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16B-018 (2) BP-2021-2139 43 BRIDGE RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 16B-018-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2021-2139 PERMISSIONISHEREBYGRANTED TO: Project# ROOF Contractor: License: Est. Cost: 2500 WAINSCOTT BUILDING 104496 Const.Class: Exp.Date:08/17/2023 Use Group: Owner: JONES LINDA M Lot Size (sq.ft.) Zoning: URB Applicant: WAINSCOTT BUILDING Applicant Address Phone: Insurance: 37 STAGE RD (413)559-0825 2001W9052 WILLIAMSBURG, MA 01096 ISSUED ON:11/03/2021 TO PERFORM THE FOLLO WING WORK: GARAGE AND PORCH 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. Signature: 86. yO :4rav Fees Paid: $40.00 212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272 Office of the Buildine Commissioner 1V :Li 1 I - 2 2021 1 , The Commonwealth of Massachus6ts I W Board of Building Regulations and Standards FOR MUNICIPALITY Building Permit Application To Construct, Repair, Renovate Or em --Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Buildin Permit Number: ^?+) " /-- j q ate Applied: Eu;►J 4055 l l-3-ZOz) Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: �� 1.2 Assessors Map&Parcel Numbers `/3 'I�r,c�� 1.1 a Is this an accepted street?yes 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: Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownerl of Rec rd: LI , va-e_ - -A1,,n9l� i'A"- Name(Print) City,State,ZIP 9 3 By-,a ti 2 yg 69S 14610 to Z-Trati ho,rsez 6../(k 1b 'V ey, k " u ilt- No.and Street Telephone J Email Addrer SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-OccupiedCRI____Repaairs(s) Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Idther Specify: Brief Description of Proposed Work': Ref its c-e_ Pc,rc-C.� a-- A_ U�r a S-c_ 3Z,,,,:_,--4_ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ -:.)—U c:y — 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ 4C Check No.ll 30 Check Amount: ` Cash Amount: 6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due: 1E, 1Gc ► 1 /Ui ,ii/t41 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS„f O ,J C r e_1 _Z 3 1 A L14.Qi J CjJ z,tit sc, License Number b Expira'on Date Name of CSL Holder 5441 ` L List CSL Type(see below) No.and Street Type Description UI % �I_U t- VAN 0 1 0 ` R Unrestricted es Restricted 1 2 Family up to 35,000 cu.ft.) LtJ �J R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding I_ n SF Solid Fuel Burning Appliances y85199 0�3 tNscb bu cJ, `�_ I Insulation Telephone Email address �Q i� /, (Dip Y1` Demolition 5.2 Registered Home Impro ement Contractor(HIC)/ ,��0 19,_,t 1 , /9/o�S v3za-zozz � HIC Registration Number Expiration Date C Company Name or HIC Registrant tie No.and Street 5.6*(1.a_ s libv Q 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 co pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuan f 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 i J 5c.t+ `�c�1 IC to act on my behalf,in all matters relative to work authorized by this building permit application. LA..1 A ...\0"-re_ / — z_ — z Print Owner's Name(Electronic 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. 0� w/Sc��i 10 — Z v— 2 ) 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 Cottuuolnt't ulth of Massachusetts Department of Industrial Accidents • kit Congress Street.Suite 100 Boston„VA 02114-2017 i • �, wtvw.mass.gov/d1a in kart' ('unapt•nsatiun Insurance Affidavit:Builders/Contractoni Electricians Pluothers. }ICED N 1111 111E PER'lI rum.;At 111OR I . • l)nhicant infortualion l'IC:tsc Print L_egibls Name IHus ness'Organtzation.individualI: yh, - ! I Address: 3 - 5)-0 S e C d _- City?Statel'Zip:Wil/b4)).A�� ),® loch Phone#: 9/s 5T5 7 oa Ate}no an emptoi.r:'l hack the appropriate b nt: d►pc of project(required j. IQ am a employer with 3 employees ees(full and or part-tinac)-• 7. New construction .0 I am a sole proprietor or partnership and have nu employees working for me in B Q Remodeling any rapacity.(No workers*comp.inaazrr ace nywtnl.) 4. ❑Demolition 1 ant a homeowner doing all w'urk myself.rio w,srkars'comp.insurance roped.] 4.0 I am a linnanwncr and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all coignaelurs either!rase workers'cucopensamun insurance cr are sole 11.0 Electrical repairs or additions proprietor with no employees. 12.0 Plumbing repairs or additions 50 I am a ee .-ul contractor and 1 base hued the attb-cuotraeton listed on the attached ahem. I Roof repairs Those sub-contractors bast employees and lust workers'comp.maurance.- 6.0 wean:a corporation and as officers have ettercnsed them nght ul esem pll&m per M(aL c. 1 Other 1S2.4t111).and we/use nu employees.(No workers'comp.insurance reyuiml.l 'Arty applicant that chucks boa a I root also fill out the section below show ins thew workers'compensation policy unfunnnrwn Humeuwnera who subunit this aflidaa it indicuung they arc doing ail work and then hue outside contractors must submit a new affidavit indicating such. :Contractor.that check the box must attached an xldttwnul sheet show mg the name of the sub-contractors and state w hether or not those eni[ics have rmplo:kcu If the sub-contractors Isaac rii,%.idu their worker,' number. I tun an employer that is providing n•orAer%'compensation insurance for my employees. Below is the policy and job site information_Insurance Company Name: JA tam . I t s/3 Policy tt or Self-ins.Lac.#: 'L.OI,>I CO 9 Cic Z, Expiration Date: / Job Site Address:V3 /5 ri j C (� J City/StateJZip:Xigf 7ue+ n4 0/GIPL !' mil Attach a copy of the workers'coiu4ensation polio declaration page(showing the policy number and ex ration date►. Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a tine up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA Ibr insurance cover-age verification. I do hereby certify under 1 / s and penalties of perjurt'that the Informasinn provided above is true and cornett J Signature:[ --- Date: /D-Z 9— / Phone 4: c//3 5-3-I Official use only. Do not write in this area,w be completed 1'v city or town offihies! ( its or I rtss n: Permit/License alF Issuiiit Authority (circle one): I. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector {. I'luutbimt Inspector a.Ot her Contact Person: Phone#: gn Envelope ID:077340EC-681A-4644-A73A-F64B7C3B09E7 R E)® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1E(MMIO /YY 21 S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 2TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES .0W. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 'RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. UBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CER CONTACT NAME: Tim Viles S AGENCY P�/AHONN.Extl: 413-665-8200 FAX.No): 413-665-8202 N Main St E-MAIL ADDRESS: t.viles@american-national.com h Deerfield, MA 01373 INSURER(S)AFFORDING COVERAGE NAIC* INSURER A: Farm Family Casualty Insurance Company :D Matthew Wainscott INSURER B: INSURER C: INSURER D: 37 Stage Rd INSURER E: Williamsburg,MA 01096-0096 INSURER F: _RAGES CERTIFICATE NUMBER: REVISION NUMBER: i IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD GATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ITIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, :LUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS !NMWVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 2001X1295 9/16/2021 9/16/2022 PERSONAL 8 ADV INJURY $ 1,000,000 IEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO JECT I LOG PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ ,UTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ ORKERS COMPENSATION PER OTH- VD EMPLOYERS'LIABILITY STATUTE ER 1--nFICER/MEMBER EXCLUDEDXECUTIVE Y/N N/A 2001 W9052 6/24/2021 1/24/2022 E.L.EACH ACCIDENT $ 100,000 landatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 yes,describe under ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 IPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) _ocation:43 Stage Rd, Northampton, MA 01060 'IFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DocuSigned by: C2F26C63nC6F414 ©1988-2015 ACORD CORPORATION. All rights reserved. 2D 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton 0.tNAM Massachusetts • DEPARTMENT OF BUILDING INSPECTIONS .rn „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, 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: VC � fee c c � - The debris will be transported by: Name of Hauler: Signature of Applicant: Date: 10