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11C-055 (4) BP-2022-1586 420 NORTH MAIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 11C-055-001 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-2022-1586 PERMISSION IS HEREBY GRANTED TO: Project# WINDOWS 2022 Contractor: License: Est. Cost: 10700 CHRISTOPHER JACOBS Const.Class: Exp.Date: Use Group: Owner: C JACOBS, CHRISTOPHER R, &MARY Lot Size (sq.ft.) Zoning: HB Applicant: BARRON &JACOBS Applicant Address Phone: Insurance: 420 NORTH MAIN ST 413-586-8998 wmz8006365 LEEDS, MA 01053 ISSUED ON: 12/07/2022 TO PERFORM THE FOLLOWING WORK: 12 REPLACEMENT WINDOWS AND 2 DOORS 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: 9.,67 Fees Paid: $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner tr DEC 1 The Commonwealth of Massachusetts �022 1' Office of Public Safety and Inspections +� Massachusetts State Building Code(780 CMR) aT°F guru • ' • ■..it Application for any Building other than a One-or Two-Family Dwelling �'ORruq�y�r� rTIONS M�060 ' (This Section For Official Use Only) Building Permit Number. p1rs/ /'I5 'Date Applied: Building Official: SECTION 1:LOCATION 7 0 N . \auv) C • L .e_t, 0\OS� No.and Street City/ wn v5c Zip Code Name of Building(if applicable) Assessors Map# Blockytr #..and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building 0 Repair❑ Alteration' Addition❑ Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No !� Is an Independent Structural Engineering Peer Review required? Yes ❑ No gf Brief Description of Proposed Work \m[c.... 12 vJ r,4)0QS QvNel Z a ' o� d;�S. 12-W 1nl.v�vJS e v r \ Y�•��u�n .)r w.rAoka. V'�\— v D� . SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE dROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business y E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile 0 R Residential R-10 R-2❑ R-3 0 R-4 0 S: Storage S-1 0 S-2❑ U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB 0 IIA 0 IIB ❑ IIIA 0 IIIB ❑ IV 0 VA 0 VB IF) SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: A trench will not be Licensed Disposal Site IF Public pz Check if outside Flood Zone INI Indicate municipal RI required El or trench or specify: Private 0 or indentify Zone: or on site system 0 permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission,Review Process: Not Applicable] Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or Nop Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner ('1r\r\s Q\1,2-r'S bs i--t2z N.V\i,kr5t . I (V\Pr OrJs) Name(Print) No.and Street City/Town Zip Property Owner Contact Information: `A\b-q6- al"l S1 4l77- . - 6 6)-1 4- YAo AcstY YK>1,--v-v�1 J•«ob5.cZ7w'- Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here p). Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor ‘/\YV)\', chva ' ri,-cbS Company Name Name of Person Responsible for Construction License No. and Type if Applicable L)\.1,0 0, `M(\,\,.C7k• kJ-L.1s Lyo c Street Address City/Town State Zip Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 9 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) =$ \0 I 1.Building $ (n 10 BuildingPermit Fee=Total Construction Cost x `4"'(Insert here 2.Electrical $ appropriate municipal factor)=$ . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ 100 (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ \J)," (contact municipality)and write check number here jali d SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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 wledge and understanding. ON\SWINaic \495 1/,' ?%(Q-b e- `A N-sk-c' J)?— Please print and sign name Title Telephone No. Date k7A) IQ M et\.-- 4\. • LP i tW o lc?s5 CG c�J�+r wv-,ti r,ds c...h.s. c«r^ Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: . 1 ' 1' ► ' A- A. Si '� Name Y V Date City of Northampton 14 ir w Sys : sic Massachusetts 4,÷ 1 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 SfW �'0. 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: ' \ S\—Vv\\pk ,k)D ( The debris will be transported by: Name of Hauler: GYY� Signature of Applicant: C /f Date: )ZI6 1Z)--1— The Commonwealth of Massachusetts O—�!l. Department of Industrial Accidents ' ' I Congress Street, Suite 100 j� Boston, MA 02114-2017 ' � www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information nn Please Print Legibly Name (Business/Organization/Individual): ')ey Gov (Air-yiIck _c �)j �S�v Address: LA-2A) VV1U,•y% SC City/State/Zip: L — S 11( U\oti Phone #: t--j 1'7)- Are you so employer?Check the appropriate box: Type of project(required): 1.1D lam a employer with \O employees(full and/or part-time).` 7. El New construction 2.0 I am a sole propnetor or partnership and have no employees working for me in m i [No workers'c 8. Remodeling a capacity. comp.insurance required.] 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. Demolition 10 Q Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. I- Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0We are a corporation and its officers have exercised their right of exemption per MGL c 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. *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 for my employees. Below is the policy and job site information. Insurance Company Name: j 1v\ Mu e. Policy#or Self-ins.Lic.#: vv I 'V? via)Co.9(ch _Q i_2-Pr Expiration Date: 1 i i ( 2,0 Z3 Job Site Address: LA 2,0 . 'MO\\r c t. a City/State/Zip: 1 MP--O\OS 5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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. 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 pai and penalties of perjury that the information provided above is true and correct Signature: // Date: 2 ' ( [ZZ Phone#: k � ' \C''1°1 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#: ACc RO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 03/03/2022 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 Adina Edgett,CISR NAME: Webber&Grinnell PHONN Ext): (413)586-0111 FAX No): (413)586-6481 8 North King Street E-MAIL aedgett@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Main Street America/MSA 29939 INSURED INSURER B: NGM/MSA Barron&Jacobs Assoc. Inc. INSURER C: A.I.M.Mutual/A.I.M. 33758 420 N Main Street INSURER D: INSURER E: Leeds MA 01053 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 03/23 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 (MMIDD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGERENTED CLAIMS-MADE X OCCUR PREM SESO(Ea occcu ence) $ 500,000 MED EXP(Any one person) 1 $ 10,000 A MPT8049D 03/09/2022 03/09/2023 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRO JECT LOC PRODUCTS-COMP/OP AGG $ 3,000,000 POLICY OTHER EPLI $ 10,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 1,000,000 B OWNED SCHEDULED M1T8049D 03/09/2022 03/09/2023 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X HIRED Ne NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY (Per • accident) Medical payments $ 5,000 UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ B EXCESS LIAB CLAIMS-MADE CUT8049D 03/09/2022 03/09/2023 AGGREGATE S DED X RETENTION$ 10,000 $ PER OTH- STATUTE __ _ ER, YIN ANY PROPRIETOR/PARTNER/E` CUTIVE E l CCCT $ 500000 C OFFICER/MEMBER EXCLUDED? N NIA 84Q63652022A 03/01/2022 03/01/2023 : EAH A IDEN , (Mandatory in NH) L E ISEASE-EA EMPLOY1EE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure ir Board of Building Regulations and Standards ConstLai at` kp Servisor `~ ._ IF. CS-060475 y ellilliw 11/10/2024 R ,.. 420 NORTH MAINS '° LEEDS MA 6953 n�4�///1��l.LVd1'J yob VVI III I 1 iJJi Vlac, vlta'"j f. c_� THE COMMONWEALTH OF MA SACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston.Massachusetts 02118 Home Improvement Contractor Registration Tyre Corporation Repo ration 100808 BARRON&JACO6C ASSOCIATED INC Expiration 06 /2024 420 NORTH MAIN STREET LEEDC MA 01063 upriser Address and Return Card THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business ReguMtion Registration varid fat individual!use army before the HOME IMPROVENIEK CONTRACTOR ezpratton dole_ If Nand return to: TYPE._Cowman office of Consumer affairs and Business Regulation RMisprO 1000 Wfsltirmron Street -Suite 710 1000011 - asa2moz4 Boston,MA 02116 BARRON b JACOB:ArC012ATES.INC. CH NORTH A STREET 420 NORTH MAN STREET LEEDS.MA 01053 Under,.ct/Wry Not valid ' signature