_„={ Boston.MA 02114-2017
o.
WN.` / www mass.gov/dia
— 1s urkrrs'Compensation insurance.% fidasit:BuiWrrs1ContractoridEkctricians''Plumbers.
tO tit_ t I I.t 1)'►ITH TILE PERMUTING Al''1'IHOItrr .
.tonlicant Information Please Print Lreibh
Tattle illusincss Organization tndo'dual I: Norwich Construction
Address: 25 Sampson Rd,
( 7 413-626-4736
City,/State/Zip: Huntington, MA 01050 t ilitlii
Are,on an empki rr?t hack the appropriate Mrs: I i1r mf project(required):
I/IgtI airs a eniplosei with a eniplolecs I1u11 and.iur part-Gnne 1• 7. 0 Nett construction
ICI I anti 4 sole proprietor ui partnership and hasr not en4ik, o s workin. for me in 8. O Remodeling
arts cipaelis. [No workers'comp.insurance reyturesl.]
J 9. bit Demuhtion
wt 30 lain a lionswnet&ant all work imsel .1Nai woEtal comp..insurance required.l r
1(I ci Building addition
a.a I am a hiirrwtmtun-and will tic hum:contractors it,conduct all work on im pr nw-tt}. t will
•7Lsurc that all contractors India lose'sorkc-rs-curnipcnNatin insurance or at.:Boole 110 Electrical repairs or additions
proprietor.is ill no eiriplustcs..
12.1:Plumbing repairs or additions
4D I am a general contractor and 1 has.:hued the sub-contractors listed on the attached sheet _
Mew sub-contractors has.:elnployees and has":workers'coinp.insurance.- 130 Runt repairs
60 we air a corporation and its officers hastau cll:txd thou nestc of ctnipirin pa M(iL c. I`� ❑Other
132.$1(4)_and we fuse no employees.[No workers'comp.insurance required] --
'Any applicant that chocks hart-1 mini also till out[Ito-wilion below%hooting thin sorkors'compensation Polk} mttrinnalion.
*Iknwtasm'rs who suMnit this atirdasit indicating Ihes arc doing all work and then hue outside contractors,must suhnut a new athdas it mix-aging such.
"(.contraction.that check this hiss insist attac'lwd an additional shoat showing the name of the sot►cunlracutrrs and slate whether is not those mastics hale
crnplo±eca It the sues-contractors hose c nploso s.th.% most prostdetheir workers'comp.polio number.
l am an employer that is providing workers i compensation insurance for my employees. Below is the policy and job site
information_
Insurance Company Name: The Hartford
Poli y#or Sell-ins.Lic.#: 6S60UB7H74435A20 Expiration Date 10/18/21
Job Site Address: 781 Bridge Rd Northampton, MA 01050
Ctrs State Zip:
Attach a copy of the workers'compensation pokes declaration page(slims ing the polio.number and expiration date).
Failure to secure coverage as required under MGL c. 152.*25A is a criminal s tolation punishable by a tine up to S I.S(K).00
andror one-year impnsonment.as swell as civil penalties in the form ofa STOP WORK ORDER and a tine of up to S250.00 a
day against the violator.A copy of this statement may be tore arded to the OB2ice of lnsestigations of the DIA for insurance
coverage ventication_
/do hereby certtjj•end r pains e d p allies of perjury that the information provided above is true and correct.
Signature(/ I)a1.. /.?/-2)
Phone.. '13 -4 — 11736
Official use only. Do not write in this area.to he comph•ted by city or town official
('it) orTosn: Permitll.icense#
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3.City/Town('kilt 4.Electrical Inspector 5. Plumbing Inspector
6.Other
('intact Person:,_ Phone#:
City of Northampton
�i � ��S�S Sy
Massachusetts _
p
Rf .- . * C.
s ( { '.. 4 II DEPARTMENT OF BUILDING INSPECTIONS
>!r' �•. }' ny
212 Main Street • Municipal Building ��
\. ~. Northampton, MA 01060 �s11, 3r '
a HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, Area .c i• cota.ilkOf r v,' ) (insert full legal name), born_ (insert
month, day, year), hereby '•0 ese and state the following: 0 c/20/DVS
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 14`day of 20 Li.
(Signature)
City of Northampton
�J•✓ Massachusetts <4,
+ � n DEPARTMENT OF BUILDING INSPECTIONS s *
f,
too ,t.,i,` 212 Main Street • Municipal Building
Northampton, MA 01060 SNyy °-�
\ ti
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:
234 Easthampton Rd
Northampton, MA 01060. Valley Recycling
Location of Facility: United States
The debris will be transported by:
Name of Hauler: Norwich Construction
Signature of Applicant: Date: - /fa
i,.CF'C I IrII.H I C yr LIHCSILI I I IIVJUKHINI.0
5/4/2021
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).
CONTACT
PRODUCER NAME:._.__..
AXiA Insurance Services PHONE N,Ext 413 788-9000 FAX 413 886-0190
933 East Columbus Ave ( ) ( ) (NC,No):( )
Springfield,MA 01105 ADDRESS:info1axiagroup.net
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:National Grange Mutual Ins.Co 14788
INSURED INSURER B:MSA Main Street America Assurance Company 29939
Norwich Construction INSURERC:
Christopher S.Golec
40 Ward Avenue INSURER D:
Easthampton,MA 01027 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. 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 NUMBER POLICY EFF POLICY EXP LIMITS
LTR !MD WVD _ LMM/DD/YYYY) (MWDDfYYYYI
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR MPT0919Y 9/16/2020 9/16/2021 DAMAGE TO RENTED 500,000
PREMISES(Ea occurrence) $
MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POUCY 781' LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
B AUTOMOBILE LIABILITY COMBINED SINGLE UMIT 1,000,000
(Ea accident
ANY AUTO M1T0919Y 5/1/2021 5/1/2022 BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOSR ONLY X AUTOSyyNE BODILY INJURY(Per accident) $
X AUTOS ONLY X AUTOS ONLY PROPERTY DAMAGE
(Per accident) $
B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
EXCESS LIAB CLAIMS-MADE CUT0919Y 9/16/2020 9/16/2021 AGGREGATE $ 1,000,000
DED X RETENTION$ 10,000 $
WORKERS COMPENSATION PER
AND EMPLOYERS LIABILITY YIN STATUTERH-
ER E
AANYIPROPRIE PBEROPRIETOR/PARTNER/EXECUTIVE
ERDEyECUTIVE N/A EL.EACH ACCIDENTOF $
(Mandatory in NH) EL.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below EL.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
Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
p ACCORDANCE WITH THE POLICY PROVISIONS.
212 Main St
Northampton, MA 01060
AUTHORIZED REPRESENTATIVE