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31B-189 (7) BP-2023-0005 75 GOTHIC ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31B-189-001 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-2023-0005 PERMISSION IS HEREBY GRANT, D TO: Project# 2022 RENOVATION Contractor: License: Est. Cost: 100000 ALISHA PHILLIPS 106378 Const.Class: Exp.Date: 02/26/2024 Use Group: Owner: BIRDSALL DIEHL WILLIAM A&J Lot Size (sq.ft.) Zoning: URC Applicant: AXIOM LANDSCAPE &HOME IMPR• MENT LLC Applicant Address Et one• Insurance: 40 PINE VALLEY RD (413)320-9669 WCC5005020083 FLORENCE, MA 01062 ISSUED ON: 01/05/2023 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN&BATHROOM 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: 51-°1 0 • y2 - • i Fees Paid: S650.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner RECEIVED JAN - 4 2023 / , The Commonwealth of Massachusetts FOR 4 oard of Building Regulations and Standards DE P' �,�!y?I.!DING INSPECTIONS IV assachusetts State Building Code, 780 CMR MUNICIPALITY N ./MPTON,MA 01060 USE Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only 1 Building P rmit Na mber:1I?DP — 000S to Applied: t'wa_ s /7& I Zvz3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1 GrJ'i+L Sf 318 -I?41-Do I 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: U R C. .14 3 aor� 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 )9 .1. 81114Mak ti Pr/ttsCo P- 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Informatio 1.8 Sewage Disposal System: Public Private 0 Zone: _ Outside Flood Z9ne? MunicipaaOn site disposal system 0 Check if yes SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 1i�.44,, f,,v A? 0/0 C O J1!4Ndt. Ql�dS4�� Name(Print) City,State,ZIP S 64/4„c 54 9/3- 32v-72/9 Ica 04 C 4,:cirlll a f.4i19•/ cc„7 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(s4Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': M ewe SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee yD ❑Total Project Costa(Item 6)x multiplier)000l)tb x 0`� 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire Su ression $ Total All Fees: $ 4t6b J„ :— Suppression) Check No2.5'O Check Amount:f/�,—Cash Amount: 6. Total Project Cost: $ 1'UU 000 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisori License(CSL) CS'" /4G 3 71 Z./Zz/Z y A'GIs t el P i11/ l'e. License Number Expiration Date Name of CSL Holder (A 1 d PC4 L uc lie n O List CSL Type(see below) No.and Street '`O( T}ye Description F�a' ( ,//�vvv / L/tR Unrestricted(Buildings up to 35,000 cu.ft.) �� !'r O�v y Z R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 463 -3lo_1661 6 Q r / / // SF Solid Fuel Burning Appliances �1 V / C)x/o �jM�/�1N ,j15i�roh I Insulation Telephone Email address l D Demolition 5.2 Registered Home Improvement Contractor(HIC) I ittiii .-/io/Zo,Z3 A'X/orh tgol l-tC�/lt. f m ...toi iebot 1-tC. HIC Registration Number Expiration Date HIC Company Name or FRC Registrar Name / / �J , 110 'JAL (AM/ cX�nh/R�O'�►r.►o/ �o%� f {9/h9i <<en No.and Street Email address F tlitoC ei 4 g OW c 2 `l/3- 32..9GL 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 Issuan f the building permit. Signed Affidavit Attached? Yes No 0 SECTION 7a: OWNE AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT / ,-y �, I,as Owner a subject property,hereby authorize �ISA`t G, A I/ ps to act o ha.lf in all matters relative to work authorized by this building permit application. i_j_li eb Print er'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 he best of m nowledge and understanding. 1 A 14s P4/// s iziz , Zoe Print Owner's or Authorized Agent' Name(Electronic Sign f Dat NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contra for (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 SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD y Cf- SIDE YARD I/ II � S SIDE YARD �t -(o � (]i4r 7 p G ! ( sf) FRONT SETBACK I 1 P4 FRONTAGE City of Northampton pas�H AMpT� �a�/ �'�; S 5 : S C'v /� ,0.,_ Massachusetts �.„ ._ <<,\ + 1 a 1 � � DEPARTMENT OF BUILDING INSPECTIONS y i M \ � �; 212 Main Street • Municipal Building J�_ �D, \ y` Northampton, MA 01060 ssI��i, a,j‘'‘, 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: LA 11 t iii, IZc(y Cam'►h The debris will be transported by: ► Name of Hauler: 1Crvyti Signature of Applicant: Date: l2 75 ZZ The Commonwealth of Massachusetts ,; Department of Industrial Accidents �a I;$ I Congress Street,Suite 100 ie . ...w 7 Boston, MA 02114-2017 �r wl4'n:ntass.gov/dia 11 uekers' Corupertsation Insurance Alydasit:BuilderslContractors/ElectriciansPluothers. It)BE FILED WITH'ftlE PLRMITI'INC AUTHORITY. Aniilicaut Infurinatiuri / _ Please Print Levi his Name(HusanessIOrt{antratianfindnidual): 4/�yi.M IAnikesJ'/� 't ay0 -7/6l�r!/[•elG,(Nf 1" 7,et_ Address: LiU e _ vci // Lg./ l City/State/Zip: F6)rem(l1 471 0/042 Phone#: y/3- 32 — 96G 9 Are yor employer?Cheek the appropriate box: 'I'ype of project(required): 1 I ant a 4.711710e»cT with employees(full and part-time).• 7. 0 New construction 2.0 I am a sok pruprictor or partnership and have nu employees working forme in 8. odelitlg any capacity.No workers'swop.insurancena aired] �' 9. 0 Demolition ICJ lam a homeowner doing all work myself.[No workers'cutup.iiwuran c required.]' I 0 Building addition 4.Q 1 am a homeowner and will be hiring emu-actors to conduct all work on my property. I will ensure that all contractors either hate workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 50 I dill a urncral contractor and 1 has c hired the sub-contractors listed on the attached sheet. 130 RWf repairs w u These b-cuntraora hate cmpluyces and hate workers'comp.insurance.; p 6.0 Wean:a c moratiun and its officers have exercised their nghi of exemption per MCjL e. 14.flOther 152,§1(41,and we has.:no employees.[No workers'comp.insurance requircd.l •Any applicant that chnika box al mint also till out the section.below show ins,their workers'compensation policy information. r Homeowners who submit this attuhrrit indicating they are doing all work and then hire outside contractors mint subnut a new affidavit indicating such. :Contractors that check this box must attached an additional sheet show ing the name of the sub-contractors and state whether or nut those entities lime empluycc-s. if the sub-contractors hat.enriploy ecs.they nosh pro%idc their workers'camp.policy number. I ant con employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ ,fin �^ Insurance Company Name: A3 I'' 1 t/� t k 1" .tI h,Sspy.,c CvMf yN . Policy#or Self-ins.Lic. :-: tV GI.3 0Q$Oa 0063 t Expiration Date: /i 7//1&Z,_ Job Site Address: -7 5- 6,r N:L S7 City/Stat&Zip: Airik of ?0 4 G/&C C 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 S I,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 S250.00 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 tender the leans and te.s of perjury that the information pro►'ided above it true and correct. Sit:naturr: v Date: /2- Z S 7 Z. SCC Phone#: t! .(3 3 3 9 Official use only. Do not write in this area,to be completed by city or town official ('its or limn: Pertnitll.icense# Issuing Authorit (circle one): I. Board of Health 2.liuildiii Department 3.City;lu►sn(jerk 4.Electrical Inspector 5. Plumbing Inspector ti.Other ('ontact Person: Phone#: AC�® DATE(MM/DD YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/29/2022 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 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 Sarah Premo NAME: Clayton Insurance Agency, Inc. lac No,Ext) (413)536-0804 FAX No): (413)534-7874 1649 Northampton Street ADDRESS: spremo@claytoninsurance.net INSURER(S) AFFORDING COVERAGE NAIC# Holyoke MA 01040 INSURER A:Safety Insurance Company INSURED INSURERB:AIM Mutual Insurance Company Axiom Landscape And Home Improvement LLC INSURERC: 40 Pine Valley Road INSURERD: INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER:2022 MASTER 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTRINSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE A CLAIMS-MADE X OCCUR PREMISESO(Ea o currrrence) 100,000 BMA0028548 1/11/2022 1/11/2023 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY n PRO I I LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 5907002 1/11/2022 1/11/2023 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $X HIRED AUTOS X AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY 1,/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE n N I A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? B (Mandatory in NH) WCC5005020083 4/17/2022 4/17/2023 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: 75 GOTHIC STREET, NORTHAMPTON, MA 01060 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF NORTHAMPTON THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPT. ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET, #100 NORTHAMPTON, MA 01060 AUTHORIZED REPRESENTATIVE Michael Regan/FMT ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) 7 414 S!x 4)- 7f S 1 IMoo, ),/vo9 i ty . . . ./b 1r .." I -?/9101 i S J 'Name )400 ,,. Vl .-, v? / j/l L `, \ 1)' / .1'd,,i -Ay "7) 4 1'1,5 5-d //irk 7j 1Na41) Jld /vorv/.4y1 • i lie S � 1 i 1 f' I , ,. ,t'Y' ' -i.,q 1191 3 /ty' - }. ,. (44/4, 4 6 U i. ri r, . ! (7 v10\\ A.- `Ii r -1)) 7114' vo '�. j ____-i