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11C-026 (10)
4 STOWELL ST BP-2021-1470 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: I IC-026 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ALTERATION BUILDING PERMIT Permit# BP-2021-1470 Project# JS-2021-002446 Est.Cost: $17482.00 Fee: $114.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WILLIAM LABOMBARD 060247 Lot Size(sq. ft.): 8494.20 Owner: MIENTKA MARGARET Zoning: URA(100)/ Applicant: WILLIAM LABOMBARD AT: 4 STOWELL ST Applicant Address: Phone: Insurance: ce: 12A PARKER AVE (413) 687-7946 O W(_'_ NORTHFIELDMA01360 ISSUED ON:6/10/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:BUILD LAUNDRY CLOSET IN GARGE 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. ' ' >9 , y . Certificate of Occupancy Signature 0 FeeType: Date Paid: Amount: Building 6/10/2021 0:00:00 $114.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1 33 The Commonwealth of Massachusetts 0 wBoard of Building Regulations and Standards FOR — .. MUNIUSE ,� Massachusetts State Building Code, 780 CMR 1` USE S i I r•t' Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar Zan_ co 1_,. D One-or Two-Family Dwelling 1 z_ ry 3 This Section For Official Use Only j`'v cro rin BuildingPermit Number: -'4 J.-1970 Date A plied: 'c at)// XasS !/ 4-I6-202) Building Official(Print Name) Signature Date ._ SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 �ws Map&Parcel Nurnberg r„ 4 Stowell Street L., �d(,(r 1.1 a 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:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public® Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Peggy Mientka Leeds MA, 01053 Name(Print) City,State,ZIP 4 Stowell Street 413-584-1344 mam7334@ gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied El Repairs(s) 0 Alteration(s) al Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': Building of a small 4'x4' stacked laundry closet into the existing garage with access from dining room. Closet to be insulated to code -no major structural changes occurring SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 12,702 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 2,330 ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2,450 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No.Z1(l I Check Amoun `` Cash Amount: 6.Total Project Cost: $ 17,482 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 060247 06/06/2022 William LaBombard License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 12 B Parker Ave. No.and Street Type Description Northfield, MA 01360 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-687-7946 bill@ aipbuilders.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 114593 William LaBombard 10/5/2021 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 12 B Parker Ave. bill@ aipbuilders.com No.and Street Email address Northfield, MA 01360 413-687-7946 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 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 Aging In Place Builders to act on my behalf,in all matters relative to work authorized by this building permit application. Peggy Mientka 5-25-21 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. William LaBombard 5-25-21 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" City of Northampton OaYHAMP0,, 5 .w s, 7 -- Massachusetts �4t., II_ 'ee w: 111 .�. i �� ,r' DEPARTMENT OF BUILDING INSPECTIONS y, .Y 212 Main Street • Municipal Building + '' Northampton, MA 01060 sf .. ,'N 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: Valley Recycling Northampton MA The debris will be transported by: Allen's Roll Off Conta ners Name of Hauler: ._ yam / Signature of Applicant: Date: The Commonwealth of Massachusetts t* -~ Department of Industrial Accidents _H 1 Congress Street,Suite 100 -;.1: Boston, MA 02114-2017 *,,, www.mass.gov/dia 11utkers'('ontpensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. 10 BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lesibty Name lHusincss;orsantzation lnditiaualt Aging In Place Builders, Inc. Address: 203 Birnam Rd. City/State/Zip: Northfield MA 01360 Phone#: 413-225-3047 Are sae so employer!(:'heck the appropriate hot: Type of project(required): 1.0l am a employer with 2 employees(NH andM pan tines)' 7. 0 New construction 201 am a sok proprietor or partnership and haw no employees working forme in S. m Remodeling any capacity.[Nu worker'conp.insurance required.) 30 1 am a huuwner doing all work myself.[No workers'comp-insurance required.] 9. ❑Demolition nw 4.0 lam a huaneowner and will be hiring uo g ntrarorato conduct all work on my property. I will 10❑Building addition ensure that all contractors citler have workers'con nsatwn insuranccor are sole 11.0 Electrical repairs or additions proprietors with no crnpluyees. 12.E Plumbing repairs or additions S 1 am a general contractor anal I have hind the sub-cuntractors listens un the attached sleet. 3f JRoofrepairs These sub-cuntrJetors have employees and have workers'comp.insurance.; 6.0 we are a corporation and as utf&:era have exercised their nghn of cternption M per GL c. 14.❑Other 1 S2 Z11(4),and we have no a rlu}res.[Nu workers'curnp.insurance required.] 'Any applicant that ch tks hot al must also till out the section below show ing then workers'compensation pulley information. +Homeowners who submit this affnda%rt indicating they*redoing all work and then hire outside contractors must submit a new affrdav it indicating such. Contractors that check this hit must attached an additional sheet show in:the name of the sues-contractors and stale whether o not those citifies tease cmpluyce,. If the.•sub-contractors have eugnlo;r ces.they must pros ilk 1hn: workers sunup.policy neanher. . I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Associated Employers Insurance Policy#or Self-ins.Lic.#: W CC50050211662020A Expiration Date: 10/28/2021 Job Site Address: 4 Stowell Street CityiStaterZip: Leeds MA, 01053 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, ti25A is a criminal violation punishable by a tine up to S1.500.00 andior 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 for insurance coverage verification. I do hereby certify unde the nil . and penultie. tf p y I I the Information pro tided above is true and correct Signature: Data. ) �Z, 2 Phone#: 413-687-7946 Official use only, Do not write in this area.to be completed by city or town official_ ('its or Town: l'erntitLicense 4 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City-fawn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: )IVE. Aging In Place Builders, Inc. AIPL., Address: Website:www.aipbuilders.com CS: 060247 203 Birnam Rd. Phone: (413) 225-3047 HIC: 114593 BUILDERS Northfield, MA 01360 Email: Bill@aipbuilders.com Before Existing Garage Existing Living Room/Kitchen After Existing I' Garage Losono Livonp Room May25,2021 0 2008-2021 Aging In Place Builders, Inc.All Rights Reserved Pie 1 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD"'"Y) 10/27/2020 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 Adina Edgett NAME: g Webber & Grinnell (A/C No.ExO: (413)586-0111 FAX NO): (413)586-6481 8 North King Street ADDRESS:aedgett@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A:EVanstOn/BRECK INSURED INSURER B:Citation 40274 Aging In Place Builders, Inc. INsuRERc:Associated Employers insurance 11104 Attn: Jeff LaBombard INSURER D: 203 Birnam Road INSURERE: Northfield MA 01360-9526 INSURERF: COVERAGES CERTIFICATE NUMBER:Exp 10/21 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 EFF POLICY EXP LIMITS LTR MOD WVD POLICY NUMBER (MMIDDIYYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTE A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 3EZ4810 10/28/2020 10/28/2021 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 PRO LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B _ALL OWNED SCHEDULED AUTOS X AUTOS BCDR51 10/28/2020 10/28/2021 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS X AUTOS (Per accident) Uninsured motorist El split limit $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WCC50050211662020A X PER ERH- AND EMPLOYERS'LIABILITY ,,I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Jeffrey J. LaBombard E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? y N I A C (Mandatory in NH) is excluded from coverage. 10/28/2020 10/28/2021 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE •W Grinnell, CPCU, CIC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) Commonwealth of Massachusetts 111 Division of Professional Licensure Board of Building Regulations and Standards Co nstrvCti 3tAbpsrvisor ---7,. / I CS-060247 , Kix,epires: 06/06/2022 WILLIAM W LABOMBARD 7 12B PARKER AVE NORTHFIELD MA 01360 aw.: . '.. iCOMMiSSiOner 14 fdfr /F; WEilidtat., A . 74,„ icsovenewhiew-0404 / „414:4001030‘.4004 am*Ot COetasifiloit Anson"& eusineis Regulation HOME WAPROVEW ENT CONTRACTCYR TYPE: netivictuai 611211111MISOI enitilallig, 114523 10,05/2021 Wit-L1AM W LABOMBAP' 1 WILLIAM W. LABC%itEtAR J 12 A PARKER AVF /.;(0444/01(a 4..e4,0044. WORTHRELD, MA 0135C. ...........---- ' Undersecretary 1116.L._