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29-175 (6) BP-2022-0705 175 BROOKSIDE CIR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-175-001 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-2022-0705 PERMISSION'S HEREBY GRANTED TO: Project# BASEMENT RENO Contractor: License: Est. Cost: 100000 ALISHA PHILLIPS 106378 Const.Class: Exp.Date:02/26/2024 Use Group: Owner: HANLEY CHRISTOPHER J Lot Size (sq.ft.) Zoning: WSP Applicant: AXIOM LANDSCAPE &HOME IMPROVEMENT LLC Applicant Address P one: Insurance: 40 PINE VALLEY RD (413)320-9669 WCC-500-5020083 FLORENCE, MA 01062 ISSUED ON:06/14/2022 TO PERFORM THE FOLLOWING WORK: BASEMENT RENO 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 Driv 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: yg 3:-A7 4j�rf1M . . Fees Paid: $650.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner The Commonwealth of Massa huse s JUN j 3 41, I, Board of Building Regulations a Sta dards 2022 R I IPALITY,i Massachusetts State Building Co e, 7:,1 •opQ�/L g�,�_� USE Building Permit Application To Construct,Repair, N trer q Revi d Mar 2011 One-or Two-Family Dwelling oN'M-,oips0 This Section For Official Use Only -- Building Permit Number: Qe--e---)-" ?DS' Date Applied: i 't ► 4., _�g�o Building Official(Print Name) f Signature l 77 D to SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers lif 8 ..,kc;d& C1r-�e Fhee.v. , Z q / 7 S 1.1 a Is this an accepted street?yes x 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 Waterer Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Publc�[ Private❑ Zone: — Outside a Fla 611 e'� MunicipalJQ On site disposal system 0 Check if ye SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: CI N ({NLb y P'1-01eENC1T , I 3 O1Ocam_ Name(Print) City,State,ZIP I'1 5, (----. 2 o o jj.S I D c C_.1 i c..j i 1413-3 / L./ai l 1/4/4114 .e.,.1 E, rn A,I•eo rn No.and Street Telephone 1 Email Addrdis SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2:"B U I t_D C)or ►-I N IS hf e-b -80)( 00 M, I_ I VI N(,- RoOM AND 73ATHRoorvt Inl /-3•9Ri Iv! J7 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) , 1. Building $ "3-0/00 0 1. Building Permit Fee: S Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ l010v 0 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ list uu a j 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees: $ 650 Check No.a�/5 Check Amount: Cash Amount: 6.Total Project Cost: $ f dj ()Liu IgPaid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) GS--, i 063'7g 411 ) R If n I i Sh T-fi n i t ( 1 ►7 S License Number Expiration Date Name of CSL Holder I U List CSL Type(see below) fibP►IvE VALLty ROAD No.and Street Type Description _� U Unrestricted(Buildings up to 35,000 Cu.ft.) r L d R L N G�-' Iv1 A to 602 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding ' ) t SF Solid Fuel Burning Appliances ` ^1 13 -3 O'9(D(o9J q y Ian.lA►tci 9 N ios gae9l i� I Insulation Telephone Email address I g D Demolition 5.2 Registered Home Improvement Contractor(HIC) ' 7414!g .2/c°td 043 n Y 1 Otn LAND SC-OPE" `f Wom�1 rn y rove(b�pH'la_e. HIC Registration Number Expiration Date Ill''Company Name or HIC Registrant Name `►0 —r 7//Vr Vo 1ley R.t)AD AI1or11 LAtJDArib FID cn&J. 0gyrii,1eo1T No.and Street Email address 0 If-LoRt:WCt M Iq n )o(oa_ Nia..Sk6-s-5126 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 0 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 A I i Ch n N 1 '4 LE iQ 11 -h►i i,ps to act on my behalf,in all matters relative to work authorized by this building permit application. e...,,,,,,„ _—_-,0,.....,........i...-.-70" LjZZ 0 Z_ Print Owner's Name tciectronic 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. ,� 24/2-22 Prin wner's or i2�i�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.) (inclting 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" C.j CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD M��'� F(vLlst SIDE YARD 17-f SIDE YARD 5'1) So Ff V FRONT SETBACK S 7 i t FRONTAGE City of Northampton so",---, 0y0 - S,n\, np' `. Massachusetts ".�. 4. , �l DEPARTMENT OF BUILDING INSPECTIONS " 1 ,t ` 212 Main Street • Municipal Building 0 i mob, \ Northampton, MA 01060 S1‘k'ytiIV,,. 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:`IfiIIi -Reid ,n7 4 &IsmhroP7oaRD, Noreliwn low M1 The debris will be transported by: Name of Hauler: 144i0rfl L AODSLipc_ Una Noin.e =n,)pro* M'en--)- L4,c . 5Z GZ Signature of Applicant: Date: Z ' _ The Commonwealth of Massachusetts Department of Industrial Accidents ! 1 Congress Street,Suite 100 il Boston,MA 02114-2017 �,:: Itrrarw.mrtss gn►elditr -- 11 orkers'Compensation Insurance Affidavit:Builders+'C'ontr tors1EkctricisnstPlumhers. Tt)Hp.FIELD%V I?II THE PERNIITIlNG AtfTHOR1TY; Applicant Information Pkatte Print l eeihh Name(nosiness or aniztion tutividuldrax 10 r1;'� �LI1�A. . ,PE, ._.Hr7 JY?f ro V L C, Address: I 1 a 1, t), 1/a /fe. `(t JJ 6l1J.._..._.................._.............._......_..___......,..............._......__...._..._.._.___...__......_........_...._.._........__....................._......._......... CityfState/Ztp: „ Ci✓ l`'lO 01O 6►2 Phone# q 13 —5—k (o -S9g Art you In ylhesser?Cheek the appropriate Mass: // Type of project(required): idI aam a aunpknler Wilt t`Oenahluy i(,fish aaaVaa part-time}.' 7. II New construction ?In I art a seek:prtepe err ur partnc-rsrirp and have nO employees ployees working for law in 9:EL odeling arty c3pneity.('No workers.'comp.rnauranee re uirr^ri_j 9. ®Demolition 3.J I mat a honaeo carter doing all work myself,[Noworkers'eon*,insurance reituired.j' CId.C3 1 arm a homexiwnel and will he hiring oreruractors to eixidoet all work ou my property.rty. I will ( Building addition ensure that all contractors either have workers'costive L aauvr usur.rnoe Os am ands II.°Electrical miry or additions proprietors with nu employe`s. 12_®Plumbing repairs or additions 5C:1 1 ant a 13.ntnal conts:utur and I have hired the slih'eonnrucustr listed on the attached sherd_ 130 Roof repairs These nub-eonttacters hakes employees autd have workers' :ion p.insurance.- t, We are a cxrrpixatiun and its ofticeri have exercised their right of exemption per WI e. I _ Othet 1 t"t §I(3),and we homes:nu ea plu sea.[NO workers'comp,transience required.] *Any applicsa that checks htEl 41 afar atsu fill out the section below allowing then a otters'compensation pulley information. i liunieownere who subar&nos attitlaait imdacata tt they are clomp all work and then hoe our.ick eintiractura Inlet aitbant a new a rlda6it,ndu.a ung Was. IC aranleat3t$&Jt T theeck thi,b.o.rni s.i attarfx d an alstsrional abew:t showing the natnc of the xa ls-,t rxtitrac tor+and:crate whether or net thou,entities:have eanlatoyers. If the sub-cenatrar tors ha',::employee",they roust prim,ick'their twr,rkers'comp.policy n> bier. Idill an employer that is providing o'rrrAers'compensation insurance fOr my employees. Rehm.is the polity and jab.site inforrnatiinn. Insurance Company Name: (4 Z N M UT U A L— — Policy#or Self-ass.Lie.t/ Or—6-00 ^�Oa 008..E 0.�,a i Expiration Date:11f l7 ca43 Job Site Address: 1 1 7 2R 0OK S l D c L I I c.4E _City/State/Zip: 'Fro it ENc-E Mil O/0(n Attach a cope of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required mulct MOL c.. 152.*25A is a criminal violation punishable by a fine up to S1,500.(I(I and/or one-year imprisonment,as well as civil pR:rrtihiesE in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of th s statement may be forwarded to the Office of Investigations of the.DIA for insurance cov r t ,.''.c rif:..trIon . I do hereby cent,fy a tier the lxri nri e ' f peerjury�that the to formation provided above is true and correct Si ta€uxc: � Date: z / 2� Phone 4: Official use only. Do not write in this area,to be completed by city or town ofciaL a City or Town: PermitiLicense#t ? Issuing Authority(circle one): I.Board of I lealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector i.Plumbing Inspector 6.Other • Contact Person: Phone#: Pao c F1cvt lte t 0r)vc C11,iQvt4- &rico&01 11, filich 5(A OVA /S-ck e ,f 2)4¢ D .4l4 C .r c-F Z4 escr bt ft=k4 grd uti 4n 14( C f 0- 104 � t at• 12c+ Idec{st'` A rs ® ACOREP DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/21/2022 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 CONrACT Sarah Premo NAME: Clayton Insurance Agency, Inc. (A/C,No,Eztl: (413)536-0804 lac,No): (413)534-Te'I4 1649 Northam ton Street E-MAIL s�remo@clay toninsurance.net p ADDRESS: ---- INSURER(S)AFFORDING COVERAGE NAIC C Holyoke MA 01040 INSURER A:Safety Insurance Company INSURED INSURER B:AIM Mutual Insurance Company Axiom Landscape And Home Improvement LLC INSURER C: 40 Pine Valley Road INSURER D: INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER:2022 MASTER 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 A - CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ - - BMA0028548 1/11/2022 1/11/2023 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY n M. []LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 5907002 1/11/2022 1/11/2023 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,1,000,000 B OFFICER/MEMBER EXCLUDED? n NIA (Mandatory in NH) WCC5005020083 4/17/2022 4/17/2023 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD Uri,Additional Remarks Schedule,may be attached if more space is required) JOB: CJ HANLEY, 175 BROOKSIDE CIRCLE, FLORENCE, MA 01062 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF NORTHAMPTON THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPT. ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET, #100 NORTHAMPTON, MA 01060 AUTHORIZED REPRESENTATIVE L' ,anacl Pegan/EMT ffi r..,/' P 7J; I i ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) , v - 0/9 .1, 1,0 T105,0 ino 1A14) 'hli,vild 'll s;,Ca I1w1 5 40 Li4iV f 1 -e4, ‘ '' 114,5777yi / /1-4-7--/ / l'7/ /4 y // u$� J7t�/5 ( s);64.5 4 us c -4_ : v s ; ca. 4 a V Qt iCbfv1 -1 -71--70 \ � o