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43-009 (5) BP-2023-0176 123 WESTHAMPTON RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 43-009-001 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-2023-0176 PERMISSION IS HEREBY GRANTED TO: Project# WINDOWS/SIDING 2023 Contractor: License: Est. Cost: 44000 MAJOR HOME IMPROVEMENTS Const.Class: Exp.Date: Use Group: Owner: S DONNELLY BRIAN F&MARINA Lot Size (sq.ft.) Zoning: WSP Applicant: MAJOR HOME IMPROVEMENTS Applicant Address Phone: Insurance: 22 VERONA ST WS470076 WESTFIELD, MA 01085 ISSUED ON: 02/15/2023 TO PERFORM THE FOLLOWING WORK: WINDOWS AND SIDING 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: t Fees Paid: $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner f -----!-”4 The Commonwealth of Massachusetts / Board of Building Regulations and Standa1ds FOR W Massachusetts State Building Code,1180 QMR�EB ' 3 2D MUNICIPALITY USE Building Permit Application To Construct, Repair`Re n Demolish a levised Mar 2011 One-or Two-Family Dwelling- Afr�°T aUur,„A,� r This Section For Official Use Only �����• �or''4livq or�TroN Building Permit Number: 80- .?3-/ 7 e Date Applied: Building •.9. •-dbil )5 a3 Official(Print Name) Signature --� Ddte g SECTION 1: SITE INFORMATION 1.1 Property Ad r ss: 1.2 Assessors Map&Parcel Number id 3 w.eJttt a.r�y� - gel . y 1.1 a 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) 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 disposals stem 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Pr-Lax- bnivueit i r etvun u RA r7/o 6 Name(Print) 00ity,State,ZIP / 3 w IJ eg p d (Oco(Y)a1 ?- 61-,S)3 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building Er. PTOwner-Occupied Er Repairs(s) ir Alteration(s) 0 Addition ❑ Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': a (e /,) Vj f ,, (4/1rh(i_C S . (A)i/'1 LSO-LC 7 l) . , 0 r,E ell - a J i r1--'rS on -e_et L/ l , SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 4 t f, 000 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: }� ' Check No. heck Amoun`i\\a) Cash Amount: 6.Total Project Cost: $ /ttir c.�-�, 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder V / HA ' , )�S J/�) List CSL Type(see below) No.and Street 1 Type Description /)„ �/ c e / av2e) U Unrestricted(Buildings up to 35,000 cu.ft.) JlJ U T Lam[ Q R Restricted 1&2 Family Dwelling City/Town, tate,ZIP M Masonry RC Roofing Covering WS Window and Siding �/�.) 2 _��4� SF Solid Fuel Burning Appliances j?1 l `l(�}L�Q� Cc�C�) C YK- I Insulation Telephone Email addr ss D Demolition 5.2 Registered Home Improvement Contractor(HIC) /SID / 41 :7Q-/ 7 3/11/ 7r S HIC Registration Number Expiration ate HIC C my Name HIC Reg'st 7 e ot f No•�ndSStie_eq ` / Email ad ress f'V.E� 1�/�iC PiCOI �l�( rc�((((..4 36 cx-t� 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 of the building permit. Signed Affidavit Attached? Yes 8' No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 6/al) I / L �` UA J-c to act on my behalf,in all matters relative to work authorized by this building permit application. / 0/14 _3 Print Owner's Name(Electronic Sign re) 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. (Yo 1/L ke,(1.11a4J141(-- 02/9 ,/0 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 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 a1cHAMe poi oti= Massachusetts it I DEPARTMENT OF BUILDING INSPECTIONS +r 212 Main Street • Municipal Building �Jy. Oar Northampton, MA 01060 .rs.y -..:goo' 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: 7)2/1ski, C J) /ed- The debris will be transported by: Name of Hauler: ( , A Ha.c.d.c.'L I / cLcz V Signature of Applican /. ��� Date: .7 — The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �t I= ' Lafayette City Center C i _ 2 Aven ue de Lafayette, Boston,MA 02111-1750 .: www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information f y Please Print Legibly Name (Business/Organization/Individual): f l_ g- . /`l 3/12_F Address: J (/. /iA Dfl a (fiLe,ti City/State/Zip: (ku I e.-Icl l owl—Phone #: 4`1 3 G 3 - 6v(--(- Are you an employer? Check the appropriat box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El 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. ❑ Demolition workingfor me in anycapacity. employees and have workers' P tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13 Other j2v 1l Gc� S comp. insurance required.] d_iL *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Cl t 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 entiti,ts 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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 2 9- 3 Phone#: 4( — 6 3 6 6 Official use ly. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): 1❑Board of Health 2❑Building Department 3,111City/Town Clerk 4.❑Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: I AFRO® CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H 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 Neill&Neill Insurance Agency Inc NA c°IAE: David R Jarry 662 Riverdale Street PHONE 413 732-4137 FAX wc.Ne,Ertl: 1IAA:,No):413-731-6629 West Springfield,MA 01089 EawL dj@neillandneill.com *mos: INSURER(S)AFFORDING COVERAGE NAIC I INSURER A: Nautilus Insurance Company 17370 INSURED Milet, Inc. Liberty M Major Home Improvements INSURERS: Ity utuaf Insurance Company043 22 Verona Street INSURER C: Westfield,MA 01085 INSURER D: INSURER E: { 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 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. LTR TYPE OF INSURANCE INSOL WVD POLICY NUMBER (R �DCY DMYYFY) R�WDD YYYYYY) LIMITS A ✓COMMERCIAL GENERAL LIABILITY NN1398696 04/28/2022 b4/28/2023 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea oavrrerlp) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n!Er- f I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUiOYOBILE �, COMBINED SINGLE LIMIT $ (Ea acddent) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY _AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY __AUTOS ONLY (Per accident) $ ' I UMBRELLA LLU3 OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WC5-31S-360160 06/09/2022 06/09/2023 I STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE Y NIA E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) El.DISEASE-EA EMPLOYEE $ 1���� If yes describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ • I DESCRIPTION OF OPERATIONS/LOCATIONS/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 bci:L.4.:JR4_,Els=, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aff4atV Business Regulation 1000 Washing -Suite 710 Bosto —••• _ •• 1,118 Home Im ro �,:r�� �e istration en j�� rw _cV " Type: Individual -0 Y��"�':e.- ation: 150841 VASILIE KUKHARCHUK r" E 6 ation: 05/03/2024 D/B/A MAJOR HOME IMPROVEMENTS ttitai>< & �� 19 HUNTERS SLOPE is • �� w( WESTFIELD,MA 01085 i :� !1m z/ Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer A &Business Regulation Registration valid for individual use only before the HOME IMPROV ONTRACTOR expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 --74_t=- Boston,MA 02118 1m. 5 VASILIE KUKHARCH ..__;, I �,.- 0/B/A MAJOR HOMS)A v ,_ / 0 VASILIE KUKHARCHU ?:. �? [__._—_.._. - i 19 HUNTERS SLOPE i< e.,,,,,K� 2,GGtsk' WESTFIELD,MA 01085.- Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Constoleil6n(S ervisor J .y CS-103054 z' r y. f ilpires: 08/24/2024 VASILIE M KE}KHARCHUK L' 19 HUNTERSrSLOPE a: WESTFIELD MA 01085 , `• Y rE-. ' O� ''Uf.Lvdil33 Commissioner n�a �' i7 , firn I0,,• P STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION HOME IMPROVEMENT CONTRACTOR VASILIE KUKHARCHUK 22 Verona St Westfield,MA 01085 MAJOR HOME IMPROVEMENTS Registration# Effective Expiration HIC.0611632 12/01/2021 03/31/2023 SIGNED