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17C-148 (12)
BP-2021-2006 33 KEYES ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17C-148-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2021-2006 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 7000 PRECISION REMODELING INC 88742 Const.Class: Exp.Date:01/16/2022 Use Group: Owner: FORMAN ELISSA Lot Size (sq.ft.) Zoning: URB Applicant: PRECISION REMODELING INC Applicant Address Phone: Insurance: 21 ROOSEVELT (413)575-1097 WC9083755 HOLYOKE, MA 01041 ISSUED ON:10/07/2021 TO PERFORM THE FOLLOWING WORK: INSULATION 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. Signature: a 1 )2 IC-1 Fees Paid: $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner • CDeoertr'nle;t t.::-= :oitl City of Northa pton �iF ;IJx , i: t. Building Dep.rtme t 007 Our "r.ra�M Perr, 212 Mai :.trek " 6 -._ t,c 1 Room :* �tiro� 420(9iv d,:, ,1 Oldr, Northampton, MA s ,QU/Ip) I T v1. :c tru t.ra r phone 413-587-1240 Fax 413- _ rb "ksso a .,kt.- ans_ _M. Mq oFeTiO �_ `"t`'iffy ___ APPLICATION TO L CONSTRUCT,ALTER,REPAIR,RENOVATE OR f My LISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION ✓� v 1,1 P.ypertyAddress Thisi section to be completed by office 33 Keyes St, Northampton MA Map i �G Lot lqg U tt __._..._. . Zone C_Iverlay Disteict 4 ! Elm sr.Oistrtct eb District SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT i 2.1 Owner_fir Record: 'e.y eS Elissa Forman 33 Kcyc St, Northampton MA 01062 Name(Print). q_ Current Mailing Address: Ega,„.... ,,,,,,,...,...., _ Teleprione Si tire 2.2 Authorized Agent: Robert Hunter 21 Roosevelt Ave, Holyoke MA 01040 Name,P rt C rrr.r,°°.ant ng Address:,___ - 413-575-1097 i P, i;,r _...._. Telephone.rrrronr _. _w ._._ r _ _ w_._] SECTION 3 -ESTIMATED CONSTRUCTION ccArs .. _ Item Estimated Cost(Dollars)to be d Official Use Only completed by aerrnit applicant 1. Building 7000 {a, Bull:ng Poinsk Fee I { p. Electrical Ib;E.;.r.;ratPd Total Cost of � .. .,.. ,_......, _-_____...__.._._... t`.or3511"uCio)lti?:7irt (Tr ;.. Plumbing Building Irrrslt fee 4 Mechanical(HVAC) I i Fire Protection , T tal 1 + t.3 4 4+ 5) i 7000 r he c' Number f _h W This Seoticn For Official Use Ohiy __ ____.., l;ttildin'i erinit Ntirnber e 41 woe )ate F .trvtr.4r >f G } i iir 11-durt t i ri,,iy c t 1n ,r-1,, Dale PRlpremits grnail.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING Ali informatwn Must Be(.;nmpteted. Penult an k,Domed Due To incomplete Information Lxisting oposed Required by Zoning t tai.t::itlitniti to IVB1.Jin by Depamerti Lot Size Frontage Setbacks Front Side R: • L.• Rear • Building I leighi t31rig. Square 1'of a f . )pen Space Footage T .0 urea pas. of Parking ii2:0 t I 04:awn) Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book Page and/or Document# • B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW YES 0 IF YES, has a permit been of need to be obtained from the Conservation Commiscion? ..„. Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0NO IF YES, describe size, type and location: D. Are there any proposed changes to apt additions of signs intelded for the property? YES 0 NO (ip • IF YES, describe size, type and location: E WII the construction activIty distud) 41ading.ec, aior r t•Iiingt over 1 acre or is 1 part of a common clan that will disturb over I acre') YES 0 NO g) IF YES then a Northampton Storm Water Me!*tqement Permrt nob th,.1 DPW:s required. SECTION§-DESCRIPTION OF PROPOSED WORK fcherk all appilce tlie) •' New House ❑ Addition t J Replacement Windows Alteration(s) Ej Roofing D Or Doors Accessory Bldg. ❑ Demolition Li New Signs Di Decks t[.a Siding ipj Other I WI Insulation Mass Save insira-ion 312sf attic cellulose R38; 416sf wall cellulose densepacfR13 Brief Description of Propose 572 crawl space ceiling fiberglass R19 & 2" RMax rigid insulation R12 Work Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roii - Sheet &a if New tiou a and.utadd°ition is g h ;.:•:;t14.Liphipiete the following a. Use of building : One Family Two Family Other o. Number of rooms at each family u',i Nuntue r or t<x<tr,aon',s c, Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f, Method of heating? Fireplaces or VVoodstoves Number of each g. Energy Conservation Compliance, Masscheck Energy Compliance form attached? h Type of construction Is construction within 100 ft, of wettaods? Yes No. Is construction within 100 yr. floodplain Yes No Depth of basement or cellar floor below finished grade v,ii building conform to the Building 8nd Zoning regoiari.cres% Yes_,__ __No • Septic Tack City Sewer Private well ______ City water Supply SECTION 7a-OWNER AUTHORIZATION•TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 Elissa Forman as Owner of the subject property Robert Hunter hereby authorize to act on my beha in all matters relative to work authorized by this building permit application. Signature of Owner Die 9-29-21 Robert Hunter as Owner/Authorized Agent hereby declare that the statements and information or;the foregoing apple utum are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of ro-o;t iry. Robert Hunter { Print Krim'? i f �.� ....__.. 9-29-21 i;gnature of wne;fAgent SECTION 8-CONSTRUCTION SS VICES 8.1 Licensed Construction Sup,rvrs+,. Net.Applicable 0 Name ziticerise rt�tr Robert Hunter i CS88742 Name _.__.._.w w..��._ ro....,. I License Number PO Box 10432 Holyoke, MA 01041 1/16/2022 ACm Expiration Date 413-575-1097 (-44ACk--- si feteprione t4tegieterr Not Applicable l7 Precision Remodeling, Inc. 152922 Company Name Registration Number 21 Roosevel Ave, 10/13/2022 Address LXprre,t011 Date Holyoke MA 01040 `!ei., thane 413-575-1097 SECTION 1.-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,,G.L..c.162,§2 C(6)) Workers Compensation insurance affidavit oiust be corr 3 <.c.'; 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.. l No I • City of Northampton •'; Massachusetts 4r'3 � -.. '0,1,":•'•• DEPARTMENT OF BUILDING INSPECTIONS 212 Hain .1 aet. •bfuni.cipa l building t,f„ «.` 4* Northampton, MA «C0 �, ..-; ' Debris Disposal Affidavit In accordance of the provisions of MGL c 40. S54. l acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MCA_ c 111. S 150A. lie debris from construction work being performed at 33 Keyes St, Northampton (Pir' print house number and street name Is to be disposed of at K&W Materials, 138 Palmer Rd, West Springfield, MA (please print name and locaf,:- 3 iaciiay Or will be disposed of in a dumpster orrsite rented or leased from: (Company Name and Address) Signatur of Permit Applicant car Owner Date if, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the iocatieh vaiiere the debris will be disposed. . , �_ City of Northampton C Massachusetts "� <'; , * c w 4 1 DEPARTMENT OF BUILDING INSPECTIONS P �' 4 ' rP 212 Main Street • Municipal Building - Northampton, MA 01060 r�l'A, ijs:''' Property Address: 33 Keyes St, Northampton MA 01062 Contractor Name: Robert Hunter Address: 21 Roosevelt Ave, City, State: Holyoke MA 01040 Phone: 413-575-1097 Property Owner Elissa Forman Name: Address: 33 Keyes St City, State: 33 Keys St,Northampton MA 01062 I, Robert Hunter (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature at4c;i / 64q Date 9-29-21 . .L\ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02E4-2017 .0; www.mass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIM-111NC AUTHORITY. ppUcsnt Itiprp.iadon Please Print Lelbly Name(BusinessiOrganizationfindividualr. Precision Remodeling, Inc. _ Address: 21 Roosevelt Ave . City/State/Zip: Holyoke, MA 01040 phone#: 413-575-1097 Are you en employer?Cheek,the appropriate hot= Type of project(required): 1.0 I arn a employer with 6 employees{fuli motor part-timal• 7. Ei New construction 20 i Dal a sole proptiohn or partnership sad have no employees working for me in 8. 0 Remodeling any capacity.(No workers'cernp insurance required) 9. 0 Demolition 3.0 I am a borneoweer doing all work myself[No workers comp.Maoism e(equired.) 10 El Building addition 4.0 I ain a aomeowutz and will be hiring contractors to conduct all work ou my property. I will ensure that all common's tither have workers'compeosatimi illAIMCC Of am solc 11.[J Electrical repairs or additions proprietors with no=players. 12.0 Plumbing repairs or additions 5.0 l am a general cononctor and I have hired the suh-comractors listed on the vatted sheet 13.0 Roof repairs These sub-coutracton have employees end have workers'comp.insurance,: &El We am a corporation and its o(ricers have exercised their right of exernotton per MO1.c 14.Ea Other Insulation ISE,f 1(4).and we have DO employees.[No workers'comp.insurance required.] 'Any applicant that r+erlti box#i must xis°Ell oirt the section below showing their workers'companation policy irtformanota, t Homeowner'who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. !Contractors that check this box most attached an additional sheer showing tie ciarne of the sub-contractors and state whether or not those entities have employees. lithe sub-contractors have empioyeesithey 1714151 pteloidiC their workers'fortp.polic-y number. lam an employer that is providing workers'compensation insurance for nty employees. Below Is the policy andjob site Information. Insurance Company Name: Selective Insurance WC9083755 16 December 2021 Policy#or Self-ins,Lic.#: Expiration Date: lob Site Address: 33 Keyes St, city/state/zip;Northampton MA 01062 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. 132,§25A is a criminal violation punishable by a tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250,00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DR for insurance coverage verification. I do hereby certify nder the pain and penalties of perjury that the information provided above Is true and correct. Signature: 4- , K Date: 9-29-21 phoneo: 41 -575-109 Official 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 1., Contact Person: Phone#: • M/DDIYYYY)(M ACc RCO CERTIFICATE OF LIABILITY INSURANCE DATE(M /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: THE DOWD AGENCIES LLC PHONE 413-538-7444 FAX 14 BOBALA RD E-MAILo.Exq: (A/C,No): ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N HOLYOKE MA 01040-9402 -------- - - - --- -- __. ... __..__.... INSURER A: SELECTIVE INS CO OF SOUTH CAROLINA 19259 INSURED INSURER B: SELECTIVE INS CO OF THE SOUTHEAST 39926 PRECISION REMODELING INC INSURER C: SELECTIVE INS CO OF SOUTH CAROLINA 19259 21 ROOSEVELT AVE — — -"-- MMURER D: HOLYOKE MA 01040-1607 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 ADOL SUBR POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY X S 2332110 12/3/2020 12/3/2021 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 A MED EXP(My one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY X JEC X LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ C AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 X A 9107250 7/1/2021 7/1/2022 (Ea accident) $ _ ANY AUTO ' BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per AUTOS ONLY — AUTOS accident) $ X HIRED AUTOS NON-OWNED PROPERTY DAMAGE ONLY X AUTOS ONLY (Per accident) $ $ A X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 1,000,000 -- S 2332110 12/3/2020 12/3/2021 —. EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED J X I RETENTION$ZERO I $ e I WORKERS COMPENSATION WC 9083755 12/16/2020 12/16/2021 x STATUTE ER PER A'AND EMPLOYERS'LIABILITY Y/N ----- ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A - .__ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 1 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 i DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) This Certificate of Liability Insurance was created by Selective on behalf of the agent. CITY OF NORTHAMPTON is included as additional insured with respect to General Liability, Automobile as required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION CITY OF NORTHAMPTON CITY MAIN ST. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 212THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Northampton MA 01060 AUTHORIZED REPRESENTATIVE -004t*"?./ iiL"'"°*.'"''' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construetibn Supervisor CS-088742 Expires:01/1612022 ROBERT R HUNTER PO BOX 10432 HOLYOKE MA 01041 Commissioner ,tTr - ';27 /(' 'tf-Y/7/.// (/1 /y(1.,./-.1Kie;44.)/V4 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 152922 PRECISION REMODELING, INC. Expiration' 10/13/2022 21 ROOSEVELT AVE. HOLYOKE, MA 01040 Update Address and Return Card. sea 0 2t.,m Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration EXPiratiOn Office of Consumer Affairs and Business Regulation 152922 10/1312022 1000 Washington Street -Suite 710 PRECISION REMODELING,INC, Boston,MA 02118 ROBERT R.HUNTER 21 ROOSEVELT AVE. HOLYOKE,MA 01040 Undersecretary Not valid without signature