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30B-008 84 WARNER ST BP-2022-0143 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30B-008 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2022-0143 Project# JS-2022-000250 Est.Cost: $3400.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MIKE GRSIWOLD 106044 Lot Size(sq. ft.). 24524.28 Owner: WOJTUSIK ELIZABETH Zoning: URB(100)/ Applicant: MIKE GRSIWOLD AT: 84 WARNER ST Applicant Address: Phone: Insurance: 59 ENFIELD RD (413)461-6914 SOLE PROPRIETOR PELHAMMA01002 ISSUED ON:8/9/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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. l / Certificate of Occupancy Signatures 4 ,v • 1 � FeeType: Date Paid: Amount: Building 8/9/2021 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 6The Commonwealth of Massachusetts /� a !� State Board of Building Regulations : d ' + Standards •II. • : PALITY USE Massachusetts State Building i de Afk .' 780 CMR o ��T 9 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMO- °d p.e OR • ILY P ELLING rOA,61!ca This Section for Official use Only '"rl-VCI. Building Permit Nu er: 0- 3' iciJ Date issued: e6o Ns Signature 8. 9-26z 1 Building Commissioner/Inspector of Building Date SECTION 1 -SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Number 6 bog Map Number 30 Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions Zoning District Proposed Use Lot Area(sf) Frontage(ft) 1.6 Building Setbacks(II) Front Yard Side Yards Rear and Required Provided Required Provided Required Provided / / 1.7 Water Supply(M.G.L.c.40,§54 1.5 Flood Zone Information: 1.8 Sewage Disposal System: Public-i Private--i Zone: Outside Flood Zone-I Municipal J On site disposal system u SECTION 2—PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: hr A At- v. l 6Q 51', Na ...�••� A dress for Service .tgna Telephoned / Or--( 2.2 Au orized Agent: C� i I,�C O(0,c d L / G,/m(L J46-Q_ S 7N, Name(Print) 3 Address for Service S� i t_(� V/ hone Wi 6F/� g P SECTION 3—CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable--1 Lice sed Construction Supervisor License Number 5'T ENr�- QP• 7c-LArNM , l—' S _a — 3 Addr / L�y/3 — �G o f/ al Expiration Date iS'gnatu a Telephone 3.2 Registered Home Improvement Contractor: Not Applicable--1 ki)ge-6 6(t IS'c.o 178 -75 , Registration Number an � rz wRM t ( 7 /7 3 JQ �t (� /7 l J —V6/ 6/ y Expirati Date Signature Telephone SECTION 4—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 Yes4 No SECTION 5—DESCRIPTION OF PROPOSED WORK(check all applicable) New Construction J Existing Building t Repair(s) i Alteration(s) J Addition Other j Specify: Accessory Bldg. tg Demolition Brief Description of Proposed Work: LDS G �� ^`6�S U J�L ST21P S�tIAI ) /" p N� nl�ti GZ Roo g d n/ A- / S y a o Pte6C- ST'R /NioInJ (, 6Ae. isE SECTION 6—ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only co leted by permit applicant 1. Building 0 C) (a) Building Permit Fee / I! Multiplier 2. Electrical (b) Estimated Total Cost of Construction 3. Plumbing 4. Mechanical(HVAC) Building Permit Fee (�(a)x(b) 5. Fire Protection Total (1 +2+3+4+5) voo Check Number ("7.3 SECTION 7a—OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS'AGENT OR CONTRACTOR AlPPLIES FOR BUILDING PERMIT I, ELI7 iq t W O F j' 5fl ,as Owner of the subject property hereby authorize — 6(I1SC,.1'o to act on my behalf in a r r i to work authorized by this building permit application. 8-6 --at ature Date S ION 7b--Zee- AGENT DECLARATION Zee- 6l 1.t sc.0 L, ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate to the best of my knowledge and belief. Signed under the pains and penalties of perjury. h1IK( Print ame 8 -6 ~ar Signature of Owner/Agent Date COMPLETED BUILDING PERMIT APPLICATIONS SHOULD BE MAILED TO: Building Inspector,Town of Pelham,351 Amherst Road,Pelham,MA 01002 City of Northampton 1A fro S`S SAC "d • Massachusetts <z.' , DEPARTMENT OF BUILDING INSPECTIONS I r 212 Main Street • Municipal Building Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 554, 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: ` 16G 7 C L) JJ AJ' IZ TEA m MA/ The debris will be transported by: Name of Hauler: I / ) I �= 6 2- S Uv Signature of Applicant: Date: 8 -6 ' The Commonwealth of Massachusetts Department of industrial Accidents • 0 i i Congress Street,Suite 100 =' � Boston, MA 02114-2017 '.....„,,,4' N'ww mass.gov/die 11 in kers'Compensation Insurance ARdav it: Buildersr('ontractorstE Iectricians(Plumbers. IO Hi. FILED WITH THI.:PER5tt Ftri(. it I HORI I• . ,ltinlicant Internretiesn Please Print Leeihh Name i l3usitt:-- s irganceau(lu ltdividual): "1 1 K C (7<2 .S (•-3 0 I-- Address: 5 I CA] F 1 eto CEO. • city statetzip: &L t-titc) iM rn A Phone#: /3 — Y41^ 6 YI y Are on an employee Clerk the appropriate boot: 1 y pe of project(required). ICI I am a enploya with iniiployers thin atadoe pan-nmrt• 7. 0 New construction 2.61 am a sale proprietor or partnership and have no employers working far tar is S. 0 Remodeling any capacity.(Nu workers'comp.rrtruranca tenured] 30 I am a Ilan owner doing all work myself:No wealtexs'comp iasurancc n utrad-j s 9. ❑ Demolition 4.0 I am a humeuwnet and will be hiring contractors to conduct all wink on my property. I will to Building addition ensure that all contractors either hate workers'con p+scna:s:s..e tic+urancr or isre sok 11.0 Electrical repairs or additions proprietors to, 'd'rs'ratpluyeeta 12.0 Plumbing repairs or additions S0 I am a general contractor and I hate hired the sob-cuotractws listed tin the attacteed sheet 13 RWf repairs these sub-auntracson hate employers and have w,xkers'rump.wurance. • 1k a arse s corporation and its officers hat a exerrue t theta right of exemption per PALL e.60 (4. Ober 152.5tf4i.and we hate no omit/ye-es.(No workers'comp.nuisance requited., 'Any applicant that chucks bus a t must also no tout the section below show mg their workers'compensation policy information r Homeowners who submit dos affidavit indicating they arc doing all work and then hoe outside contractors must subenrt a new afftdasit indicating such. :C Orstracron that check this box must attached an additional sheet showing the name of the soh--contracture and state whether ur not those cssuties hate c,,y•I ..: , lithe sub-cesntrsetura base employees.they most pwside their workers'uonp policy number I um an employer that is providing n orsters'compensation insaraact for my employees. Beloit is the polies'staid fob site information. insurance Company Name: Policy#or Self-ins.Lic.#:_ Expiration Date: Job Site Address: City:State:Zip: _ __ Attach a copy of the aorkers'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 S1.500.00I and or one-year imprisonment,as well as cot t1 penalties in the trim of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. A copy of this statement may he forvtarded to the Office of Investigations of the DIA for insurance coverage verification. I do he•re'hr cer►if under the pi .ns and Pen ties of perjury that the information provider!above i.t tree and correct. Signature Date 8 _ 6 a 1 Phone r+': V/3 " Vol - Ci_2/� Official use only. nu not write in this urea. to be completed hP city or town official ( it. or Town: Permit/License A Issuing Authority (circle one): I. Board of Health 2. Building Department 3.('it!,A to n Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other ( outaet Person: Phone#: A CERTIFICATE OF LIABILITY INSURANCE DATE 6MIDDYYY)1 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 Diane LaFieche The Dowd Agencies, LLC PHONE FAX 14 Bobala Road (py c.No.Ext):413-538-7444 (A/C,No):413-536-6020 Holyoke MA 01040 ADDRESS: dlafleche@dowd.com PRODUCER CUSTOMER ID#: ONTHELE-01 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:Hudson Specialty Insurance Company On The Level Builders 59 Enfield RD INSURER B: Pelham MA 01002 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:176120592 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 AWL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR 1M/D POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) A GENERAL LIABILITY HBD10045202 9/8/2020 9/8/2021 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PR S( RENTED PREMISES(Ea occurrence) $100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000.000 POLICY X TA: - LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (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/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,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. Proof of Insurance AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD