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24A-157
BP-2022-0509 353 PROSPECT ST COMMONWEALTH OF MASSA HUSETTS Map:Block:Lot: 24A-157-001 CITY OF NORTHAMPT N Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED ONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FU D (MGL c.142A) BUILDING PER 1T Permit # BP-2022-0509 PERMISSION IS HP 'EBYGRANTED TO: Project# ROOF Contractor: License: Est. Cost: 9750 JSICARD CONSTRUCTION 088788 Const.Class: Exp.Date:03/23/2024 Use Group: Owner: S FLEMING JO N J &SHEILA Lot Size (sq.ft.) Zoning: URA Applicant: JSICARD CON RUCTION Applicant Address hone: i nsuran e: 43 LAMB ST (413)535-9908 WCMA000213601 SOUTH HADLEY, MA 01075 ISSUED ON:05/12/2022 TO PERFORM THE FOLLOWING WORK: STRIP AND RE-SHINGLE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHA PTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signatu re: Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413' 587-1272 Office of the Building Commissioner — i. at- ----- so C The Commonwealth of Massachusetts t!! , „ Board of Building Regulations and Standards FOR / 1 1 ?022 Massachusetts State Building Code, 780 CMR MUNICIPALITY :.,. `M A USE Building Permit'4pplication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 --`"— !*��° c''tc��1 'One-or Two-Family Dwelling This Section For Official Use Only Buildin Permit Number:&" a A-- ,60` Date Applied: /jq4 y �l J 0 0 evi t..) (o5s 17& / Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 3S3 1'renrce k Si— / 1.1a Is this an accepted street?yes t/ 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 17 Private❑ Zone: — Outside Flood Zone? Municipal CAI'On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: �1 "ia N A) F I eMm t,N ktriki, 1 J -c ut.i /144 O /U (o CJ Name(Print) City,State,ZIP 3..s*-2Prt) pec i S k 4///- S 73'6Q3r W hi A/ ,t0A 5U //) '4AA.►.Cow No.and Street Telephone E ail Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) d Alteration(s) ❑ Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief De cription of Propose4 Work2:p 5 ii Pre f l (, R #1,.. 1 OC/3 � y y P -p `NO ��p 5 f- ,S w0-I- +ot) al 4�OR sM rim ii8ZP,P SECTION 4:ESTIMATED CONSTRUCTION4 OSTS "'le Estimated Costs: Item (Labor and Materials) Official Use Only 1. Building $ i 750, ,c, 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fe- . Check No. 1 0 Check Amount: LP 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: i City of Northampton ,�a +o� Sty.«. ;s,;,,. Massachusetts :w_ .44 ad t m� ,' !i ' DEPARTMENT OF BUILDING INSPECTIONS 'A 212 Main Street • Municipal Building .'per` 1N ,.: Northampton, MA 01060 S}. 0 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS, DOORS, ROOFS, RENOVATIONS, ROOF MOUNTED SOLAR, ETC. 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work (Digital and hard copy). 3. Construction Debris Affidavit filled out and signed by applicant. 4. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance. 6. Energy Conservation Compliance Certificate (new /replacement windows). 7. Home owner's License Exemption Form (if applicable). 8. Note any Special Permit requirements (if applicable). 9. Energy Code —all new construction(Gut/Rehab) requires a HERS Rater Affidavit 10. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. - v.+ / 4 i SECTION 5: CONSTRUCTION SERVI ES 5.1 Construction Supervisor L' ense( SL) 41C93 c91J vvUU I��J �,�ige Licens um er Expir 'on Dat / Name of C L Holder ,7- e List CSL Typ (see below) U No.and Street �f Type Description SO 41 ,1/ in 411S5"O� 7) - U nrestricted(Buildings up to 35,000 Cu.ft.) [CC777 R I .?J R estricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances �/3 077S7y'* PaN3 7 mail Co'4I I Insulation Telephone E ' address D Demolition 5.2 Registered Home Im rovement C tractor(HIC) npo q'umber � �� 1�iL'..-- C HIC_ egistration at on tel HIC Company Name or HI Reeigtrant Name ,�r tt 3 Cam, ',, 1 % j 5 )-`4eh 0005leti cka gpfe,rtii No.and Street r !g les A �,`/3 5S^F9� Email address h {.� (yr cj��s 7 J 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 Issuannce of the building permit. Signed Affidavit Attached? Yes . B' No . 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIESr - FOR PERMITBUILDINGr � /� Owner of the subject property,hereby authorize J0 '5(( 2( COA6+ / w�/as act on my behalf,in all matters relative to work authorized by this building permit application. I'l j tvl rA) .— nt er s N5322- ame(Elect 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 accura the st my kn ledge and understanding. Print Owner's or Authorized Agent's Name(El tro is i ature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an.owne-who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will HHt 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 haaths 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" 1 4 The Commonwealth of:%fassachusetts - 1 Department of Industrial Accidents 7 cA 1 Congress Street, Suite 100 ,. ..1 .-2.-. Boston, AfA 02114-2017 wwocmass.gov/dia %%orkers'Compensation Insurance .1f1ida%it: Builders/Contractors/Electricians/Plumbers. TO BE i'll.1.0 11 I I it I it L PERM!1-11,st;AUTHOR!lv. .1.nolicant Information Please Print Leeibls Name(liusiness,organizatiorondividuno: J, 5 ICA e 1 Cc)/(JS (Z (./e-i 0 Ai;..:---L,./_______ ....ir' 1 Address: LJ36 ' ‘ ..,... _ City/StaterZip: a, 7-111 .1-, .1 ( 1, one .ey 1)413(61)h tt- q 13- S39-9q0 ." Are yen an employer'Cheek the appropriate bat: Type of project(required): 1.E3 lam a employer with , , etripiw,ces k fiat:Icator partrime)." 