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31C-024 61 FORD CROSSING BP-2021-1521 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3IC-024 CITY OF NORTHAMPTON Lot: - PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ADDITION BUILDING PERMIT Permit# BP-2021-1521 Project# JS-2021-002536 Est.Cost:$59450.00 Fee: $386.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MICHAEL M POWELL 170515 Lot Size(sq.ft.): 4500.00 Owner: MEYERS JILL Zoning: PV Applicant: MICHAEL M POWELL AT: 61 FORD CROSSING Applicant Address: Phone: Insurance: 149 POMEROY LANE (413) 374-0963 AM H ERSTMA01002 ISSUED ON:6/24/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:BUILD 13.5'X 13.5'4 SEASON PORCH ADDITION 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. 55-, 1.1 . Certificate of Occupancy Signature:! I 1 FeeTvpe: Date Paid: Amount: Building 6/24/20210:00:00 $386.50 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner +� The Commonwealth of Massachusetts 0Boarf,. f d of Building Regulations and Standards FOR c. gCode, 780 CMR Massachusetts State Buildin MUNICIPALITY = 7 "' A ilding Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 z One- or Two-Family Dwelling UT m Official Use Onl • 4; Number:f3P Za2l -152This1 Section For O Date Applied: , .9. 'R. ., ,i, ai Building Official(Print Name) 1 Signature i 8n Da SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 6/ ? ORD Ceosslnr6 3/G-pa.9 do( 1.1 a Is this an accepted street?yes Y no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 1/, sm 1S" 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 IS Private 0 Zone: _ Outside Flood Zone? Check if yes[{! Municipal a On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: —i1t NIE•.C•grS /dr t..M.f2� , mit 0106o Name(Print) t City,State,ZIP G ( oR�7 (s g CR055INt76R 7 57cl juLsk7d4 .q 1 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition all Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': :L. • l 3.5-X 13- Cr 5 ea can Pt,r c 4 SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Ite' (Labor and Materials) $ 56r o-- - 1. Building Permit Fee:$3g1, Indicate how fee is determined: 1. Buildbag $ El Standard City/Town Application Fee •2.Electrical .1/1 d'v7) 0 Total Project Cost' Item 6 x multiplier 1 Plumbing3. $ 2. Other Fees: $ $ tj S D List: 4. W. l (HVAC)5. Mechanical (Fire $ Total All Fees:$ 326.•. Su ti•ression Check No.q t2 Check Amount:326,`%Cash Amount: 6.Total Project Cost: $ 9' 'S 0 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Constructionr� Supervisor License(CSL)/ CC,-. 09'3A i 5— I. —S/- 2 2 i _AA t C('t a e ( p, T 0c,/e (/ License Number Expiration Date Name of CSL Holder CI III 1"3� {� 0 y / List CSL Type(see below) No.and met �--�/h Type Description !1''I _- eAS 4--1 A /) A. O 1 Q U Z 6 Unrestricted(Buildings up to 35,000 cu.ft.) k f R Restricted l&2 Family Dwelling City State,ZIP M Masonry RC Roofing Covering WS Window and Siding Lir 33-7t,/ °go''{ A4 QPoveIj %� (� SF Solid Fuel Burning Appliances (( It '� V/ !Vlr` I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) i f 0 5-r 3— 2—2 S'-22 All t c Cuts ( M t O we V HIC Registration Number Expiration Date FIIC Compan Name or HIC Registrant Name d t iPC)�� ..a.�.l l ' No. ,.1 �11 - ( A^ j Q t d ` 7 `O 01� Email address City/Town,State,ZIP /�/Y el hone 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 ...1c- 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 /t/(i C4 q,e ( /4, l"d,,..C £r to act on my behalf;in all matters relative to work authorized by this building permit application. r � ;/1 NI e et S - ' ait''AC2 �ff 22:1 2 ) Print Owner's Nakne(Electronic Signature) . DLte 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 knowledge and understanding. Iôve1 ( lvL) 12 "z ( 4iJ ,LJ t wner's or uthorized Agent's Name(Electronic ature) 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.tzov/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 C 'h c Number of decks/porches / A a✓`c Type of cooling system atrG • Enclosed Br,c`o S_q 1 Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton c. Massachusetts " DEPARTMENT OF BUILDING INSPECTIONS ;y'.\ r .° 212 Main Street • Municipal Building C� Northampton, MA 01050 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 !3P-202-1-l2-( 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. s The debris will be disposed of in: a Location of Facility: \/tt Re CycLI The debris will be transported by: 3y Name of Hauler: ✓"( J diA ?- ( At • Pw t( 2. Tc Date: ' 2 Signature of Applicant: Nt Ni T• T• 3. The Commonwealth of Massachusetts Department of Industrial Accidents -- 1 Congress Street,Suite 100 _ � Boston, MA 02114-2017 ww►kmass.gov/dia Waters'Compensation Insurance Affidavit:BuildersIContractora/Ekctriritns/PIumbers. TO RE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ly Please Print Lerih Name(Business Organtmtion'Indtvrdual): CCca J�L. ( L" ' L� Q(ei/C l( Address: / Y g Pikyy€4,0y . City/State/Zip: 4-M A.eit f, 1(/t ,I 01°6 2 Phone#(V3) 37 y ' 0f 6 Are' a re employer!Cheek the appropriate boa: Type of project(required): 1.111 am a employer with 3 errtptoytra(fall and'or part-time).• 7. 0 New construction 20 I am a ark proprietor or partnership and have no employees working fur me to t. Q Remodeling tiny capacity.[No winters'comp.insurance required.) 9. ❑Demolition 30 I am a homeowner doing all work myself.[No workers'comp.insurance mouins:I"' 4.0 1 am a homeowner and will be hiring cw ct uraoex to conduct all wont on my property. I will 10 a Building addition ensure that all cmhtracton either have waken'compensation insurance or are role 11 a Electrical repairs or additions proprietors with no exnplopcces. 12.0 Plumbing repairs or additions SCJ I am a general contractor and I have hied the sub-contractors tilted on the aaarbesi sheet. 1 3❑Roof repairs These aui,contractor have employees and have workers'camp.itLaur lee 6.0 We are a corporation and its officers have exercised thee nght of eac,itptien per MCA_c. i 4. Other 152,§Ili),and we have no emploees.[No workers'comp.insurance required.' 'Any applicant that checks box el mtwt also fill out the Section below showing their workers'compensation policy information. t Homeowner who submit this affidavit indicating they are doing all work and then hire outside amtractors must submit a new affidavit indicating such. ;Contractors that cbrc'k this box must attached an additional sheet showing the cane of the sob contractors and state whether or not those entities have employees. If the subcootracwn have employees.they muse provide their workers' .policy number. Ian:an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site Information Insurance Company Name: C t 4j el/ An✓ 411 gQ —�—f1 f CO ( Policy#or Self-ins.Lic.#: W)G c — 3 f s-‘/9‘10-00 Expiration Date: e 7- 2 / Job Site Address: I Ford C(O S 5 ',4./ City!StatetZip://4 ri4a,� � 7 � O/'d 19 Attach a copy of the workers'compensation policy de taration page(showing the policy number and exp ration Mite). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 fine 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 cent under the pains and penahi of perjury that the information provided above Is true and correct. Sipa tare: Date: -/ 0 - 7 ? Phone#: ��})Jn 7Y Gyficial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY '1 ( INSURANCE POLICY '1 Liberty Mutual. ;arne INFORMATION PACE INSURANCE ,Sued by LM INSURANCE CORPORATION 175 Berkeley SSW Boston.MA02116 so.a 27243 Policy Number WC5-31S-619610-010 Issuing Office 016C RENEWAL OF= WC5-31S-619610-019 Issue Date 06-25-20 Account Number 1-619610 Sub Account 0000 1. Insured and Mailing Address MICHAEL POWELL 1-4 r 149 POMEROY LANE RISK ID 000026275 AMHERST,MA 01002 Status 01 - INDIVIDUAL Other workplaces not shown above: SEE ITEM 4. PREMIUM-EXTENSION OF INFORMATION PAGE 2. Policy Period:The policy period is from 07-27-2020 to 07-27-2021 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per$100 , Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 2,737 Premium will be billed ANNUAL Producer 0004-106757 ROSS WEBBER & GRINNELL INSURANC AGENCY 150 LOWER WESTFIELD RD STE 2 HOLYOKE MA 01040-2889 WC 00 00 01 A 0 1987 National Council on Compensation Insurance,Inc. WC 00 00 01 B(CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1 Insurod CoDY I- - .. ..Adel...` DATE(MMJDDA'YYYI .�1�RO® CERTIFICATE OF LIABILITY INSURANCE 06/04/2021 TE HOLDER,THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER I It I�.ryr 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. d IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the polioy(les)must have ADDITIONAL INSURED provisions or be 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 endorsements►. PRODUCER CO A wary Cleric CI$R 1— � NAME: PAX (Q13)5J8•BOBB Ross.Wsbber&Grinnell Insurance PHONE (413)538-8380 (A/C No: 98 Lower Westfield Rd Ste 301 L mclark(BRossWG.com �— ADDRESS: Holyoke INSURER(S)AFFORDING COVERAGE NAIL M MA 01040 Main Street America/MSA 29939 INSURED INSURER A INSURER B• Michael Powell INSURER C• 149 Pomeroy Lane INSURER 0 Amherst INSURER E • MA 01002 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2152015753 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 LTR TYPE OF INSURANCE LIMITS ` n INSD MD., POLICY NUMBER IMM K( JDDtYYYY) (MM/ YYYY) COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE S 1,000,000 I �,/� DAMAGE TO RENTED SOO.000 CLAIMS-MADE I X OCCUR PREMISES(Ea oorurrance) S =r MED EXP(Any one person) S 10,D00 e A MP087548 11/10/2020 11/10/2021 PERSONAL&ADVINJURY S 1,000,000 GENII AGGREGATE LIMIT APPLIES PER-. 2,000,000 3 GENERALAGGREGATE S X POLICY ECT LOC PRODUCTS-COMP/OP AGO S 2,000,000 t OTHER S 4 AUTOMOBILE UABIUTY J COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ �[ OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED l I RETENTION S S WORKERS COMPENSATION PER OTH- ' AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N IA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED' (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1 If yes describe under DESCRIPTION OF OPERATIONS below _ E.L DISEASE-POLICY LIMIT $ 7 S 9 / DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddRlonel Remarks Schedule,miry be attached If more space le requlnd) 1 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 1988-2015 ACORD CORPORATION. All rights reserved. are registered marks of ACORD ^. ..... I* (.11#?e C610 m we o luticai t orc),Iradjacitaijelk i . Office of-Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR TYPa: Individual . 1 1129121rAtza\A Expiration 170515 1 • V. •••V,• logelp, j4 - 02/25/2022 , MICHAEL M. POWa.12-4'‘'-''' ,,Ifi, ......„. ...: 7, - ..._. .., MICHAEL M. po1A/F#c, ,--- _ii . 149 POMEROY LK -''-i...zie•-• :trts‘Y's 0,(4;„,(Aortea.4,4: kt AMHERST, MA 01002 A Undersecretary ',. . . .. _ • • , . . ..7.: le - Comtbonweallh of Massachusetts 1 ( Division of Professional Licensure• - . klurf.. Board of Building Regulations and Standards i a r , *4.7 Co snskrvt1 nastIpprvi or ..... 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