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17A-160 35 FOX FARMS RD BP-2022-0062 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 160 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BASEMENT RENOVATION BUILDING PERMIT Permit# BP-2022-0062 Project# JS-2022-000113 Est.Cost: $31300.00 Fee: $204.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN D ROSS 079160 Lot Size(sq.ft.): 17990.28 Owner: DITKOVSKI JACOB Zoning: URA(100)/ Applicant: STEPHEN D ROSS AT: 35 FOX FARMS RD Applicant Address: Phone: Insurance: 36 SERVICE CENTER RD (413) 584-1224 () SOLE PROPRIETOR N O RTHAM PTO N MA01060 ISSUED ON:7/19/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:BASEMENT RENO 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. 4 • t ›.2 Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 7/19/2021 0:00:00 $204.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner / 19 The Commonwealth of Massach sett4. l 1/ Board of Building Regulations and St d a �9 FOR Massachusetts State Building Code, 780 ` '%�� I PALITY � �1%,�� `�D�I US Building Permit Application To Construct, Repair, Renovate *t olish a evised ar 2011 One- or Two-Family Dwelling ti 19n1, This Section For Official Use Only '0�r)o4<s, Buildingl ermit Number: IA0-a Z-0 2- ate Applied: 6WO/ K955 /� —7.i zoz, Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assesso Map& Parcel Numbers 6 Q 3.3-pe x F PA-r ea , 77t-1.1a Is this an accepted street?yes no Map Nuer 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) /1/ /9, i r7i„�, L,,,�CZ 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 Recprd: TA cc' � l�t`.d-is -1(i K/o r-4-We-_-c zt4 A D/D (l Z Name(Print) City, State,ZIP 33---FOX `44'115 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSEDWORK2(check all that apply) New Construction 0 Existing Building Owner-Occupied Ef/ /AdditionRepairs(s) ❑ Alteration(s) ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Descriptio o Proposed W rk2: C'�7�- �,''� j.�te - / AY,4 t lto . - J I 1� vc4,2-1. --e X ` (% t(`s' `i. < ..�.►�I t SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ j t/ U t)c •" 1. Building Permit Fee: $ Indicate how fee is determined: ..' 0 Standard City/Town Application Fee 2. Electrical $ / G d 4''' 0 Total Project Costa (Item 6)x multiplier x 3. Plumbing $ S��v - 2. Other Fees: $ 4. Mechanical (HVAC) $ _ U List: 5. Mechanical (Fire $ Suppression) Total All Fees: �� �' Check No. Check Amount: 011 Cash Amount: 6. Total Project Cost: $ i ( ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor�,LL�icc,ense(CSL) 075760 1-� / /C 0 /'Z VZ- 3S` --...&,.�i,., D.. rw5/ License Number Expiration Name of CSL Holder J� List CSL Type(see below) 1 ?6 S-ee(1,:C,.-r- (!-ems--71:-c.T raC- No.and Street T i.•'. Description /g, W // 0Unrestricted(Buildings up to 35,000 Cu.ft.) � v lit ! a Restricted 1&2 Family Dwelling City/Town,State IP M Masonry RC , Roofing Covering WS , Window and Siding / SF Solid Fuel Burning Appliances to 3/S g y fi ZLy 5 CiOns G Kai,,Cv.h I _ Insulation Telephone Email address D Demolition 51 5.2 Re istered Home Improvement C�Qntractor WIC (ter 1.) m I prov m• n c-1 Cvtor,-HI c it, � J�/7 ��� e HIC Registration Number Expiration Date HIC ompapy Name pr HIC Re tstrant Flame f )6 5•-e eVi C--c. Ltw -c/ �o r-� 5T No. nd et ' �dv u, ��E� C�a�-- A, V,e Em ' address City/Town,Slate,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 . E t/ No . 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPPLIES FOR BUILDING PERMIT t--I,as Owner of the subject property,hereby authorize Xi _V'- D. L'7 57 to act on my behalf, in all matters relative to work authori d by this building permit application. P Own ' 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. c42� u p• At SS 7// & . 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" Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual STEPHEN D. ROSS Registration: 150847 36 SERVICE CENTER RD. Expiration: 05/03/2022 NORTHAMPTON,MA 01060 Update Address and Return Card. SCA 1 Ct 20M-05/17 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-079160 Expires: 04/28/2021 STEPHEN DROSS & 36 SERVICE CTR RD NORTHAMPTON MA 01060 Commissioner , The Commonwealth of Massachusetts 111 t Department of Industrial Accidents `i I Congress Street,Suite 100 • Boston,AlA 02114-2017 •� ., �,� www.massgov/din 1lorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. I.{)BE FILED N'ITU HIE PERM!lUNG AL`THORI'T1`. Applicant Information Please Print Leeibiv NatnC Business/Oganization`lndi 'dual): $1 t. Address: �- f.c S''e...-^- ���-/ �,,X d_ City/State/Zip:/$7 fl^4., "�& ,44- phone#: 4-("7 off,/ -/ z z c( Art'or ank, tt f Cheek the appropriate bur: Type of project(required): I.©tarn a employer with _ employee%(full and sr part•tirtati-• 7. 0 New construction 2E41 am a sole prupnetor or partnership arid hove nu employees working for me in 8 ET/Remodeling any capacity. [No workers'comp.insurance riapunxi. ecc��� 301 am a homeowner dwng all work myself.rm.work:as'comp.irrturraue required.)' 9. © Demolition 4.01 am a homeowner d.will lac luring contractors to conduct all work on my property_ I will to 10 Q Building addition t-- insure that all contractors either hate wurkcn'compensation insurance to arc sole l I.Q El4etrical repairs or additions prupti,etors with no employees. 12.0 Plumbing repairs or additions Sri I am a general contractor and I base hued the sub-cum:actors listed on the attached sheet. These sub-contractors have employees and!sate workers'comp.tnsurunce_ 130 Roof repairs h.n eve are u corporation and its offteen have exercised their right of exemption'per Mt it.t_ 14. Other 1S?.'§I(4),and we have no ettiiloyees.[No workers'comp.insurance required.) •Any applicant that Husks box al mast also fill out the sectrrrtt below showing their workers'compensation policy utfunrwtuwt 4 Homeowners who submit this affidavit mtheat rag they ate doting all work and then hire outside contractor:mint submit a new affidavit indicating such. :Contractors that cheek this box must attached un aolditiurutl sheet stunting the name of the sub contractors and stoic whether or not those entities have employees. if the sub-contractors have employees.they muss provide their workers'comp.policy number. I am an employer that Is providing workers"compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name:_ Policy#or Self-ins.Lie. #: Expiration Date: Job Site Address: CityiStateZip:_ 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 line up to S1.500.00 andlor 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 certify under the pains and pen allies of perjury that the Information provided abo e Is t ue and correct Signature: Date: /4- 2" Phone 4: Official use only. Do not write in this area,to be completed by city or town official ('its 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#: City of Northampton At;-- .Am,,, w 1 ; Massachusetts 4�,s ce, 4' /e el, v°i 4� � 4 c KDEPARTMENT OF BUILDING INSPECTIONS S� f} :,' .- '-' 212 Main Street • Municipal Building ON. 'a1 p' �.pr+- Northampton, MA 01060 'r•S6:j,;-••....�'..� 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: �,,'.i/�� 2�-G' �� � � Y y / 1 The debris will be transported by: Name of Hauler: y'vPiAC- of Applicant: /� Date: ? /.1c Z- ""1 CONSTRAS01 CKELLY '4�oRo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 6/30/2021 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 CONTACT NAME: AXiA Insurance Services PHONE FAX 933 East Columbus Ave (A/C,No,Ext):(413)788-9000I(A/c,No):(413)886-0190 Springfield,MA 01105 AD RESS:Info@axiagroup.net INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Arbella Mutual Insurance Company 17000 INSURED INSURERB:A.I.M. Mutual Insurance Co. Stephen Ross INSURER C: 36 Service Center Road INSURER D: Northampton,MA 01060 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 INSD WVD IMM/DDIYYYYI IMM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500071119 7/1/2021 7/1/2022 DAMAGETORENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X FjpT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: EPLI $ 25,000 A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000 000 (Ea accident) $ — ANY AUTO _ 1020098280 02 7/1/2021 7/1/2022 BODILY INJURY(Per person) $ _ AUTOS TU EONS ONLY X SCHEDULED 1,000,000BODILYO INJURYp (Per accident) $ 1,000,000 X AUTOS ONLY X AUUTOS ONLY (PPerr acaiident)AMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE _$ 2,000,000 EXCESS LIAB CLAIMS-MADE 4620098565 02 7/1/2021 7/1/2022 AGGREGATE $ DED X RETENTION$ 10,000 $ 2,000,000 B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER WMZ-800-8006546-2020A 7/1/2021 7/1/2022 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE - E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.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 Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIV E I ' ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ___-...41 CONSTRAS01 CKELLY ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 41.------ 6/3012021 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 NAME: AXiA Insurance Services PHONE FAX 933 East Columbus Ave (A/C,No,Ext):(413)788-9000I(A/C,No):(413)886-0190 Springfield,MA 01105 ADMDRESS:infocaxiagroup.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Mutual Insurance Company 17000 INSURED INSURERB:A.I.M. Mutual Insurance Co. Construct Associates Inc. INSURER C: 36 Service Center Road INSURER D: Northampton,MA 01060 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 INSD WVD .IMM/DD/YYYYI IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500071119 7/1/2021 7/1/2022 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JELQT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: EPLI $ 25,000 A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO _ 1020098280 02 7/1/2021 7/1/2022 BODILY INJURY(Per person) $ ^_ AUTOS EONS ONLY x SCHEDULED BODILY INJURYD (Per accident) $ 1,000,000 X AUTOS ONLY X AUTOf ONLY (Perr amdent)AMAGE $ $ A X UMBRELLA X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE 8500071119 7/1/2021 7/1/2022 AGGREGATE $ _ DED X RETENTION$ 10,000 _ $ 2,000,000 B WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STATUTE EH R Y ANY PROPRIETOR/PARTNER/EXECUTIVE � WMZ-800-8007507-2020A 7/1/2021 7/1/2022 E.L.EACH ACCIDENT $ 500'000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NE) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.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 ACCORDANCE ANY OFWITH THE THE ABOVEPOLICY DESCRIBEDPROVISIONS.POLICIES BE CANCELLED BEFORE Proof Of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD