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23B-094 (4) BP-2022-1063 200 NORTH ELM ST COMMONWEALTH OF MASSACHUSETTS Map Map:B1OBlock:Lot: 23B-094-001 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-2022-1063 PERMISSIONIS HEREBY GRANT D TO: Project# 2022 RENO Contractor: License: Est. Cost: 95000 KAREN LAVERDIERE 055344 Const.Class: Exp.Date:08/29/2024 Use Group: Owner: MCAULEY JAE Lot Size (sq.ft.) Zoning: URB Applicant: KAREN LAVERDIERE Applicant Address Phone: bsurance: 21 FAIRFIELD AVE (413)268-2080 6s62ub5n25195321 HAYDENVILLE, MA 01039 ISSUED ON:09/06/2022 TO PERFORM THE FOLLOWING WORK: REPAIR WATER DAMAGE, ADD 2 SKYLIGHTS, CHANGE OUT/MOVE 2 WINDOWS, INSULATE, SHEE OCK &TRIM, RE-SIDE 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: �. Fees Paid: S617.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner T The Commonwealth of Massachusetts r, o ; Board of Building Regulations and Standards FOR �`r • I Massachusetts State Building Code, 780 CMR MUNICIPALITY USE rn Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling r II This Section For Official Use Only Building Permii Number:_Z07JL-i OL 3 Date Applied: I A i j IV r 4' ii . ; `ice1 ! 4, d Building Official(Print Name) Signature 'I ate SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 20o ' ChMMI S4-•, 236-o'1'y- 1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 1,111S .361 aCr.. 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 i 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 Owner'of Record: T ' 0 r e ,n c e_ -:.-co.e- McP.T.j\ e 1 l•lot-a1na Pin 1 gm 4 0166 Z- Name(Print) City,State,ZIP "Zoo ^1. cl ,Vn S41 L113 -s8s -19B8 sae . rne_ Aulettdcelonki)e.o No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) i•.or New Construction 0 Existing Building Owner-Occupied iii/i Repairs(s) VAlteration(s) iir Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units r Other 0 Specify: Brief Description of Proposed Work': I-I eh)s c if-4 L e, d. .1..A ry c o. 1 4.5\1 lSr'vs � A Cti I.Vt c.1 ` t�An4 c L. 1r,as VGt.n t'c r^Ovaa , vJc,r S 1� SiA .L e J‘c" •F-„v e 1IIv \ a [. A t- . sN 11 1.4t , s i„... ►...,,, 1. 1 *,Z v,..4 ,iv e r Q; r"s/) SECTION 4:ESTIMATED CONSTRUCTION COSTS re- c i LC. Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 6 5 l 60 6 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 0 0 Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 1 S., 00 ° 2. Other Fees: $ 4. Mechanical (HVAC) $ 0 List: 5. Mechanical (Fire / 'J Suppression) $ Total All Fees: $ Co/ OD Check No. k 6. Total Project Cost: $ Q.5 a Check Amount: l i Paid in Full 0 Outstanding Balance Due: T• 1 City of Northampton Massachusetts c't� I ` o DEPARTMENT OF BUILDING INSPECTIONS . 212 Main Street • Municipal Building Northampton, MA 01060 ti14 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. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 11 o5S - 3`LH I"Zq ` Zy Kart vk La Je,{d i We License Number Expiration Date Name of CSL Holder Z` e' 1 A t1 v _List CSL Type(see below) G 1 r d No.and Street Type Description -`Q ?.Y1 t' Qi 3 U Unrestricted(Buildings up to 3',000 cu. ft.1 Cil�/T State,ZIP 1 1 R Restricted 1&2 Family Dwellin:. n' o , M Masonry RC Roofing Covering C y 13\ WS Window and Siding // SF Solid Fuel Burning Appliances 53�1-` 188 `"1 Qi-ev11 o.V`-(y ( gvina i i•L 0-i I Insulation Telephone Email address 1 D Demolition 5.2 R gistereedd H me Improvement Contractor(HIC) /6 6£9 / 7 ZZ/ 1')i 'l�- HIC C Registration Number 9E it on Dater HICCompany Name o C Registrant Name ( No.and Street Ka re a` t'J -1 9 44 Ia t I , co"i Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 25 (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 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r I,as Owner of the subject property,hereby authorize A(z'� L Q\P_f o l e-'rc. `OIl S Jiu C�- to act on my b alf,in all matters relative to work authorize by this building permit application. i )- ,� riV-Arvc v-vy 2 s12 Z— O�Gner's ame(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. e..—...—.__ .\--.... ...a.--c-S.-.............- °t2D\-1._lx, \ "2-72— 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 Z Number of half/baths Type of heating system ., i..i S pi .. S Number of decks/porches Type of cooling system ,,,„',,n', C o i l-S Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" The Commonovealth of.11assachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.govldia • Workers' ('ompensation Insurance Affidavit:Builders/Contractory Electrician.,Plumbers. Ft)BE }IL} )1%11111 IIE PERMITTING At I ilt)Rtt i. Annlicant Information Please Print LeiEiblv Name Business:Organization. l<6 r rt L lceir_ C.0 nc C••/ Address: Z Fo:\ e..1 e_ City/State/Zip: \--\czcIcr,vitle ‘ ,NAR Phone#: ts 5 3 1 - 4-1 ca Are yes se eesiptayee Check the appropriate hats: Type of project(required): 1.0 I am a employer avtth employees tfu1midair patt-timet..* 7_ 0 New construction 20 I am a tole proprietor or pusinentup and htaveno employees working for me in 8. Remodeling any capaciry [No workers'comp.Insurance regional] 9. Demolition 1 am a horneatavner doing all want myself.[No workers'comp.insurance trapaired,l. I 0 Cl Building addition 4.C3 I am a lithilte0WaCr and will bie tuning coraratioci io ceriduct all*ark on my properry. I will ensure that all coutnicturs either have*mien'amerscrnsation insurance or are vole Electrical repairs or additions proprietors with no employem, 12. v4 Plumbing repairs or additions sleam a general contractor and I have Fined the sub-contractors listed on the situation dicer I 3.1::Roof repairs These sub-contractors have employees and have workers'comp.tesurance.: 6.0 We am a corporation and its officers have exercised their right of exemption per WA. .. 14_0 other §1 t4b and we have no employees.[No*otters'comp.insurance required.' •Arty applicant that checks box"1 must at.)till out tlw m.n.e.a.vn brclu iii. -lc .,or cr,' informatiott. fkiaricowtriers who 3U6nlit this affidavit nailscating they are doing all work and then lure outside contractors must submit a new affidavit indicating sutch. Coritractors that check this bits' Walla attached an additional sheet showing the name of the soh-contracters and-state whether or not those ernium have etripherter If the ieh-COnirstitors have employ cc,.thcy rated provide their workers"sanno.1uhr number I am an employer that i)providing worAer., compermaion insurance for my employee.N. Belo lci. the policy and job Aim information. L'e *WI e_8 Insurance Company Name: Policy#or Self-ins.Lic.#: Expira.tion Dam: Job Site Address: City.State2ip: attach a copy of the workers'compensation policy declaration page(showing the policy number and expirati'on date). Failure to secure coverage as required under MGL c. 152. §25A is a criminal violation punishabk by a fine up to S1.500.00 and/or one-year imprisonment,as well as end 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 cov cra,44: N,en ficatton. I do hereby certify under rivepuin wit!penalties of perjury that the information provided above is true and correct Signature: Date: 2 5 I 2_7— Phone - 3 Official use only. Do not write in this area.to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electric.ti Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone 4: City of Northampton Massachusetts !{� *gag w $c DEPARTMENT OF BUILDING INSPECTIONS ?, 212 Main Street • Municipal Building Northampton, MA 01060 ss' 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: " ' �� e \- + c-1 e The debris will be transported by: Name of Hauler: SE'\( Signature of Applicant: r -- Date: k Z L5 \ z Z City of Northampton r�7'., . Massachusetts A.� . 4{ DEPARTMENT OF BUILDING INSPECTIONS 5s�aa 7.90 ` 212 Main Street • Municipal Building *. . a� tea'" Northampton, MA 01060 .ate*,,—44 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) who owns 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) ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 08/24/2022 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: Erin Knechtel AMHERST INSURANCE AGENCY INC PHONE 413 253-5555 FAx (A/C,No Eldt: ( ) -._. (A/C,No): E-MAIL encies.comlh k enecte nathana ADDRESS: @ J PO BOX 48 INSURER(S)AFFORDING COVERAGE NAIL# AMHERST MA 01004 INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: LAVERDIERE KAREN INSURER C: INSURER D: 21 FAIRFIELD AVENUE INSURERE: _ HAYDENVILLE MA 01039 INSURER F: COVERAGES CERTIFICATE NUMBER: 808274 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 RE.PECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJEC TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF 1 POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY)j(MM/DD/YYYY) IMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrent:) $ MED EXP(Any one perso I $ N/A PERSONAL&ADV INJUR $ GEN'L AGGREGATE LIMIT APPLIES PER: • GENERAL AGGREGATE $ _ POLICY JECOT- f LOC PRODUCTS-COMP/OP G $ OTHER: _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMI $ (Ea accident'. ANY AUTO BODILY INJURY(Per pe ) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per acci ent) $ HIRED NON-OWNED i PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) • UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X STATUTE O H AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?ECUTIVE E.L.EACH ACCIDENT $ 100,000 N/A N/A NIA 6S62UB5N25195321 11/26/2021 11/26/2022 (Mandatory in NH) E.L.DISEASE-EA EMPL I YEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY L IT $ 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 t. 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/. Sole proprietor has not elected coverage. 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. Northampton Building Department 212 Main St#100 AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. 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