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11A-028 (3) BP 2022-0790 17 CHESTNUT AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 11 A-028-001 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-2022-0790 PERMISSIONIS HEREBY GRANTE I TO: Project# 2022 SOLAR Contractor: License: INSIGHT VENTURES LLC DBA Est.Cost: INSIGHT SOLAR CS-1 14618 Const.Class: Exp.Date: 10/31/2023 Use Group: Owner: HALE EVER ELIZABETH R& KEVIN Lot Size (sq.ft.) Zoning: URA Applicant: INSIGHT VENTURES LLC DBA INSIG I T SOLAR Applicant Address Phone: Insurance: 59C NORTH ST (413)338-7555 C5055224A HATFIELD, MA 01038 ISSUED ON:07/08/2022 • TO PERFORM THE FOLLOWING WORK: REMOVE EXISTING SLATE SHINGLES & REPLACE WITH NEW ASPHALT SHINGLES 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 VIOL TION OF ANY OF ITS RULES AND REGULATIONS. Signature: I 9)'I • LlUka I )2 . I ' Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner awls Fa The Commonwealth.of Massachusetts Board of Building Regulations and Standards FOR _ Massachusetts State Building Code, 780 CMR MUNICIPALITY �� USE *ding Ferriit Application To Construct,Repair,Renovate Or Demolish a Revised Mar$011 One- or Two-Family Dwelling -_ ` This Section For Official Use Only Builkdirig Permit Numbe 'ir 13P-2022-0'79 D Date Applied: O7f OQ20Z2 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numb 17 CHESTNUT AVE /I fl —O 'OO ( 1.1 a Is this an accepted street?yes X no Map Number Parcel Number 1.3 Zoning ning Information: 1.4 Property Dimensions: . 4021 a.cre..S 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 Flooyes Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: RUTH EVER LEEDS,MA 01053 Name(Print) City, State,ZIP 17 CHESTNUT AVE 413-374-2645 everhale(4)gmail.com No. and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK' (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 I1 Specify: RE-ROOF Brief Description of Proposed Work REMOVE EXISTING SLATE SHINGLES AND REPLACE ROOF WITH NEW ASPHALT SHINGLES. _ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 26,424 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees: $ 12° Check No.)57/ Check Amount:70- Cash Amount: 6.Total Project Cost: $ 26,424 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-114618 10/31/2023 EDMUND P.SEPANSKI License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 59C NORTH STREET No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) HATFIELD,MA 01038 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonr y RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-338-7555 Applicationsggetinsightsolar.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 192102 6/8/2024 INSIGHT VENTURES LLC HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 59C NORTH STREET Applications(a,getinsightsolar.com No.and Street Email address HATFIELD,MA 01038 413-338-7555 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 APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize INSIGHT VENTURES LLC to act on my behalf,in all matters relative to work authorized by this building permit application. RUTH EVER 6/29/22 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. EDMUND P.SEPANSKI 6/29/22 Print Owner's or Authorized 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.) (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 :_ `� k, CDEPAR4MENT OF BUILDING INSPECTIONS /, , Ap' 212 Main Street • Municipal BuildingI. Wit+"` Northampton, MA 01060 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: 59C NORTH ST, HATFIELD, MA 01038 The debris will be transported by: Name of Hauler: INSIGHT VENTURES LLC Signature of Applicant: Zeflr,,,Q1- F4' Date: 6/29/22 1 ne uummunweaun of.iviassucnuserrs Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Insight Ventures LLC Address: 59C North Street City/State/Zip: Hatfield, MA 01038 Phone #: 413-338-7555 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 14 4. ❑ I am a general contractor and I 6 n New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P t3' 9. n Building addition [No workers' comp. insurance comp. insurance.. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no q ] employees. [No workers' 13.0 Other Solar comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance fir my employees. Below is the policy and job site information. Insurance Company Name: Ace American Insurance Co. Policy#or Self-ins. Lic. #:C5055224A Expiration Date: 10/1/2022 Job Site Address:- 17 Chestnut Ave City/State/Zip: Leeds MA 1053 Attach a copy of the workers' compensation policy declaration page(showing the policy number and a piration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimin I penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK RDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the ffice of Investigations of the DIA for insurance coverage verification. I do hereby certi,under t ains and penalties ofperjury that the information provided above is true and correct. Signature: — Date: 6/29/2022 Phone#: 413-338-7555 Official use only. Do not write in this area, to be completed by cite or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 2❑Building Department 3.City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: AccioRL1 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �►...-'' Aced/. 2932720 5/26/2022 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 888-828-8365 Lockton Companies. LLC PHONE FAX 3657 Briarpark Dr., Suite 700 (A/C.No.Extl: (AIC,Ne): E-MAIL Houston,TX 77042 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Ace American Insurance Co. 22667 INSURED INSURER B: INSIGHT VENTURES LLC 59C NORTH ST INSURER C: HATFIELD,MA 01038-9748 INSURER D 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 FOI: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 (MM/DD/YYYY) (MM/DD/YYYY)I LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL 8 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 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER STATUTE E ERH- ANDEMPLOYERS'LIABILITY YIN R ANY A OFFICER/MEMBER EXCLUDED PROPRIETOR/PARTNER/EXECUTIVE NIA C5055224A 5/1/2022 10/1/2022 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIM T $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 INSIGHT VENTURES LLC. NORTH HAYFIELD,,MA 01038 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD