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43-089 (2) BP-2022-0041 84 WHITTIER ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot:* • 43-089-001 CITY OF NORTHAMPTON Permit: Alts Renovations • Repair . • PERSONS CON)rRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Penriit # - BP-2022-0041 PERMISSIONISHEREBYGRANTED TO: Project# CHIMNEY REPAIR Contractor: License: Est. Cost: 543,0 FIRESAFE CHIMNEY SERVICES INC 105507 Const.Class: Exp. Date:01/I9/2022 Use Group: Owner: ROWAN KATHLEEN N Lot Size(sq.ft.) Zoning: 'WSP Applicant: FIRESAFE CHIMNEY SERVICES INC Applicant Address Phone: Insurance: 277 PALMER RD (413)436-7946 7pjub06033546 WARE, MA 01082 ISSUED.ON:01/13/2022 • TO PERFORM THE FOLLO WING WORK: RELINE CHIMNEY 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: Gas: Final: Final: Rough Frame: • Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: cm\ .9:1; • " ., O / Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 . Office of the Building Commissioner The Commonwealth of Massachusetts 4, Board of Building Regulations and Standards FOR ��i j� Massachusetts State Building Code, 780 CMR MUNICIPALITY J USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling � This Section For Official Use Only Building rmit Number: !U►'� 07v." 9 Date Applied: Et)1 if-) al 0* .5 )-/2262Z Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Asimrs Map&Parcel Numb 1.l 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 OWNERSH�IIPI 2.I Q�ey1 of Rel. l� -V1 clo,E.r Q i 1 ' Pr d t o u Name(Print) 1 City,State,ZIP SL-f UDh t burr` 54) q i3-31 -5 Li 014 (-3j rDWana rillSn.t_Om No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other Specify: ein i VA VAL? re42 u rs Brief Description of Proposed Work': PeA C Iyi L\Yk-e- lam/5-ka.LIA1sLS5 STe t ( ru/l sun SECTION 4:ESTIMATED CONSTRUCTION COSTS, Item Estimated Costs: Official Use Only. (Labor and Materials) 1.Building ,,, $ 6436,to 1: Building Permit Fee: $ Indicate how fee is determined: Standard City/Town Application Fee 2.Electrical $ 5 El 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ V List: 5.Mechanical (Fire $ Total Ofotal All Fees: 4 Check No.I S V Check Amount: ,(3 Cash Amount: 6.Total Project Cost: $ 5LC30,Old 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CJ i. [6t. Jois LoalL L R8 License Number ;Expiration(f19002a ate Name of CSL Holder S © Sr, PO. 2 J)(_ ( List CSL Type(see below) No.and Street . \ -[' Type Description S out-t-V ,i � - O I�� J U Unrestricted(Buildings up to 35,000 Cu.ft.) 1 i `-( R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry 0.1.rne ire-Sa all V l S I, JLCO .C6 RC Roofing Covering 1 Y1�t— I(� d� V WS Window and Siding � j f p Solid Fuel Burning Appliances [L4(, Insulation Te ephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Q, 14+9 (1J 1 a6 a3 5 res L .eq Calk)Le e S HIC Registration Number Expiration Date HIC Co a e or HIC Regis an Nam (977 a� i t^ 1 eascard%(\ )Ocim ee 1rnney No.and Street Email address LOGS,L61(Y1 tM 34 tbad CI OLL3t12-76H L) 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 0R CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize j fS CV _orknev to act on my behalf,in all matters relative to work authorized by this building permit applicati n. (2_nu,)o _n Li Li,/ cRoaa Print Owner's Nam (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. DCLrn.es Local t. I L, I aooa Print Owner's or Authorized Agent's Name kElecgbnic 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" City of Northampton Massachusetts ,440 %� } `'T DEPARTMENT OF BUILDING INSPECTIONS r�. . 7 212 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: 0917 Qc2.jt v\/\12-' The debris will be transported by: Name of Hauler: P' V Ok CV `l-I vt.. ()air li L-ccs Signature of Applicant: Date: I C4o20a7c? Ooi fiCtWx St..5}se.M sor Specialty • CSSL-105507 &acpires:01/19/2022 ' • ' JAMES J WAL-LING • 40 HIGH STREET ? _ P.O.BOX40 ,• - •Y;;..• SOUTH BARB MA 01074 . Commissioner • I 1 • Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvemetn Contractor Registration Type: Corporation Registration: 182449 FIRESAFE CHIMNEY SERVICES INC °I s , Expiration: 06/25/2023 277 PALMER RD UNIT 2D r " WARE,MA 01082 •i, _• m t +}.'ie�^.:fit.Y�, rr_�^— f:•1.rf Update Address and Return Card. SCA 1 !S 20M-05i17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TXRE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation •=-182448,= 06/25/2023 1000 Washington Street -Suite 710 FIRESAFE CHIMN f:SERVICES INC Boston,MA 02118 JAMES WALLIH R—,7 1,_ 277 PALMER RD ".„4:1 j� ajjd�yj signature WARE,MA 01082" Undersecretary __ The Commonwealth of Messu'chnsetts .1 - 1.' Department ofIaadatslrlalAccidenats _—C ` =?` � 1 Congress Street,Smite 100 �M — ;i=°. 0_ Boston,M ft 1l4-20 ? E,.'-�NI I' W1d19i mass.govit0aa Walkers'Compensatlon Insurance Affidavit:I;ul ders''ContrastorsdElech elnns Plumbers. TO IllE FILED WITH THE PESIMITTING ALT i, as Brill'. Afoxalkcant Information Please Print Legibly Name(Busiot a nizationfindiw"adnal): f - . CVLWl ey ,tA . _. Address: o&7.1 Q Y�vl er V ) L13 _ . Are you an employer?Cheek the appropriate boat Type of project(required): loam a at/atoyer with 9 employees gull andforpratt-tiaa .}_' 7. 0 New construction 2.0 I am a sole proprietor or patinas/rip and have no map/oyes wanking for the in 8. 0 Remodeling at tycapac►ty_[Nowotfoms"comp.insomnia!eo uina.] 30 l ant a itoat►rovsaterdoimg all work myself.[No waked'comp_tm uaartea realuntu9.] Demolition "1 f am a Itonn-ou and will be contr�ms to c dutt all work on my property. 1 will Building addition ensure that ail tontraenna cicLer haw w-a °co ttsa iaat insane=or am Dole 11.[]Electrical repairs or additions proptietaras with no empleyecs. 12.0 Plutatflnit repairs or additions 50 lain a gpier.ai contractor and 1 have hitedthe sub-a•ontrxtots listed em the attached shed. 13 Roof gars These su mttractoralrave+�t ploy and lcaveworkc& comp_irstu-,n¢reet •.�' f� i� ai. i re ant:as oapo:mica and its officers have exereistaltheir tight ofe exemption per MIL a 14. Cher �Y 1 f" 152,§t('t)and we haws no cn eloyr [No wet/ate camp.ioso anee requited.] reFU.r �I 'may app!e:ntt that ritegot 1oa rol maw atvo fdl out the station below showing their ww orb'compantation pmoi yr information_ t Humenovems who submit this affidavit indicating they are doing all work nod than Hie aUmide coatanctors aori submit a new affidavit ittdirteing sora :Gantt-awns that cheek this box moat attached an additional sheet Armies tame of the sub-contractors end,t,,tr whether an not tiros,a titieN have carrphoy acs. lithe sub-connactets have arployees.they must provide their w^nrken'away policy maw. I am an employer that Is providing workers'compensation lnsnranse for my employees. Below Is the policy tudja bsite► information. C - . Insurance Company Name: -T Cu)` ,'QJ�J Policy#or Self-ins.Lac_# c��-i-c�� INd�3�J�L9 Et�ratimti Date: 5 i ►a} aoaa Job Site Address: I.LiV al' air J C • Gaty/staateiZap (.( V v 1CQ( mn 01 D c Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required wider MOL c. 152,§25A is a criminal violation punishable by a fine up to$1,5 i0.00 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 IDIA for insurance coverage verification. I do hereby refill d rthe pains and penalties rr,fpe4ary that the information provided above is treed correct. Signature: Date: I 1 L0-I c9 Phone#. qi N a-57 -Ci L1P Off/card use only. Do gnat write in this area,to be completed by city or town official Cie*or Town: Permit/License# Issnwfng Authority(circle one): 1.Board of Health 2. r;,ut[tiang Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 1 6.Other Contact Person: Phone#: 'r ��.•, FIRECHI-01 JPIERCE '4C.CAT EY CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 8/3/2021 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). CONTACT PRODUCER NAME: Brabo Insurance Agency PH(AIONE Est):(508)830-3800 I FAX No):(508)746-1540 65 Cordage Park Circle Plymouth,MA 02360 E-MAIL ADDRESS: �!info@braboinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Northfield Insurance Company INSURED INSURER B: Flresafe Chimney Services Inc. INSURER C: 277 Palmer Rd INSURER D: Ware,MA 01082 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDDIYYYY1 (MMIDDIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR WS420788 7/15/2021 7/15/2022 PRA M sas(EaEoccurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECOT- 1-1LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: CBINED $ AUTOMOBILE LIABILITY Ea aden SINGLE LIMIT _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ _ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION PER OER TH AND EMPLOYERS'LIABILITY Y I N ANY IPROPRIMBE�R EARTNE/E ECUTIVE N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Puchalski Municipal Building 212 Main St Northampton,MA 01060 AUTHORIZED REPRESENTATIVE I <e ACORD 25(2016/03) • ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ' r DATE(MM/DD/YYYI� A`�o CERTIFICATE OF LIABILITY INSURANCE 08/03/DD/Y 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(les) 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 A CONTACT Jessica Pierce BRABO INSURANCE Mat,.Eat): (508)830-3800 FAX No): E-MAILierce braboinsurance.com ADDRESS: Jpierce@braboinsurance.com Cordage Park Circle INSURER(S)AFFORDING COVERAGE NAIC# Plymouth MA 02360 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: FIRESAFE CHIMNEY SERVICES INC INSURER C: INSURER D: 277 PALMER ROAD INSURER E: WARE MA 01082 INSURER F: COVERAGES CERTIFICATE NUMBER: 681364 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 ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD VOID POLICY NUMBER (MM/DDIYYYY) (MMIDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PR S RENTED E PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB — CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PERTUTE 0TH AND EMPLOYERS'LIABILITY Y I N ER ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A 7PJUBOG03354621 05/12/2021 05/12/2022 In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory If yes,describe under EL.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Crovey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD