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43-138 56 LONGFELLOW DR BP-2021-1453 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:43- 138 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-2021-1453 Project# JS-2021-002414 Est.Cost: $5500.00 Fee: $30.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg.ft.): 56628.00 Owner: DERR THOMAS SIEGER& L VINCENT Zoning: Applicant: DERR THOMAS SIEGER & L VINCENT AT: 56 LONGFELLOW DR Applicant Address: Phone: Insurance: 60 HARRISON AVE NORTHAMPTONMA01060 ISSUED ON:6/9/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:F I LL IN SWIMMING POOL 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 Sit;natur`f r .• i l FeeType: Date Paid: Amount: Building 6/9/2021 0:00:00 $30.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner RECEIVED The Commonwealth of Massachusetts wt , FOR Board of Building Regulations and StandarI JUN _ 7 2d2 CIPALITY Massachusetts State Building Code, 780 C USE Building Permit Application To Construct,Repair,Reanova SS •- 1.s ' '.-6, ,d Mar 2011 One-or Two-Family Dwelling'I °FTi RTHAfl-t)1}'SA 1.060 This Section For Official Use Only- Buildingg Permit Number: AP"—a( —14 3 Date Applied: &)i..i 43 _ 6-9•Z6zi Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 5'E, L o/v -Ec. Idw )P , y 3 /36 1.la Is this an accepted street?yes f 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 ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 1 U� '2_-/71,0, /1-s �r Q.- �-L tiV V 1 ixic a x)r 42 7 t-f/-r`f Pt vN Name(Print) City,State,ZIP • 5----6 26)nVG--ram 1-1 fie,v( spy_,7L)6, 74e_rv@s r fk, u_ 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 0 Demolition 181 Accessory Bldg. ❑ Number of Units Other 0 Specify: Brief Description of Proposed Work': t-i 4-[.- /n1 S/1//it ill/,U c- f'dd 2--- SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ElStandard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No515.3 I Check Amount: Cash Amount: 6.Total Project Cost: $ s s a ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ` S A/2_v? License Number Expiration Date Name of CSL Holder Fib ,1) T List CSL Type(see below) No.and Street V Y` � Type Description LL;1— c L 7/Y 7 U Unrestricted(Buildings up to 35,000 cu.ft.) /� Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry Q `C 7,5' RC Roofing Covering ,�✓ 7�"'�C��/�f WS Window and Siding �/ `- /� L `�`� / e ft y�tcr,ei I Solid oliIns Fue l Bunting Appliances Telephone Email address ,nj�S` on D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address 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 ..)gr No .O 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. Pri er's ame(Electronic Signature) Date SECTION 7b:OWNER1 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. 1-I+0 n?A s .1)c , 1 >>r- l NCB n,n- &� 2 Print Owner's or Authorized 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" `. The Commonwealth of Massachusetts IM WEDepartment ofIndustrial Accidents ==� I Congress Street,Suite 100 : ' Boston, MA 02114-201? ►vwtt mass.gov/dia VI ai kers'Compensation Inaurancc.Midas it:Sui deraic.ntractora/RkctricianstPlumber,. t t) HHI. III LI)%►1 f H 1 11E PER%1ITI ING AtITHOWTI. Applicant Information Please Print I eLibls Name IRUSIDns organization I nth vtvduat): M Address: City!State Zip: Phone 4: Are you as empbvrr:'(Meek the appropriate hot: Type of project(required): I.El lam a employer with______.. __employees(full m f nt part-tintef• 7. 0 Nev.'construction 2.1:1 i am a sok pmpraes nor partnership and have no employees working for me to K. 0 Remodeling any eapmeaty.[Nu worker,comp.insurance mowed] t--+ 9. 0 Demolition 3E3 I am a mien tirun-r dutng all wutk thyself.[No oorkaas'emras insurance moulted.)' 10 Ca Building addition 40 xw I am a hutrwskx and will be butnnv swntra item to vondu.t all work on my property. I Will tGa t ensure that all contractors either have workers'rcmrpenxsi:,,tt tnauranrx ur are sole i I.fJ Electrical repairs or additions ptupneturs with no employer+ 12.0 Plumbing repairs or additions !In I am a general cantractar and I ha+e hired the sub-tontrac!,rr,hsted an the attached sheet. 13.❑Root repairs 'Me w b,cunu n acto have employees and have worker, :4-.trtp.insurance. 6.0 We ape a corporation and its officer.hate exercisd then r:eht of exemption per!d(aL c. 14. Otltet---- __—.__---- 152,f1M,and we have no employees.[No workers'comp insurance.required.I *Any appticuisthat chocks boa#I mint also fill out the section below stamina their wutkua'campensatum polcy information 1 Homeowners who summit tdm atutdasit rndacatmg they are doing all work and then here outside contractors mint,utnut a new affidavit tndtea7letg such. teontractors that cheek this box most attached an additional sheet show mg the name at the sub-contractors;tad state w Itether at nut those enrutirs has*: cripk,y-ecs It the suds Contractor hr+e ernplu?i ea.till;!, pro',idc their workers'comp policy number _ _—._ . . ._ its l rem an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site infurnrotiun. Insurance Company Name: Policy dledrSelf--ins.Lie.#: Expiration Date: Job Site Address: Cityr'State.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 S 1.500.00 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA our insurance coverage verification. I do hereby certify under the pains penalties of perjury that the information provided above is true and correct. Signature: ���--11 1-- /c/-:e.- 1-4-- 1)atc. Phone#: .5 it '1 4 C' Official use only. Do not write in this area.to be completed by city or town official City or Town: Permit/License a Issuing Authority(circle one): I. Board of Health 2.Building Deportment 3.City/Town Clerk 4.Eketrieal Inspector 5. Plumbing Inspector 6.Other ( ontact Person: Phone#: THERBRO-01 JOCELYN ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDmm) 6/2/2021 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 NQM CT Jocelyn M Douglas Phillips Insurance Agency,Inc. PHONE FAX -- 97 Center Street (A/C,No,Ext): (A/C,No): Chicopee,MA 01013 L i, ass:Joceiyn@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC INSURER A:State Automobile Mutual Ins Co INSURED INSURER B:State Auto Property&Casualty Theroux Brothers,Inc. INSURER C:A.I.M.Mutual Ins.Co. 33758 622 Granby Road INSURER D: South Hadley,MA 01075 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 W ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD VD, (MM/DD/YYYY) IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PBP2910404 4/10/2021 4/10/2022 PREMISDAMAGE TO Ea RENTEDoccurrence) $ 500,000 ES( MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) ANY AUTO BAP2483682 4/10/2021 4/10/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY X AUTOS E BODILY INJURYpp (Per accident) $ X AUTOS ONLY X AUTOS ONLY (PerraccidengAMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE PBP2910404 4/10/2021 4/10/2022 AGGREGATE $ 1,000,000 DED X RETENTION$ 0 C AND EMPLOYERS'LIAABIILOITNY PER STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCC-500-5007038-2021A 4/10/2021 4/10/2022 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 $ 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 Linda Vincent THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Longfellow Dr. Northampton,MA AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD City of Northampton ,`ri (,1- r.�j ys srMassachusetts �4t s�._ .'<<c vt DEPARTMENT OF BUILDING INSPECTIONS sal��' 212 Main Street • Municipal Building ZJ`` 'a. " Northampton, MA 01060 'r�' ` . 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: LD 'j- 55 t LLA it ��`� /92 .,Location of Facility: � `/G, h-'C The debris will be transported by: Name of Hauler: —/ /O >' 1)5 V2, $, Signature of Applicant (F6/2- Date: / /1/ BUILDING DEPARTMENT DEMOLITION PERMIT SIGN-OFF SHEET Date: Address: 225A141;7 LJ Building Use: R�_� � / Owner:r91. 4_4-/-i N)p,4 \CI Oet-ti7-- Phone: .1l'1— -9— f`T6 6— Owner's Address: 6 .6 6-) 112.%) l`=20Q&-•f)' UTILITY CUT OFF (Signature of Authorized Representative of Utility Department required) As required by the Massachusetts State Building Code (780 CMR), a permit to demolish shall not be issued until a release from the utilities is obtained, stating that their respective service connections and appurtenant equipment have been removed or sealed and plugged in a safe manner. Eversource (Gas) Signature Title National Grid (Electric) /1/O L 2_ of& Signature Title DPW (Water) Signature Title DPW (Sewer) A///1 �, 2;111 5�e77-1e__ S?�7 "3) Signature Title DPW (Storm water) '//A Signature Title DPW (Tree Warden) A//L Signature Title DPW Director Signature Title `l i Historic Comm. Review , // ? Signature Title ASBESTOS REMOVAL All residential, commercial and institutional buildings are subject to Massachusetts Department of Environmental Protection (MassDEP) asbestos regulations at 310 CMR 7.15. Therefore, owners and/or operators (e.g. building owners, renovation and demolition contractors, plumbing and heating contractors, flooring contractors, etc.) need to determine al asbestos containing materials (ACMs), both friable and non-friable, that are present at the site, and whether or not those materials will be impacted by the proposed work, prior to conducting any renovation or demolition activity. Examples of commonly found ACMs include, but are not limited to, heating system insulation, floor tile and vinyl sheet flooring, mastics, wallboard, joint compound, decorative plasters, window glazing, asbestos containing siding and roofing materials and fireproofing materials. Failure to identify and remove all ACMs prior to its being impacted by renovation or demolition activities, can result in significant penalty exposure, and higher clean-up, decontamination, disposal and monitoring costs. A DOS certified asbestos consultant must be contracted to determine if asbestos is present and whether removal/repair is necessary. If the building is a state owned facility, contact DCAM and DOS. DOS provides a list of licensed asbestos abatement contractors and consultants. You may wish to inquire if a contractor has any history of violations. Only DoS licensed and DOS certified asbestos abatement contractors and consultants may be hired to perform asbestos related work in Massachusetts. Received by: Print Name Title Signature Date Po 5 g � �� dE/A-(6 v/ -L / rev'