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11C-055 (3)
BP-2021-2036 420NORTH MAIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 11 C-055-001 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-2021-2036 PERMISSIONIS HEREBY GRANTED TO: Project# REPAIRS Contractor: License: Est. Cost: 14410 BARRON &JACOBS 060475 Const.Class: Exp.Date: 11/10/2022 Use Group: Owner: SPEYER JACK &SHARON MAYBERRY Lot Size (sq.ft.) Zoning: HB Applicant: BARRON &JACOBS Applicant Address Phone: Insurance: 70 OLD SOUTH ST NORTHAMPTON, MA 01060 ISSUED ON:10/21/2021 TO PERFORM THE FOLLOWING WORK: OPEN CEILINGS FOR ELECTRICAL ACCESS, INSULATION, REPAIRS TO DRYWALL 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 .52 ci"T's � I; • 1 Fees Paid: $105.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner // P- zl 203C, ,/. '. Oili c,;. VO Ne Commonwealth of Massachusetts VT�� i� Office of Public Safety and Inspections 'Ty Gii �c�J Massachusetts State Building Code(780 CMR) ' '' 94'��0:' 'lding Pe it A lication for any Building other than a One-or Two-Family Dwelling ti ti`11?4 , (This Section For Official Use Only) Building Permit Number ?, o '"ad (/ Date Applied: Building Official: SECTION 1:LOCATION r'120 NIniA-1.\ Mb'%in 9r. -e.ed-5 Ml- onS3 No.and Street City/Town Zip Code Name of Building(if applicable) I l C.— 055-'Mk Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building 0 Repair)l Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No pi Is an Independent Structural Engineering Peer Review required? Yes 0 No al Brief Description of Proposed Work b f(2,4\ Ge4; g 0ti S:.(sn.e.__ fcrtrs•-> accsrss -1/4O olltc .0 `ems (.\\' IV).--) \kr5 .\4,- ,,,,A_ 1o\ocJ�rr,0.,„ 1D c�..s4 }, O 'A wVu4_ GcuSS:bl,.. o,.- 15''^Gin t. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) y\.;0 LAe•ati,,� Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business p E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2❑ I-3 0 I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA El IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV 0 VA 0 VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public igl Check if outside Flood Zone 0 Indicate municipal❑ A trench will not be Licensed Disposal SiteriP Private 0 or indentify Zone: _ or on site system 0 required or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 13 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 01 Yes 0 No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 13 -5 - ..\•' `kb-`,C. - C.C.1 - ',, c ..�r r-t+�,t.�t �-ti JS . Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application, SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name CY �t�S' 3f vttt f c �..,, ' C}(c L Name of Person Responsible for Construction License No. and Type if Applicable CA (tn.,'.din. St i\YJ`,(" .Y,.,. }kW O\C1(aO Street Address City/Town State Zip Telephone No, (business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes pi No D SECTION 12 CONSTRUCTION COSTS AND PERMIT F Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1. Building $ Vk, 10 Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ (Dt CDO appropriate municipal factor)_$ . • 3.Plumbing $ 4.Mechanical (HVAC) 5 Note:Minimum fee=$t (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 0,t,��0 (contact municipality)and write check number here 02.E oCF . • p �') SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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. q^ C.- -,f,. tN ic,,-, C/17` 6-C.. .,.., .'-\ - K"1ail�___At4Lg,2A Please rint and si name P � Title Telephone No. Date C) `k.. y "`' ` '"`` l`X O\Q1aO 'ts-^ . ,Nx« SG ,.. Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name•�•'�'►'�% o/ i 1 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner r,\e"\,C 5 Gas 10 0\0.904 St- ) r\ j\NPr 0\090 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: `-13 -5X(0- 'ykse Lilly 7.50 - 6fo \V V c)i)6.v Pro.4,i,- oS-orr. Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yesp No D SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ L,‘,1-A10 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ (1),1D0 appropriate munisjpal fator)=$ 3.Plumbing $ `/'fir (fJ�`�, 4.Mechanical (HVAC) $ Note:Minimum fee=$ G (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ \''\,�\0 (contact municipality)and write check number here 0 A U� SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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. (.}Nr• 4t91nQ,r 'Sc.-e-olis i _ `�� - �'- — 4"k Please print and sign name Title Telephone No. Date D\CK 504, \cbO -orko( .vvim-a�.J�1�,r-ob4 Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts ► * ia 1Department of Industrial Accidents :a1= 1 Congress Street,Suite 100 t= �i=_ Boston, MA 02114-2017 %,,� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORIT\. Applicant Information Please Print Legibly Name(Business/Organization/Individual): ba ' Q(\ c,,'ry\S, 1"s .,;:x...cA..4ss,\y'.L- Address: 0 G\a S cw A-v. St City/State/Zip: 0•f.-\"n AtNN ov" IV\Pc 01060 Phone #: LAC5 ' iK4.:- 5Mck X Are you an employer?Check the appropriate box: Type of project(required): I ®I am a employer with tip employees(full and/or part-time).' 7. ❑New construction ❑I am a sole proprietor or partnership and have no employees working for me in 8. Ri Remodeling any capacity.[No workers'comp.insurance required.] 0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. Demolition 10 0 Building addition 4❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.n Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6. We are a corporation and its officers have exercised their right of exemption 14.❑Other ❑ rpogh p per MGL C. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box It I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees.they must provide their workers'comp.policy number. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: f'\ svk Mi)kUAk _ Policy#or Self-ins. Lic.#: W M 100 C-56,5 20 2 O A Expiration Date: 3 I \ /20 yZ Job Site Address: (---k?—V N . (Jla'ky‘ "t- City/State/Zip: l 5 A-- Q 1 a5-j 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 fine 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 DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 1 e\r 2—f-y Phone#: `'(1),' '6,: ( 'y) c3' 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 Contact Person: Phone#: DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit # was issued with the condition that all debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: a\\ ��.iCiv Name of Waste 'acility Address of Waste Facility 111.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or structure, M.G.L.c.40 s.54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c. 111 s. 150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department. If the debris will not be disposed of as indicated, the holder of the permit shall notify the building official,in writing,as to the location where the debris will be disposed. 780 CMR—6th Edition Signature of Permit Applicant C \ I 2-1 Date AC ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) kkom...----' 0 212 3/2 0 2 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 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 Adlna Edgett NAME: Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481 (A/C,No,Ext): (AIC,Noy 8 North King Street E-MAIL aedgett@webberandgnnnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Main Street America/MSA 29939 INSURED INSURER B: NGM/MSA Barron&Jacobs Assoc Inc INSURER C: A.I M Mutual/A I M 33758 70 Old South Street INSURER D: INSURER E: Northampton MA 01060-3833 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 03/22 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 LTR TYPE OF INSURANCE INSD MD POLICY NUMBER POLICY EFF POLICY EXP {MMlDO/YYYY) (MM/OD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1.000.000 DAMAGE TO RENTED 500.000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) S 10,000 A MPT8049D 03/09/2021 03/09/2022 PERSONAL BADV INJURY S 1.000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000.000 PRO- JECT LOC PRODUCTS-COMP/OP AGG S 3.000.000 POLICY OTHER EPLI $ 10,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S 1.000.000 B OWNED X SCHEDULED M1T8049D 03/09/2021 03/09/2022 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED v NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY AUTOS ONLY (Per accident) . Medical payments s 5.000 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S B EXCESS LIAB _CLAIMS-MADE CUT8049D 03/09/2021 03/09/2022 AGGREGATE S DED X RETENTION S 10,000 S WORKERS COMPENSATION PER ERH AND EMPLOYERS'LIABILITY Y/N 500,000 ANY PROPRIETOR/PARTNER/EX N NIA PROPRIETOR/PARTNER/EXECUTIVE �yZ EL EACH ACCIDENT S C OFFICER/MEMBER EXCLUDED WIN28OO8006365202OA 03/01/2021 03/01/2022 (Mandatory in NH) E.L?DISEASE-EA EMPLOYEE S 500.000 If yes describe under 500.000 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S Inland Marine Borrowed or A MPT8049D 03/09/2021 03/09/2022 Rented Equipment $100.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it 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. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 'L'L U bL Barron &Jacobs BANKESB 2t DESIGN . BUILD . REMODEL 70 Old South Street,Northampton,MA01060 53-7093/2118 Tel:413.586.8998 10/12/2021 PAY TO THE r ORDER OF City of Northampton $ **105.00 i One Hundred Five and 00/100**...*****.*************.,.«*********,►*****.,*****„.**,,,,*. . .****.,.***.,,.,,*„****,.,.,,. ., ** DOLLARS V PA City of Northampton Building Department _ [I 1 212 Main Street ' Northampton, MA 01060 _A Cam\ R .'t) ' 1` MEMO - AUTHORIZED SIGNATURE -- - Buildingp.ermrt-420.North Main treet "022062" 1: 21L8709351: 8 2 2800 39 3e BARRON & JACOBS 22062 City of Northampton 10/12/2021 Date Type Reference Original Amt. Balance Due Discount Payment 10/12/2021 Bill Building permit 105.00 105.00 105.00 Check Amount 105.00 ESB Operating Accou Building permit -420 North Main Street 105.00 BARRON & JACOBS 22062 City of Northampton 10/12/2021 Date Type Reference Original Amt. Balance Due Discount Payment 10/12/2021 Bill Building permit 105.00 105.00 105.00 Check Amount 105.00 ESB Operating Accou Building permit-420 North Main Street 105.00 PRODUCT SSLT104 USE WITH 91663 ENVELOPE Deluxe Corporation 1-800-328-0304 or www.deluxe.com/shop • 5175400 E2F053 STKDK03 11/20;202010:35 .191- Barron & Jacobs DESIGN . BUILD . REMODEL Dear Code Official, Enclosed please find an application and supporting documentation for a requested building permit. I have enclosed a self-addressed, stamped envelope for your convenience. Please mail the building permit to our office. Thank you. Sincerely, Chris Jacobs A Tradition of Building Satisfaction, Since 1986 70 Old South Street, Northampton, Massachusetts 01060 413.586.8998 barronandjacobs.com