7. 0 New construction 2.173 1 am a sole proprietor or partnership and have no emptoyeex working for me in ' 8. pi Remodeling any capacity.[No workers'comp insurantv require&j _ 3.Eil lam a hoeneow ner doing all work myself.[No workers'comp_in surance reptiinta 9 111 Demolition l' 10 El Building addition 4.0 lam a lairrittAsner and will he hams contractors'to i.-tandua all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11 a Electrical repairs or additions proprietors with no employeei_ 12.EI Plumbing repairs or additions 50 1 am a general contractor:find I have hired the sub-contractors listed on the attailied sheet e52. sub-contractors have eimployeti ad base workers comp.insurance.: 131:Roof repairs We art a corporation and its officers have exereraed their righton of exerrmti per?skit e. rse ' ,§I i.1),and se have nu eniployres.[No workers'eomp inatrani-e required.[ 14.4710thet applicant that...lucks box 41 must also till out the sx•enen below showing their workers'vonipen,ition policy information. thorax- 'owners who submit this affidavit msbeating they are doing all work and then hire otir‘iile ectrometort.must Alkirnit a new AtridaY II indieating such. Cortuactors that check this hot must atachied an additional sheet showing the name oldie sub-eontractors and state w Itnihi.7."01 nut those erillli..., ccIpl.R'et-s_ If the Nub-contractors have employees.they must pro,idi.their *tirLerN'.,:v/rip.po he.,.. number. I am an employer that is providing workers'compensation insurance Or my employees. Below is the policy and job site information. .-----, ,...-. Insurance Company Name: ,--i A., -3 r,X-)Orb X--)(8 l'A.)--1-,us S . tfa I ci t`A...5 g — — Policy#or Self-ins.Lie. :±: C 'fe•-At:)5 r CD 99?-0 1 Expiration Date: Job Site Address: -55S rec)srec-1- S I- CityiStateiZip. _ iWifft 0/e6 Attach a copy of the workers' compensatioh policy declaration page(showing the policy number and es.iiration date). Failure to secure coverage as required under NIGI.c. 152, §25A is a criminal violation punkhable by a fine up to$1.50000 andior one-year imprisonment,as well as civil penalties in the fcvm 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 Invt-stigations of the DR for insurance coverage verification. _....i51 _ I do hereby certi ad the ins a allies ) perjuo.th th trite and at e information provided above is d correct. Signature: Lit'/ . ' Date: ,ef.( i S' CdCg g Phone ,4.: ' .53S---RC, F POfficial use only. Do not write In this area.to he completed by city or town official City or Town: Permit/License ft Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other 1' ('ontact Person: Phone#: --- ..... ,. . t City of Northampton Massachusetts t 414. DEPARTMENT OF BUILDING INSPECTIONS S °' 212 Main Street •• Municipal Building rt, Northampton, MA 01060 - ii 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: A. c__, Ae7yo ,r6 ,4) Location of Facility: 2 'c lc61 (,), , L=' "a The debris will be transported by: Name of Hauler: )/ T/./7/e L , jSignature of Applicant: /� tfAji Date: City of Northampton rl `' Massachusetts �c:, DEPARTMENT OF BUILDING INSPECTIONS k"', ,i'.. 212 Main Street • Municipal Building , 6,c- --�' Northampton, MA 01060 6.t'y �1. HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born __ (insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) wh4ivns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures. accessory to such use and/or farm structures. A person who constructs more than one home in'_, • a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20_. (Signature) ACCoRo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/29/2022 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: Barbara Araujo BRZ Insurance PHONE (508)603-677' FAX 508 603-6777 fAIC.No.Extt: (A/C.No): ( ) _ 107 Concord St EMAIL Do ESS: coi@brzinsuranoe.com INSURER(S)AFFORDING COVERAGE NAIC 0 Framingham MA 01702 INSURER A: Atlantic Casualty Insurance Company '""F.D INSURER B: PENNSYLVANIA MANUFACTURERS ASSOC INS I J NUGRA CONSTRUCTION INC INSURER C: 32 WEST ST APT 3 INSURER D INSURER E: MILFORD MA 01757 INSURERF: 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 EFF POLICY EXP UNITS LTR _MD INVD POLICY NUMBER• (MMIDD/YYYY) (MMIDD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A I Y ACI4633480PC 03/25/2022 03/25/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JE LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ AWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANY B OFFICER/MEMBER ER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N/A N/A WCMA000213601 03/26/2022 03/26/2023 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) J Sicard construction is listed as Additional Insured's under the General Liability coverage as required. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN J Sicard construction ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 43 Lamb St South Hadley,MA 01075 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD