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31B-084
BP-2022-1380 77 HENSHAW AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31B-084-001 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-2022-1380 PERMISSION IS HEREBY GRANTED TO: Project# BUILD OUT 3RD FLOOR Contractor: License: Est. Cost: 151600 ROBERT J WALKER 034783 Const.Class: Exp.Date: 10/18/2023 Use Group: Owner: RUBAIYAT HOSSAIN SYEDA Lot Size (sq.ft.) Zoning: URC Applicant: JUST WALKER Applicant Address Phone: Insurance: 36 Service Center (413)584-1224 0 WMZ-800-8006540 NORTHAMPTON, MA 01060 ISSUED ON: 10/28/2022 TO PERFORM THE FOLLOWING WORK: BUILD OUT 3RD FLOOR. ADD BATH AND BEDROOM 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: $ A - ''� • Fees Paid: $986.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner k)E9 Ll C,►2D1.)iG ,_ ��5 CEIUE The Commonwealth of Massachusetts OCT 2 on OR wt. Board of Building Regulations and Stan ds 5 Massachusetts State Building Code, 780 MR L2ojJITYaU IP� SE Bu ilding Permit Application To Construct,Repair,Ren _ U d Ma 2011 Hq ►NSA One-or Two-Family Dwelling 'TON.Mq ooso"s Q This S tion For Official Use Only Building Permit Number: g " -/2 10 Date Applied: )/evi,..., 455 // 10- Ze- z Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Proper Address: 1.2 sess rs Map&Parcel Numbers cc 7 7 1 -E-tom►s-N- w A 5 Y ° '�/ 1.la 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) Nb-r- 0-p p -i clear-%1 *_/ �t oQ. u..)OQ11 D e.'Ly 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 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP1 2.1 Owner'of Record: Sy EOA tS fkt`1; (.-4 o SSA+14 Name(Print) City,State,ZIP if6 7 77 l- s-w rk. dvfi tvc1/ AIV1PM" l3 547- L(7554gs (UU( glr L \ a "Pin No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) i Addition. 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': G:;ILA) 0 v-r . r4 F 'vim 1S 14-0.40 try C ,OQ c .. Ap n g.P--r-1-4- i A-o 0 'p)Q . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ t z. -7 0V. 1. Building Permit Fee: $ Indicate how fee is determiied: 0 Standard City/Town Application Fee 2.Electrical $ i(pOV 0 Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ `el` nie, 2. Other Fees: $ 4. Mechanical (HVAC) $ 4.1 soot List: Mechanical (Fire $ pression) Total All Fees: $ 0Cash Check NoNO) Check Amount: Amount: otal Project Cost: $ 5 I) l- ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) P, L.. License Number Expiration Date Name of CSL Holder Z List CSL Type(see below) �710 S e..e.V 1 G G E- No.and Street Type Description N 002^r14 f�4-�M C�Tc,`h4 r LV� q- o l()co U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding wgk1e---e-i �• SF Solid Fuel Burning Appliances (-443) 5134-1 ZZ4 Cori 5.1-v'1vC l GSS cec 044s.Cows I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 51 13 17„4_ le-op)rcv jW 2 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address S4..N1� 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 o e 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 �-b PStl_1Z S. w A LIL (L to act on my behalf,in all matters relative to work authorized by this building permit application. 5 A-1 1/41 floss (ktv`-.) to 0-41 Z Z i 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. 1..12X J u. 4\rt~ c i2 t o t Z•y.{ Zz _ 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 umber of bathrooms Number of half/baths _ e of heating system Number of decks/porches _ e of cooling system Enclosed Open _ "Total Project Square Footage"may be substituted for"Total Project Cost" 7. ' '^ The Commonwealth of: lassurhusetts t•. Department of Indn.ctria1.4 ec•idents li i 1 Congress Street.Suite 100 � Ww Boston. liA 02114-?017 ' siiw mass.goiVdin - 114uLace' 4 tunl►crtsulion IrtsurautrAfiidia%al: Builder%!('onto'aetotw`EirrtririnniiPiuu►he It1 Ilk 1'LLD N1111 I Ill: 1'1;1L flhT!_LL AlUTIIU1t.1II. Apttlirnnt Information Please Print loath* Name t liuk,r.css 1_n ganr_aation,i nch%idual t: Address: City/State/Zip Phone#:_ :trrtun etnittartl':+ hitL it.r appratrrrale14It" Type of project:required► 1 Ism ataaipltrytz .4ittl 4r carer:.'. _:tirail rut ixport-inn.:.• 7. ❑ ties ic'r.sTructien I in'a lois pmPt-niararranaaa:r-tup anil bortnu rraplasx*wading) rnrors:In S. Q RernttheItng soy Latat.-aty [No%vaun•comp.urrtuance teywrnt_) 9. 0 Demolition t,0 I AM a lbrttlaOwoci Limas all butt myself.(No wwntten"cum. nrennutot unttil:WA a Q I am a lunnacov i a and mull be nr ion 13ut1[t►ngt addition aft aratttx�nn b a�tdrnt rl!work on or?pntrlrcltj. 1 WW1 enamor dud ell cdottnitlint either:have wr atatta':,mrpcaunLun iruwuncc cc ate able i t.Q Electrical repairs.or dddincin 5 F.sytnelLves acids cry anpIuyew. i10 Plunking repairs ut JAIthl,unV, '1 f3 I am a itnmcrai crtntraitur and 1 haws hmrtl the tt.bswttratum finical.to nu smarm theft l E1 Roof repairs u. tlte artb.aoel>Istttuta�a_e vistpttt)'<as and bao.a wutkl'b Lump tT.ae-m ci 6 D Vic r a caaptteabun and �k hue st•tI4 urlw .ruIrct![Isar nista o r c.►.-Lapin nt par %ti il.I:. 14.006E1 at 15.1;II 4 i.wet wt haw be anplut'c* I Nei wutim'emir melee:.:.rianar,•d.I 'Ant apptliinr ihaL Liun.ki but s I taut Akio lily out the.ecciant below ria•H imp them a mini'.-temp.ueauuu Iwlin:y tattn-nwuam lienneotettera who-auhtnd dua striae,it iarlal chug llir►sir drmi 41 wink and tlwn ham..auaide cart wet as taunt uatElUi a nca tt ula+.it !lath. 1 .rnlra sorb that:heck!haa lsrt ram a nunchnl an.al.lattanal nhnv trhnw In4 tix aam.el Ilia eub,c ottfrackara and stet*whether or n..t the=- haw crarlu'.c.-. I?'b v.1--col:try.•.e>I.o:crn{rlaaeca tiles.mum tvu.ode t!u-tr .:esker, ,umtr.whey rtmrmber i 1 am ton employer blot is irroeiif%ng workers'cawg t'ntaliois lawn-once for my c'rrtplorere. Below i b the police and f ah.Aitc information. Ittsu1:1111 +_•t•mivuty NAM:. P'r s a PA. INA v41jttkk is C0 , _ — C'ulit:S'Itt at Sdd1-wa. L .. 4. '`,1ffIN L 0"''. Vbelt S fie,— Z L-LI 4- Exptrauuf Duce. —1 i c I Z 3 fah Site Atlhr": 71 1A-f'ct—' - '+e'..--, -.Asv-e eitt+'Stntc-Zip-t cRi 4114Wv Vrerj 1 ► .1.4- L t�..., Attach a copy of the workers'compensation polio) drrl.uration page:showing the pink) number and expiration:hart. Futl[ut: to secure coverage as required under M(il. c. l;—'_ ;'SA is a criminal violation puimmh.bid by.t tine tip to Sl,51ki1 iii ant1 ar one-}cnr impnaoninenl.m well as clad penult/0k in the form ofa STOP WORK ORDER and n lint cal up to S 51LIMl u day agtunl t the Ytulutut_A copy of this statement :obey be torwdrikd to the Offtcc of In%cstrg:tttotb of the D1A for insiaant:c cuturUR4 terlii.:IitloiL. 1 do hereby certify tattler the pacts aid penalties of perjure(hut the inkrmnllnn provided abvs i is trite and correct -..,nalurt: �.�V2�` Dam. I()J Z-7---- [shone 4‘3 SSA - 17.2 4 Offrcaal itSc Ohllt 1)a not write in this art%to be completed by eidi or town of/kiul City ur Iowa: Permitlldcense R luyuing,Authority :circle nuek I. Board of Health 2.. Building Department 3.trO.Tawu tier!, 4.Llertrical Inspector '. Phi utl+tub lu.ltrt tltr b.:tiller urrlact I'erwii: f)tuur ri: ,.........1111141 CONSTRAS01 CPOROWSKI �'`�`�R� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD"YYY) 6/20/2022 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 WANED, 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). CONTACT PRODUCER :NAME: AXiA Insurance Services (Aiacc No,Est):(413)788-9000 c,No):(413)886-0190 84 Myron Street Suite A ,ADORkss:info©axiagroup.net West Springfield,MA 01089 L INSURER(S)AFFORDING COVERAGE I NAIC$ l INSURER A:Arbella Mutual Insurance Company 117000 _ INSURED 1 INSURER B:A.I.M.Mutual Insurance Co. _ Robert Walker INSURER C: —. 36 Service Center Road INSURER D: Northampton,MA 01060 • INSURERE: _-- -.--__._ _- 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 RESPCT 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' IADDL;WSUBR'I I POLICY EFF % POLICY EXP LIMITS5 LTR• TYPE OF INSURANCE INSD VD POLICY NUMBER (MM/DD/YYYY),(MM/DD/YYYY1 A 1 X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000 — CLAIMS-MADE X OCCUR '8500071119 7/1/2022 7/1/2023 DAMA3ES(ERRENTrrence) $' 100,000 MED E)CP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY' X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 EPLI $ 25,000 F� OTHER: • COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) It$ ANY AUTO 1020098280 7/1/2022 7/1/2023 BODILY INJURY(Per person) ,$ _- OWNED X SCHEDULED ;AUTOS ONLY AUTOS BODILY INJURY(Per accident),;$ HIRED NONWNg PROPERTY DAMAGE X:AUTOS ONLY X_AUTO ONLE (Per accident) i$ A X UMBRELLA LIAR X OCCUR ,EACH OCCURRENCE $ 2,000,000 EXCESS LIAR CLAIMS-MADE, 4620098565 03 7/1/2022 7/1/2023 AGGREGATE - $ 2,000,000 DED X RETENTION$ 10,000 • $ B WORKERS COMPENSATION PER ER AND EMPLOYERS'LU16tLnY Y/N WIMZ-800-8006548-2021A 7/1/2022 7/1/2023 1 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE — N/A ' E.L.EACH ACCIDENT .$ OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory m NH) — ' E.L.DISEASE-EA EMPLOYE$ 500 000 If yes,describe under + DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT i$ • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES 101,Additional Remarks Schedule,may be attached If more space is required) (ACORD CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL', BE DELIVERED IN Proof Of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ,__ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD City of Northampton oacW�iMNro� S%.. Massachusetts ; DEPARTMENT OF BUILDING INSPECTIONS *cl3. ?y ,� °d1' 212 Main Street • Municipal Building ti Northampton, MA 01060 JsbW ‘'s 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: VA L The debris will be transported by: Name of Hauler: Co A.) St-cZvc j Signature of Applicant: ` 4---.t Date: Za I '-