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30C-075 (4) BP-2022-0232 560 BURTS PIT RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 30C-075-001 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-2022-0232 PERMISSION IS HEREBY GRANTED TO: Project# CHIMNEY REPAIR Contractor: License: Est.Cost: 6836 FIRESAFE CHIMNEY SERVICES INC 105507 Const.Class: Exp.Date:01/19/2024 Use Group: Owner: J DUNN JENNIFER L& SETH 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:03/09/2022 TO PERFORM THE FOLLOWING WORK: CHIMNEY REPAIR 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: . ,2 Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner i___ ______EL._j:.i v, ...1----F-TEO----7:.----L---___y ...I The Commonwealth of Massachuse !FORI Board of Building Regulations and Stan rds MAR — 8 ICIP ITY ; �� Massachusetts State Building Code, 7801C 20� US Building Permit Application To Construct,Repair,Rentova De trIjch a Revi.ed r 2011 OP 5UILt)rNr,INSP=CTIONS One-or Two-Family Dwelling __ No.�rt,AMp1 MAr,op.° This Section For Official Use Only "-J Buildin Permit Number: SO— Q.1--13� Date Applied: �� �'I�>ss __Z___ 3 9 ZDZZ U Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 PropertyAddress; 1.2 Assessors Map&Parcel Numbers 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 p _ ecor u.,(\n f a t/Y1Ir On 1N\ Name(Print) City,State,ZIP 5 LID Q u i- 91A- 128_ (11)( I.S-O-w 1 5 j3.1/6,Ac o)G yl-Nit,k No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other Specify: 1 Lovv,./ refrain Brief Description of Proposed Work': i^e-V`he dr\LV•nv/ u& c�l'-N U sS S-ke_ L . r k 1 �YL3 l�� Stoll SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ g at Q, C,m 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 0 2. Other Fees: $ 4.Mechanical (HVAC) $ ezc List: 5.Mechanical (Fire $ Suppression) 0 Total All Fees:: $ i Check No.164 Check Amount: (6 Cash Amount: 6.Total Project Cost: $ LQi ct,DO 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1.0 65o 1 I t q 1.2q K� l1 ` __5 License Number ExplrationDate Name of CSL Holder �� ��� , l List CSL Type(see below) No.and Street Type Description SDu.-Nr) eafre ( MA N o�y U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted l&2 Family Dwelling City/Town,State,ZIP ' M Masonry Jl V6)--C`ITc,. �/sex v t uS F RC Roofing Covering �l Y 1 J COM Window and Siding SF Solid Fuel Burning Appliances Cq1�(4,�(S) — 1-qq4 Insulation Telephone Email address D Demolition 5.2 Registered Home -Improvement Contractor(HIC) ' SOLI 4 n 4..2,51 C1 . U1\Lr `C€e lit CQ" HIC Registration`Number tiDate HIC?Cunlany(li e orHIC Regis tIName 1V Vc — CGS MPA ,c ka u rn No.and Street Email address &ay^Via S,L G Yv1 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 .0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR A PPL�IES FOR �BUILDING PERMIT ` ' I,as Owner of the subject property,hereby authorize Y'ty' ^ - C)r `LV\(\ IJ � r V U S to act on my behalf,in all matters relative to work authorized by this building permit application. Sikh Qmin{n 3EL t ) :t , 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. S k)L t (_ LV 3)L ci � C &c Print ? 1%f\ L 's or Authorized Agent's Name(Electron gnature) 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 `tyy�Tr.4,;,,` SAS . sic' Massachusetts �4 L <', ii j DEPARTMENT OF BUILDING INSPECTIONS y` ' 2 4,•�1,. 212 Main Street • Municipal Building vs;;., a llorthampton, MA 01060 rsby"Y"' j��4� 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: 02-11 ad f _01(2-AaDcire lq MIC?a The debris will be transported by: Name of Hauler: Ca. �tck Signature of Applicant: Date: O)o2 _ The Commonwealth of Massachusetts l' Department of Industrial Accidents elnh_ 1 Congress Street,Suite 100 =__ i= Boston.MA 01114-2017 ,`' www massgov/dio Winters'('unmpensation Insurance Affidavit:Builders/C.ntractorslElectririanslPlumten. f0 BE FILED WITH THE PERMITTING AtJTHOREI . Applicant Information (�, ( � Please Print LeEibh Name(lltasmcs ( aoitation'lndi. tael): r`r`t G`1r� l�i�� ►� �r�1 Q _-- Address: a1 Ti 0.1r ..v., CZd City/StatePZip:\Thfe,'er CAC>?"& Phone 0: L4 13) w-79 LI (0 Are r DU an employ tom''!Check Ile appropriate his. Type of project(reqoired): i 11: 1 am a employer with_. -` employees hull srdlor part-tinre).• 7. 0 New con traction 1 I am a sole prnprietot'or partnership and have no employees wurkung for me in g. 0 Remodeling any capacity.[No workers-comp.insurance required_] 30 I am a homeowner Join work myself_ Nu workers'cu imurur-e r 9. ❑Demolition g all ?� [. comp. required" 4.0 laina homeowner and will be hiring contractors to conduct all truck on my property- I will I g Blii�lllg addition r i hhune that all cum:maim either have workers'comarimesatims i suranee or are sole 110 Electrical repairs or additions proprietor,with nu cerspaoyees. 12.0 Phnnhing repairs or additions NDI am a general contractor and I hare hind the subcmatrackns listed on the attached sheet. 130Roof These subcontractors hart employees and have wuckers'comp.insurance_' suranc repairs 6 0 We are a corporation and its officers hart exrz.Yseal their right of esemptirnn per Wit.c. 14. Other C it .IMl/ 152.f 1(4),and we have nu employe a.[No workers'comp_insurance required" (^ Ar J 'Any applicant that ducks but VI trust also fill out the section below showing their wurk►ti compensation policy infonnativa. 4.Romeo*MIN VAII0 submit dis a$ittarit indicating they an Ming all wmrlt SSA OM his uttmde crrttracturs mum subunit a new affidavit indicating such IUontraeknn that cheer tit boor new attached as addttinnnal sheet it showing the mars tithe a1 onatr'acturs and state*tether or not those amities have employees. If the sub-contraetars hare employees.they Hurst pros ale their %others"dur>tll.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the police and job site information. Insurance Company Name: -'7 �Ve ir\s — ' 6 Policy#or Self-ins.Lic.#: PJ U.1 ) )GO33 3-1 ut Expiration Date: q is 1cke007 Job Site Address: 5 l al. .v--t Pik 1` a City/State/Zip: Attack a copy of the workers'crmpeasatioa 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 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 DIA for insurance coverage verification. I do hereby certify a the pains and penalties of perjury that the information provided above is true and correct. Signature: Date :31 L 1. 1 a Phone#: ( t L1,ri.R--lCL`Cfflicial use only' Do not write in this urea,to be completed by thy or town official City or'Faun:n: Permit/License# Issoing.tuthorit) (circle one): 1.Board of(Health 2.Building Department 3.(Ilya-own Clerk 4.Electrical Inspector 5.Plumbing Inspector (.Other Contact Person: Phone#: FIRECHI-01 JPIERCE '4`�/WP CERTIFICATE OF LIABILITY INSURANCE DAT8/3/202 ) 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; Brabo Insurance Agency 65 Cordage Park Circle jaHJc°O,"r o,Ext):(508)830-3800 FAX No):(508)746-1540 Plymouth,MA 02360 ADDR ESS:info@braboinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Northfield Insurance Company INSURED INSURER B: Firesafe 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 TYPE OF INSURANCE ;ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR WS420788 7/15/2021 7/15/2022 DAMGSEE SO ENcTuEnDe nce) $ 100,000 MED EXP(My one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JEa LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $— OWNED SCHEDULED _ AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS NON-OWNED PROPERTY DAMAGE (Per ccident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ _ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY OFFICEMEME EXCUE PROPRIETOR/PARTNER/EXECUTIVE 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/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 Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. Puchalski Municipal Building 212 Main St Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC i® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 08/03/2021 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 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 Jessica Pierce BRABO INSURANCE rac°.No.Ext►: (508)830 3800 FAX No): E-MAILfi ADDRESS: Jpterce@braboinsurance.com 65 Cordage Park Circle INSURER(S)AFFORDING COVERAGE NAIC# Plymouth MA 02360 INSURERA: 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER ",(MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR 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/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A NIA 7PJUBOG03354621 05/12/2021 05/12/2022 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/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/Iwd/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 x Daniel M.Crowley,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 • NW Board of Building Regyulations and Standards CIIi' Constructiquper Specialty CSSL-105507 6cpires:01/19/2024 JAMES J WAJLING 40 HIGH STREET , P.O. BOX 40• SOUTH BARR .MA 010T4 n! Commissioner du.n t /;. VErn Li'La_ • ay-ZeAc&i.-itar/ka-ele4- Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 182449 FIRESAFE CHIMNEY SERVICES INC Expiration: 06/25/2023 277 PALMER RD UNIT 2D WARE,MA 01082 Update Address and Return Card. SCA I O 20M-OS'17 Fly.4.9,wiviei Fwf/.c n/.l44-;44-/re.,../f• 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 182449 - 06/25/2023 1000 Washington Street -Suite 710 FIRESAFE CHIMNEY SERVICES INC Boston,MA 02118 JAMES WALLING JR 'J 277 PALMER RD aiid wi signature WARE,MA 01082 Undersecretary