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36-248 (14) BP-P 022-1336 46 MAPLE RIDGE RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-248-001 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-2022-1336 PERMISSION IS HEREBY GRANT:D TO: Project# RENO BATHS Contractor: License: Est. Cost: 54000 RHI CONSTRUCTION 055236 Const.Class: Exp. Date: 01/18/2024 Use Group: Owner: A PALM JEFFREY A& KELLY Lot Size (sq.ft.) Zoning: WSP Applicant: RHI CONSTRUCTION Applicant Address Phone: Insurance: 128 RYAN RD 413-885-9038 7PJUB I K06038421 FLORENCE, MA 01062 ISSUED ON: 10/18/2022 TO PERFORM THE FOLLOWING WORK: RENO BATHROOMS 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 VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: • V . )2 . T. , - Fees Paid: $351.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner . s pepartment usefonly I City of Northampton O '\ Sta us"�af ermit G�,I _ ;"'l,.r "e .,ig ig Iry`"St ,ad iwxn G�:r ram,, ;-_ .i e Ltd '"-1 nregt MIggiingiaMlii Building Department Cr c� cuT/Dr e�vay Perntit _ 212 Main Street � ?O^ 5ev r/se m AuaIla61i ty ` '- F r' �" '�3 Room 100,'�: 2 ter/VV LAva�la6illty Northampton, MA 010 CY"M(. WaIS s~ofStractr;ral Ptans_ ' ` y 72 G! G N phone 413-587-1240 Fax 413-587-22^Y �cr/ Iof/S.,Plans°� {; j TES ` • �▪ � �'0so°N Othe_Specifyj, .:v-. APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: f:;-4,..7.7:-.1!,::;:.:: -!-:.;-..;:-! This section to'be complefed by office =Map Ok Lot � t Unit �_ n �l �' . _{Zone Overlay District IA to (Y\ktkc I :_Elm St trict CB District i SECTION 2.-PROPERTY•OWNERSHIP/AUTHORIZED AGENT 2.1 Owner ord: stkk of :Rec ��\�. �P c,\m,. �-i m�Q�. (2'‘‘ �- c (2—Z Name (Print) Current Mailing Address: Telephone �, — ` - 04 NI Si ature 2.2 Authorized Agent: Name(P '' t) Current Mailing Address: Signatur Telephone e SECTION 3 ESTIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be Official Us Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical //��V- (b) Estimated Total'Cost of $a57. Construction`from(6) 3. Plumbing 550° Building Permit Fee ° 4. Mechanical(HVAC) 5. Fire Protection Op 6. Total=(1 +2+3+4+5) Check Number 3�©� This Section For Official Use Only �, Date Building Permit Number: ��� '� i Issued: �• �' f1 20ZZ. Signature: Building•Commissioner/Inspector`of Buildings: Date • w w Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department I Lot Size I I ' 1 ' Frontage ---j { __ Setbacks Front i ! �_� Side L: I�:' + L:1 _i R:l 1 i--- Rear 1 i t I Building Height 1 _I 1 1 Bldg.Square Footage _ % f f 1 - Open Space Footage (Lot area minus bldg&paved 1__1 L_ I >_ i ! 1 parking) #of Parking Spaces 1 I i Fill: II I 1 , l (volume&Location) • A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 Yli,S Q IF YES: enter Book L Pager and/or Document#1 B. Does the site contain a bropk, body of water or wetlands? NO `.0 DONT KNOW 0 YES 0 IF YES, has a permit ben or need to be obtained from the Conservation Commission? Needs to be obtained 0 " Obtained Q , Date Issued: 1 lie C. Do any signs exist on tirproperty? YES Q NO 0 1 IF YES, describe size, type and location: : I D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0 IF YES, describe size, type and location: i E. WII the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. I. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition 0 Replacement Windows Alteration(s) Ei Roofing El Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [[] Siding [O] Other[O] Brief Description of Prop sed Work: (LC-/lt: �jc,-t -2.4.ire5 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa., If New house and.or.addition:to existing housing, complete the following: a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attabhed? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will buildin§conform to the Building and Zoning regulations? Yes No. • I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. , lVt' c-. fc-- Q - \VY\ , as Owner of the subject property hereby authorize \nC;/h -J Ky\i„\`^'t-- to act on my behalf, in all matters relative to work authorized by this building permit application. —'4727 W — 0 — a- Signature of Owner Date I, Q.h/\t VNMi i/ril-- , as Owner/Authorized Agent hereby declareat the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. trvu. r ('(---- Print Na Signature of wner/Age Date or SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: `,�,, Not Applicable £ Name of License Holder: \ W" Y'`�\�T�� ( License Number Address Expiration Date Signature Telephone j 9-Registered Homeamprovement Contractor..;' _„,_ Not Applicable £ Company Name Registration Number Address Expiration Date Telephone I\\V ---e1d)F SECTION 10-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 £ 11 Mine Owner.Egemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own 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 homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature, • The Comzonwealth of Massachusetts —" Department of Industrial Accidents 'tip,' Office of Investigations Eig1= w ;�„ 600 Washington Street =rlp= '.1S Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): c).---\11 -kS L'Pl 2 -`C,:__ Address: \a "YL-y.,` (L.L_ City/State/Zip: ' .IY — Phone#: L\\ ` oY Are you an employer? Check the appropriate bo : Type of project(required): 1.El I am a employer with 4. OW am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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. 0 Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. Ei We area corporation and its 10.0 ElectrcaI repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners 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 for my employees. Below is the policy and job site information. \ Insurance Company Name: �-. t -13 AN- / kc ` L 31i r+,c^-\ . Policy#or Self-ins.Lic. #: rr Expiration Date: Job Site Address: � Mti 4. p`'t. i� j1.1 City/State/Zip: ,t/ t PN,A-c\oo - Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal 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 ORDER 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the ins and penalties o erjury that the information provided above is true and correct. Signature:-.'.7 Date: It-) —An -Zr.-L.. Phone#: A Z15 -c,..)-. r 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): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: City of Northampton • r e- 40;:l Massachusetts 1 '{ DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building w1•, Jr =fib Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footinqs (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits - and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: to C\ The debris will be transported by: 'r`r`-, Uu`L- The debris will be received by: 'it �At./1 Building permit number: Name of Permit Applicant Date Signature of Permit Applicant • .- . '' --'1,140....V...ilibulisA.........*,,,,..ea,w,t,,,,,,,..1.1.4;.....,,,,m,,,.,,,,,,,,,,,,....1,...M.1...1.41.1.140.14,6,5,4e.,,,,..,,,,, ..."*o.'."•.',.....er......,...- .-nto - ............. ..... . . _ 4,.... ...,,,„,__ .......,„„ -„„-...........___,,..... vt,) . , . . ---- , .., I . i i.,. . 4 1., icI 4 , ..., , 1 , 1 5‘,1k teltirlt), C 4 S VArA !., 9,14.4441 Mjit. c %, I • 1 Y, t f 1 ------ .1.4.1 k . . 01, ... . 1 1 .' ,k 34 1 A*,,,,I............) 0 Duct.-k --N..-- 1..,,- 0u( ...........--..........--...„...,-,............. .'"i kip . ivy --l � 11 v i ,. ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `,�.----- 10/17/2022 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 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: Susan Fleury KING & CUSHMAN INC (A//CC,,No,,Ext): (413)584-5610 (A/C,no): E-MAIL ADDRESS: sfleury@kingcushman.com sfleu kin cushman.com P 0 BOX 447 INSURER(S)AFFORDING COVERAGE NAIC# NORTHAMPTON MA 01061 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B RHI CONSTRUCTION INC INSURER C: INSURER D D. 128 RYAN ROAD INSURER E: _ FLORENCE MA 01062 INSURER F: , COVERAGES CERTIFICATE NUMBER: 825021 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. ,ADDL I _._-------- INSRI 1SUBR POLICY EFF POLICY EXP ' LIMITS LTR TYPE OF INSURANCE INSD I WVD I POLICY NUMBER i(MM/DD/YYYY) (MM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ --DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) I $ MED EXP(Any one person) 1 $ -1 - N/A PERSONAL&ADV INJURY $ I GEN'L AGGREGATE LIMIT APPLIES PER: �, GENERAL AGGREGATE $ I POLICY _ PE 0 _ LOC . PRODUCTS COMP/OP A($G $ OTHER. $ AUTOMOBILE LIABILITY ' COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ', BODILY INJURY(Per person) • $ OWNED I BODILY INJURY(Per accident)I $ N/A _ ;AUTOS ONLY l___) AUTOS II � i. ___ AUTOSON-O ONLY I PROPERTY DAMAGE $ , SCHEDULED i HIRED 'I NON-OWNED I i I AUTOS ONLY , , (Per accident) • ,I UMBRELLALIAB I I OCCUR EACH OCCURRENCE :• $ EXCESS LIAB r 1 CLAIMS-MADE N/A AGGREGATE $ DED 1 RETENTION$ I $ WORKERS COMPENSATION 1 v PER+'- STATUTE L_ FOR. j AND EMPLOYERS'LIABILITY YIN I - - --- ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A 'OFFICER/MEMBEREXCLUDED? N/A N/A : N/A 7PJUB1K06038421 11/30/2021 11/30/2022 r (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE' $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT `$ 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 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/Iwd/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 City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Crowley.CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD