24A-089 (5) 10 DICKINSON ST BP-2022-0126
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A-089 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR BUILDING PERMIT
Permit# BP-2022-0126
Project# JS-2022-000216
Est.Cost: $29000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MICHAEL PHILLIPS 082683
Lot Size(sq.ft.): 5227.20 Owner: ROMAN ELIZABETH
Zoning: URA(100)/ Applicant: MICHAEL PHILLIPS
AT: 10 DICKINSON ST
Applicant Address: Phone: Insurance:
P O BOX 514 (413) 250-7990 0 WC
GOSHENMA01032 ISSUED ON:8/2/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR FOUNDATION
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 NORTHAMPT U N VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. . , if ,
Certificate of Occupancy Signatur I
FeeTvpe: Date Paid: Amount:
Building 8/2/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
I
i
i op,
2201
The Commonwealth of Mass luOtt$,^
lq°S Board of Building Regulations and Spanr'ds"= 10
FOR
J Massachusetts State Building Code, 780 CAI ''`O 'Vs MUNICIPALITY
USE
Building Permit Application To Construct, Repair,Renovate Or D - h a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building P rmit Number:9,>D• a?12-Cj Dat Applied:
c--�„� � 5> i 8- z-zoz
1
Building Official(Print Name) Signature Date
' v(F�SECTION 1:SITE INFORMATION
1.1Property Address: , ��e N ef
1.2 Assessors ap& Parcel Number
1.1 a Is this an accepted street?yes V 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:
Zone: Outside Flood Zone?
Public Private 0 Check if yes❑ Municipal 0 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2 wnert of Records L ,�
Ei(
Name(ttrin(t `}! ,^ City',State,ZIP
11(_ "�//: - Ci ci/L
j o.an 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)'
Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work'-: ;1_ � �� �' n
aSA
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
( r and Materials)
1.Building $ ‘bqv 6 6 I 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
0 Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$ 4/ C
Check No)6.1 W Check Amount: (jG Cash Amount:
6.Total Project Cost: $ in W1 �� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor icense(rCSL) b 0 1 ()SO
1 Ok`o\ y)b)
M.,Gv p c 4 \'\p P 5 License Number Expiration Date
�/V
Name of CSL Holder
List CSL Type(see below) `/
No.?Id Stre t Type Description
vb NA Mebilo\o��( UUnrestricted(Buildings up to 35,000 cu.ft.)
City/Town, te, t �/ R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
\te5i)st O J I Insulation
Telephone Em d addre ; D Demolition
5.2 Registers Home Impro ent Contractor )
V� L\t. I ..ill C ` HrlegistrationNumber xp. tion Date
HIC pany Name a R gi trant me
0ft.41.,QC1cd. e
No.a Stre Email address
City own,State, IP elephone
° Mph l cam
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 ?C. 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.
M Ito
'nt Own a(Eke c 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 lication is true .1f ac ca - o the best of my knowledge and understanding.
4 fok"iA)0°6 I
Print wner's or uthorized Agent ame ,lectro .c 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
Information on the Construction Supervisor License can be found at
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
.S =• sj
- Massachusetts 4?S c�
� - DEPARTMENT OF BUILDING INSPECTIONS
\o- 212 Main Street • Municipal Building JjP CD
Northampton, MA 01060 S 3,7.E
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: ��`��1 C�(C�•�
The debris will be transported by:
Name of Hauler: Z \L_ \` C
I �Signature of Applicant: Date:
_..' The Commonwealth of:ilassachusetts
"- -11— Department of industrial Accidents
1 Congress Street,Suite 100
= r � 1 Boctv►r. .tit. 0311!-'lll
-- . I t 'sc.niass gotklia
110/kers' Compensation Insurance Affidasit: Builders.('ontractorsAlectricians.Plumbers.
ft) BE FILED 1!um 1 IIE PEIt11I film;Al lItt)Rffl.
Annlicant Information e Please Print I-reibls
. .(Name IBusiac >i_ir_an::mein lndrsuduall:- L\\Pi`p k IC/PS _ A.._C • —.—
Address: --?ti.0 t \ r ' ---
C its,=State.'ZiP �-� _�� Phone =r: � -�JCS r�9�-d
.5rr%uu an cmplucr?('hick the appruprialrlust: Ty pe of project(required):
1.0 I am 3cniplo c:with . . ernrloy2cailua anal or part•titmct.' 7. J Ness construction
2.D I am a sole proF actor or partnctahip and has.:no cmploycc.notlin_ for nic in i;ig Remodeling
and capacity.1\o y%oi.c:->'comp.itnurantx nyuuui.l
9. D Demolition
3 J t am a hunkv.tnei tloma all wtei r:is,1ti.iNc worker.'corm,-insurance rc tuuul.1•
4.0 I am a h r cn ncr and w ill I-:huin�contractors toconduct all u mt.on in!. I Hill r---
r10 j Building addition
taaurc that:di t.ntraeton cith:r kayo t.orkcro•ceny•n� aalum uuuraatc or arc udc I 1 a Electrical repairs or additions
prapnacr with no criphr eta
t_.D Plumbing repairs or additions
. I am a general contractor and I hay c hued the sub-conic a:tut>li>icd on ds arathc.!>bed.
13.0 Rout repairs
Th.:se sub-contra:tom Isy c ci:rplu_.cc>and h:y c...Luker.':urtp.insurance-'
51 c an:a torp..xatilnr and its lt:ietma hoe cstx.ued their mitt ul cte:144ton per!c1GL c.
It. i 51 1114).l and r c hate no trkncca.1No t urlrn'eumr.in>uance retluiredl 14.DOther
'An}applicant that t!iceli hot=I mint also till out the ucetarn bcluat shots in_tl:cir w utkc-s'tamesnaaliun p she}infermatt on.
'Homeowner.who u.ttrrnt chi.atlid.o.it man:atuum they ate thing all woel and then i ire out>i k:tmtract.tt must>ubuu►a new aff.lat it toditsttnc such.
:c nt.•actot>that clic,.k t:u>by must att.al•<J an.,.hhitunai alieet shah in:the name ci the>ut-tvntra.tt'r>and state it hatter or not thute omititie.>hat c
cl:trlt•yees. II tb.atb-eurtna:tor.I"-n c et:r1 tutees,they mu,:rift ale then ,%oiler. ceirip pti1te♦nurihr.
1 am an employer that is pruridin„t worAers'c'ompen.sation ins:ranee for nil'employees. Beloit is the polio.and job site
' its jurnrutiar. „���� ` 1,t� �
Insurance Company Name: �.. }}� . nc —
Policy =or Self-ins.Lie.16+ba V0�L'� '3e5. 5 1 I Expiration Date:
Job Site Address: < p 5-71 City` State.Zip: IJ 0C / i l
Attach a copy of the ssorkers iisat►on policy declaration page(showing the policy number and expiration date). 004
Failure to secure rut era?_;c as required under MIGL c. 152.§25A is a criminal s iulattun punishable by a fine up to S I.=00.00
anti"or one-year itnpnsonment.as sell as civil penalties in the limn of a STOP WORK ORDER and a line of up to 5250.00 a
day against the s tolator.A copy of this statement may be furssarded to the Office of Ins estigations of the DIA for insurance
co'erage cerifiratiun.
/rho hereht'certify under the p 'is and nen if, •rjur•that the information provided above is true and correct.
Stenature: Date_ dal I ( l
Phone:::: Li sc2.? ...„ s 6....
et 0
Official use only. Do not trite in this area,to be completed by city or town official
Cits or Toss n: PerutitiLicense f
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3.City-ffossn Clerk 4. Electrical Inspector 5. l'lumhing Inspector
G.Other
Contact Person: Phone 4:
VDAC
CHUBB'
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S62UB-4N43852-5-21)
RENEWAL OF (6S62UB-4N43852-5-20)
INSURER: ACE AMERICAN INSURANCE COMPANY
A STOCK COMPANY
NCCI CO CODE: 12165
1.
INSURED: PRODUCER:
MICHAEL PHILLIPS INC AQUADRO & ASSOCIATE INS
PO BOX 514 P 0 BOX 357
GOSHEN MA 01032 NORTHHAMPTON MA 01061
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 06-24-21 to 06-24-22 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) 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: $ 500000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 500000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 06-09-21 we ST ASSIGN: MA
OFFICE: RND CHUBB 24M
PRODUCER: AQUADRO & ASSOCIATE INS 26XDW
016341
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Co nstruCttOfl'Supervisor
CS-082683 expires: 1�i 1012022
MICHAEL J PHILLIPS
PO BOX 514 ON,
GOSHEN MA 01032
Commissioner ';,f„•1 I
Office of Consumer Affairs&Business Regulation •
HOME IMPROVEMENT CONTRACTOR
TYPE:Corporation
Registration Expiration
171266 03,04,2022
MICHAEL PHILLIPS.INC.
MICHAEL PHILLIPS
31 MAIN ST
P.O BOX 514
GOSHEN.MA 01032 Undersecretary