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25C-057 (11)
BP-2022-0650 31 LINCOLN AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25C-057-001 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-2022-0650 PERMISSIONISHEREBYGRANTED TO: Project# FIRE REPAIR Contractor: License: Est. Cost: 10224 MARK DAVIAU 056785 Const.Class: Exp.Date:09/09/2023 LAROUCHE JOSEPH E& ROSEMARIE TERESA M Use Group: Owner: TONER & PETER LAROUCHE Lot Size (sq.ft.) Zoning: URB Applicant: BAYSTATE RESTORATION GROUP Applicant Address Phone: Insurance: 69 GAGNE ST (413)532-3473 6S62UBIK79231322 CHICOPEE,MA 01013 ISSUED ON:06/07/2022 TO PERFORM THE FOLLOWING WORK: REPAIRS FROM FIRE 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 NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 9 3-1 �U l � Fees Paid: $66.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner The Commonwealth of Massachusetts RECEIVED FO) * Board of Building Regulations and Standards _U Massachusetts State Building Code, 780 CMR MUNICIPALITY JUN - 6 USE Building Permit Application To Construct,Repair,Ren vate Or Demolish a2022Revited Mgr 2011 One- or Two-Family Dwelling I This Section For Official Use dnly N DEPTORTHAn4P OF DUILOINTnrr INMSPECTA01060IONS y Building/Permit Number: ' ate. 45�d Date Applied: jfev is a 1/.2 6 7-Z02 z Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address:n �t l� 1.2 Assessors Map&Parcel Numbels� 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) ,/V CLlL„i,Di' 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❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 22 k(te ck 1 aSeph L-Ctro)C ►-e— Y\1r5( rn rho- 61 D'PO Name(Print) City,State,ZW 1.- 1 V)Co hi A—V t- Lh 3-�3ao-9��S7 Nle!and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Owner-Occupied it Repairs(s)% Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg. ❑ Number of Units Other SK. Specify: SM,,/I 4ivf w 1114. Brief Description of Proposed Work2: A , 4 j�40 Q#, / SNAVL,, Apri 5 /49h÷Afrd use,(4_ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ - List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ (i / dl\ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 6 0 t) ),S 7 0 Paid in Full 0 Outstanding Balance Due: SL...—ON 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS_o567 M 11 A( . ;eN( lcl U License Number Expir io Da e Nam of CSL Holder 15 6 I I �_ /� �� List CSL Type(see below) U No.and Street ( / Type Description A a� 11 O' 6-7 U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,Z R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding �- SF Solid Fuel Burning Appliances lil - 1).��33 CO d I � �j,C/n I Insulation !Telephone Email addre ✓ D Demolition 5.2 RegisteredHome Improvement Contractor(HIC) t7P eZi e, ( S�Q rats c el Grpdp L� HIC ReggiOtrati n UNumber ExI Iati Date HI Coripan6 ame or HIC R 'strant Name d 5treef Ck n &S CCind t (ily/l address' r Lvm, iti 347 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 V 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 l Ctl 6 g es I a bon 6✓O L� to act on my behalf,in all matters relative to work authorized b this building permit application. "tl D i-e V'l arc 1 ii d'o t (f�-e__ . A4.4xceell, Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER1 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 tilt' ion is accurate to the best of my knowledge and understanding. Print er's or Authorized Agent's ame(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 Conunon wealth of Massachusetts e-r Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 wootImass-goviclia liVorkers'('ompensation Insurance Affidavit:BuDders/ContractorstElectricians/Plumbers. 11)BE FILED WITH TILE PERMITTING AUTHORITY. Applicant Information Please Print Legilds Name lausinesvOrganizationiinclividual 1, 1 -)C4. £IcvIt (2453 1-°116-1/0 67foor Address: teci City/State/Zip: Olb Phon : L•i-—7 3 Are"uu Att ettipitlee Cheek the appropriate boa: Type of project(required) I ant a emptiryer with employees(full anctiot Flan-time).` 7. New construction ant a auk proprietor or partemithip and tto critployees working for me c3 Remodeling any Cipscity_[No workers.'comp.insurance required.] EI30 I am a homeowner doing all work myself.[No workers'comp.insur.uk-e 9. Demolition a 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all weal on my property. I will ciiaurt that all contractors either hac worken,*compensation irnarame or are sole l ICI Electrical repairs or additions proprietors with no employees. 2.0 Plumbing repairs or additions 50 I am a general contractor and 1 have hired the sub-cuntructors listed on the attached sheet Thcac I 31-1 Roof repairs iub-eontracturs hare employem and have workers'comp.insurance.: 6L—J. 6.0 Vie are a Lex/rotation and its officers have exercised their right of racing:Aim per 1401 14.ir Other .3-4010) /tee 1- 152, li 4).and we hare no eersplia),ces.[Nu van-kers comp.insurance required] J'5n71 .Any applicant that ch,clis box n1 must also fill out the sectien below strewing their workers'compensation whey inform:dim_ RaineuWnem who submit this afraboit indicating they are doing all work and then hoe outside color-actors mint siihnut a new affialai it inditatting suck Contractors that check this box mina attached an additional sheet showing the name of the sols,contraetors and sate whether or not ihc entities hare empl.rLti it the sub-eurstractors bare employets.they must provide their workers'comp polky number. I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job.site information. Insurance Company Name: e1-11---"L.Sil C - Policy#or Self-ins.Lie.#: (DS COD. 9,)-31_3;)-Expiration Date: Job Site Address: 31 City/State/Zip: NO ri-lAclow-i-on gi+- 0/Deo Attach i 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 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$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 and s and pe of mildly that the information provided above is true and correct Sinaturc: Date: 6--_1— C)1 c)-- - phone#: 1/13- #?3 Official use only. Do not write in this area,to be completed by city or town official ('its or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone 4: city of Northampton fr'!H M 4 ,a Massachusetts was c,�; 7� * lam; ,t t�c DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 41%! {N` 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: The debris will be transported by: • Name of Hauler: `.h \---\()W f-�� GI( ✓� Signature of Applicant: Date: CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE A„.----31 SRES-01 ANGELA ACORL CERTIFICATE OF LIABILITY INSURANCE DA2/16/2022 TE ) 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 Angela DiAugustino Phillips Insurance Agency,Inc. PHONE FAX No): 592-8499 97 Center Street (A/C,No,Ext):(413)594-5984 ( (413) Chicopee,MA 01013 MAIIIEss:angela@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Admiral Insurance Company 24856 INSURED INSURER B:The Cincinnati Insurance Companies Baystate Restoration Group LLC INSURER C: 69 Gagne St INSURER D: Chicopee,MA 01013 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD WVD (MM/DD/YYYY) (MMIDDIYYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR FEI-ECC-28228-01 1/14/2022 1/14/2023 DAMAGETORENTEo 50,000 PREMISES(Ea occurrence) , $ MED EXP(Any one person) $ 5'D00 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PRO-JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 GL&Pollutlon45,000 Deductible X OTHER: $ CD AUTOMOBILE LIABILITY (aa acccident)SINGLE LIMIT $ _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY _ NON-OWNEDS PROPERTY DAMAGE (Per accident) $ $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 X EXCESS LIAB CLAIMS-MADE FEI-EXS-28229-01 1/14/2022 1/14/2023 AGGREGATE $ 2,000,000 DED RE I ENTION$ $ WORKERS COMPENSATION PEPERTUTE ERH AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A EL EACH ACCIDENT $ (Mandatory in NH)EXCLUDED? EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Pollution Liability FEI-ECC-28228-01 1/14/2022 1/14/2023 2,000,000 B Bailees Coverage ENP 0599754 1/14/2022 1/14/2025 750,000 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ^�� ®A � CERTI. ._ATE OF LIABILITY INSURAL _ _ E DATE(MM/OD/YYYY) 02/17/2022 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 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: Christina Penna BERKSHIRE INSURANCE GROUP INC PHONE n/cNo.Extl: (413)447-3519 a,No): E-MAIL c enna berkshireinsurance rou ADDRESS: p @ 9 p•com 43 East St INSURER(S)AFFORDING COVERAGE NAIL# PITTSFIELD MA 01201 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: BAYSTATE RESTORATION GROUP LLC INSURER C: INSURER D: 69 GAGNE STREET INSURER E: CHICOPEE MA 01013 INSURERF: COVERAGES CERTIFICATE NUMBER: 746320 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. IICY EXP NSR TYPE OF INSURANCE ADDL WVDSUBR POLICY NUMBER MM DD//YYYY) MMPOLICY EFF LDDIYYYY) LIMITS LTR INSD WVD � 1 COMMERCIAL GENERAL LIABILITY 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 AUTOS N/A BODILY INJURY(Per accident) $ 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 PTTUTE ERH A AND EMPLOYERS'LIABILITY A OFFC E.L.EACH ACCIDENT $ 1,000,000 ER/M MB REXC UDED?ECUTIVE N/A N/A NIA 6S62UB1K79231322 01/14/2022 01/14/2023 (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) 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MA 01103 Daniel M. � .CroW y,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 Commonwealth of Massachusetts •®� Division of Professional Licensure Board of Building Regulations and Standards Construdi8n+Supervisor ''f CS-056785I Ejtpires: 09/09/2023 MARK R DAVIAU �{Y,, 75 GILBERT RD C SOUTHAMPTOJI MA 01073 Commissioner cla. ct K. uCoickut.- • Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite .710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation BAYSTATE RESTORATION GROUP, LLC Registration: 180478 Expiration: 11/18/2022 69 GAGNE ST CHICOPEE, MA 01013 Update Address and Return Card. 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 180478 11/18/2022 1000 Washington Street -Suite 710 BAYSTATE RESTORATION GROUP, LLC . Boston, MA 02118 MARK DAVIAU Itop.4-69 GAGNE ST a ' CHICOPEE, MA 01013 Undersecretary Not valid without signature