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17D-022 (3)
BP-2021-2000 101 STRAW AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17D-022-001 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-2021-2000 PERMISSION IS HEREBY GRANTED TO: Project# ADD STUDIO Contractor: License: Est. Cost: 29000 STEPHEN ROSS 079160150847 Const.Class: Exp.Date:04/28/202305/03/2022 Use Group: Owner: LACLAIR JESSICA L Lot Size (sq.ft.) Zoning: URB Applicant: STEPHEN ROSS Applicant Address Phone: Insurance: 36 Service Center Rd (413)584-1224 WMZ-800-8006546-2020A NORTHAMPTON, MA 01060 ISSUED ON:10/14/2021 TO PERFORM THE FOLLOWING WORK: CONVERT GARAGE INTO STUDIO 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: i . �� )2CS-11 • Fees Paid: $189.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner BP-2021-2000 101 STRAW AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: I7D-022-001 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-2021-2000 PERMISSION IS HEREBY GRANTED TO: Project# ADD STUDIO Contractor: License: Est. Cost: 29000 STEPHEN ROSS 079160150847 Const.Class: Exp.Date:04/28/202305/03/2022 Use Group: Owner: LACLAIR JESSICA L Lot Size (sq.ft.) Zoning: URB Applicant: STEPHEN ROSS Applicant Address Phone: Insurance: 36 Service Center Rd (413)584-1224 WMZ-800-8006546-2020A NORTHAMPTON, MA 01060 ISSUED ON:10/14/2021 TO PERFORM THE FOLLOWING WORK: CONVERT GARAGE INTO STUDIO 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: O ,I • I; • > - 3". Fees Paid: $189.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner I RECEIVED j 1 , OCT he I ommonwealth of Massachusetts . _ 5 2021 Bo;rd o' Building Regulations and Standards FOR {� 'A; M..sac setts State BuildingCode, 780 CMR MUNICIPALITY i ,.` a7 OF � USE -- NOi37 4r4O e tj,;...pli'ation To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 ,A o�oso 1 One- or Two-Family Dwelling This Section For Official Use Only Building Permit Number: j ,r4 cm" Lotro Date A plied: Building Official(Print Name) Signature 4 _ O-1 SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers to 1 �T J AV-c' VI b o22. 1.la Is this an accepted street?yes X, no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: tit )O Gl}M't E. ¶1.00 sq -FT• b 0 T 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 No ctkiNuG NO ctkic .s NO c ik-ocNC. 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private 0 Zone: Outside Flood'one? Check if yes Municipal l�On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: J SS I c-A u/kGl. i R. fL P- ,/kl C- M►k 0 t 0(,2- Name(Print) City,State,ZIP rr-- I,O 1 51I4' AV 1.)LIE 643 t?I3- 44-ob -j Cs rhirkZ 1lakvvt4tt , cm , No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2 (check all that apply) New Construction 0 Existing Building l Owner-Occupied.%i Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: CO Nvc-t2 l X v-5TkN 4 A-TThCEFEt. a APA4-E -to STupco SECTION 4: ESTIMATED CONSTRUCTION COSTS IVEstimated Costs: Official Use Only (Labor and Materials) 1. Building $ Z eve,ce, 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee f UU- 0 Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ d- "`� 3 3—ad 2. Other Fees: $ 4. Mechanical (HVAC) $ ,, c List: 5. Mechanical (Fire $ 0 _ Suppression) Total All Fees: $ p 6.Total Project Cost: $ ��.0 e'O Check No.7 I Check Amount: •I!Cash Amount: Z,' 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) L5 — 07 ct Go 4 ab , z3 '-TE9.1m-i.) p. P.-OS License Number Expiration Date Name of CSL Holder List CSL Type(see below) o (2-6 D No.and Street Type Description 0(2T 4M�T(>�tJ N1�t \p�� Unrestricted(Buildings up to 35,000 Cu.ft.) Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 4[ .'7M, 12-24- • kepdro 6s.0 yahoo Lore I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ISO 641 Uc •03. 2_UZZ ST fr♦ J D ✓ -o 6 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 3( . Cc A/'T - POM th-e a(O6 ' cMOCJ. v No.and Street P y [: ►n 11.OP-'R}4MP'Ta!J AAA o\OE,b [� Email address City/Town, State,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 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 to act on my behalf,in all matters relative to work authorized by this building permit application. >Jcssi a.Lu.Gcac, is & ZI Print Owner's Name(Electron 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. dp-cepo ) c ¢vis to-1 -24 Print Owner's or Authorized Agent's Name(Electronic 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 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" The Commonwealth of Massachusetts °i Department of Industrial Accidents ii :FII J Congress Street,Suite 100 ':t-!—_ Boston,MA 02114-201' =,- www mass.gov/dia Waiters"Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. It)BE PLED WiTH THE PERM)rIL'G AUTHORITY. Applicant Information '/ Plea,Print Leek% Name(H cs�`O usitt gantration`Individual) mot'- \. L- id' 5- , Address: 3c.. S'-t fa1'ee, e,,, �-✓ Voe Z City/State/Zip /r%/dtri i'�vt /n 4 ®/©Cr 0 Phone#: C// -5-6Y - r ez-Lt Are you an employee Cheek Ole appropriate bon: Type of project(required): i a et:player with employees(full andbr partaime).• 7. D New construction tam a sok p.opnetur or partnership and have nu CI7iptoyeel working for me in $. 0 Remodeling testy capably.[Nu outliers'comp.insurance nyuim)[ 30 I am a homeowner doing all wurY myself.flu*oilers'comp tttsurrru:e nayuncd.)' 9. 0 IX-molition 4.0 I am a luln esmtw in tcowawr and wall he hiring tran to conduct all wink on my property. I will I0 CI Building addition .rule that all contractor,either base workers'compensation insurance cis are sale 111:3 Electrical repairs or additions proprietors with no cznpluyces. 12.0 Plumbing repairs or additions 5C3 lam a general cunuw cur and I base hired the suh-cuntractors listed on the atwefird sheet_ These sub-contractors base employees and►a n s a wurkc 'comp.insurance. l? Roof repairs (,.0 we an:a I.-avocation and u u officers have eaerrcd their nght otexemption per M(&L c l4. Otht"r---- 152.v t(4).and we lwst no employees.[No winters'comp.uasurnncc required.[ 'An applicant that chala boa el[trust also till out the sccttom below show ing their wutkets'compensation pulley udonnatwn 'Homeowners who submit this affidaYit indicating they are doing all work and liens bare outside contractors must submit a new afftdav it indicating such :Conuactwn that check this box mug at-WAWA an additional shut show ins the narnc of the sub-contractors and state w'tether CT not those entities have employees. lithe sub-eontract rs have employees.they moo provide their workers'tannp. lacy number. I um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ----------.-------_.___ Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: C'ity/State''Zip: Attach a copy of the workers'compensation polity 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 fine up to S1.500.IX) 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.U0 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 the xt#its and penalties of perjury that the information provided above is true and correct . ... ._t;.,,______ Sibnatttrer Date: ' / {` Phones: �1//' .3 "/- S i -/- / �' Official use only. Do not write in this area,to be completed by city or town official City or Town: Pernik/license i'? • issuing Authority (circle one): ' I. Board of Health 2. Building Department J.City/Town Clerk 4.Electrical inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: CITY OF NORTHAMPTON SETBACK PLAN MAP: ri b LOT: O 2 2 LOT SIZE: r1C.OD REAR LOT DIMENSION: &Z) REAR YARD r 1 0 l SIDE YARD t SIDE YARD 2-2 FRONT SETBACK' Sal `FRONTAGE 6 d 1 i i 7D ..... 021 ,„,.,,..„ 3 - ,,,:s, -:- ---"L"'""'---. . _i_sp.,... .4,,,,- ‘43'1 60.„,„ , • A., „ ..., .. ,.„, ,,,,, ..-_„, a „-- ,.., ._ A _. •,,......„. ...„..„.„,,_ f ,,,,- 60 /r , _ .„ ,,, , .. _.„-:-... 16 .: ,-, ,,„„, .7 .„,„., „ 4.,,., . ,..„ DI= I . / 1 6. ., . _... 6 . .. .... , ar 7-*-4'...4614./ 02 ‘, fr 1 .,. 60 ,,,,,Jrcr. , ,. r City of Northampton pYMAltp�` /vo r o~� S,S `•SfC Massachusetts 1' DEPARTMENT OF BUILDING INSPECTIONS aj fp 212 Main Street goMunicipal Building J'ti �L Northampton, MA 01060 `9" "aro• 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: V .$`P PtG1C:LIit) No TtkAAAP-Tc.);J 'S r N v P-TNAMP-Tc.))•.) ILA The debris will be transported by: Name of Hauler: CONI7TRU C Signature of Applicant: Date: --/ • ° Commonwealth of Massachusetts Division of Professional Licensure , Board of Building Regulations and Standards Construction Supervisor CS-079160 Expires:04/28/2023 STEPHEN D ROSS j. 36 SERVICE CTR RD • NORTHAMPTON MA 01060 r • Commissioner •i0. �i. L7�mc at c/iZ F6L/7 m nreeleadI 6/e ce e:el�l Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 150847 STEPHEN D. ROSS Expiration: 05/03/2022 36 SERVICE CENTER RD. NORTHAMPTON. MA 01060 Update Address and Return Card. SCA 1 0 20M-05/17 �.....iN CONSTRAS01 CKELLY ,4`o�RO• CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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,Eat):(413)788-9000I(A/C,No):(413)886-0190 Springfield,MA 01105 noDREss:info@axiagroup.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Mutual Insurance Company 17000 INSURED INSURER B: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/DD/YYYYI (MM/DD/YYYY) 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 PECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: EPLI $ 25,000 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 ONLY OWNED — X AUTOpoDWUL.�ED BODILY INJURY(Per accident) $ 1,000,000 X AUTOS ONLY X AUOTOS'ONLY PROPERTY acEcidentDAMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE 462009856502 7/1/2021 7/1/2022 AGGREGATE $ DED X RETENTION$ 10,000 $ 2,000,000 B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N WMZ-800-8006546-2020A 7/1/2021 7/1/2022 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER FFI /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 REPRESENTATIVE i 1 ' ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD