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17C-283 (11) BP-2022-1166 22 LILLY ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17C-283-001 CITY OF NORTHAMPTON Permit: Demo PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-1166 PERMISSION IS HEREBY GRANTED TO: Project# DEMO Contractor: License: ASSOCIATED BUILDING Est. Cost: 10800 WRECKERS INC 062382 Const.Class: Exp.Date: 10/31/2023 Use Group: Owner: KARKAZIS KATRINA, Lot Size (sq.ft.) Zoning: URB Applicant: ASSOCIATED BUILDING WRECKERS INC Applicant Address Phone: Insurance: 352 ALBANY ST (413)732-3179 WCA154516521 SPRINGFIELD, MA 01105 ISSUED ON: 02/16/2023 TO PERFORM THE FOLLOWING WORK: demo garage/carriage house 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: )1.5TAL 31.44 Fees Paid: $30.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner File #BP-2022-I 166 APPLICANT/CONTACT PERSON:ASSOCIATED BUILDING WRECKERS INC 352 ALBANY ST SPRINGFIELD, MA 01.105(413)732-3179 PROPERTY LOCATION 22 LILLY ST MAP:LOT 17C-283-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $30.00 Type of Construction: demo garage/carriage. house New Construction Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(sec below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay SSG, 9Rlv4ij SV►3141 iit_ (Lo d\CIO C N q1Ji,S) a_ Signa re of BuildingOfficial a Date � Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. / Csi'' ''*- .,...,ri -`,... 7.‘-' 4,,,-,, / ,/ / C4co The Commonwealth of Massachusetts .,. Office of Public Safety and Inspections -I* 'i•114 ' a It A -•-•:),ti--;`341 Massachusetts State Building Code(780 CMR) .... • ' ..11u.-}td4Agfermit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number:.2.).-110Ce Date Applied: Building Official: SECTION 1:LOCATION 22 T. AVenue Nort No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#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 i Repair 0 Alteration 0 Addition 0 Demolition ti(Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy CI 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 0 No lig Brief Description of Proposed Work: r-,1(-!---:,',t.' -:,t,--L,,--"--0:1 Of ciE 1-‹,'--•Itd , , .s.nd foundations. Use water for dust coot rci via I.-- ' ' I oari delyr is out o ABtry Lr al ler s for riisposal a...... 1 i censed :a c.131 r y Leav, graded with onsite so:Lis SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDMON,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) CI 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.) 36, SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 CI Nightclub 0 A-3 0 A-4 0 A-5 C3 B: Business El E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 El H-3 0 H4 0 H-5 0 I: Institutional I-1 CI 1-2 0/I-3 El 14 0 M: Mercantile 0 R: Residential R-ID R-2 0 R-3 0 R-4 0 S: Storage S-1 CI S-2 g, U: Utility El Special Use 0 and please describe below: Special Use Description SECTION 6:CONSTRUCTION TYPE(Check as apylicable) IA 0 IB 0 IIA Cl IIB 0 IIIA Cl IIIB g IV CI VA 0 VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supp y: Flood Zone Information: ".,- Sewage Disposal: Trench Permit Debris Removal: de w Pi Public ICheck if outside Flood Zone Ill" Indicate municipal 0A trench )/1 not be Licensed Disposal Site required 51 or trench or specify .-YeA.±:)9 Private 0 or indentify Zone:_ or on site system 0 permit is enclosed 0 al ' W!,Ihl rout Railroad right-of-wv: Hazards to Air Navigation: MA Historic Commission Review Process Not Applicable.g Is Structure within airport ap7uach area? Is their reetv completed? or Consent to Build enclosed 0 Yes 0 or No Ili Yes ,1114 No 0 SECTIONS: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 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: karicazis@gir:ul.l..corn Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Associated Frui d-rnq Wreccssr•s, Inc. 352 S" , _ng•ti.. _.: MA Oi10-_ 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 . Otherwiseprovide : {see section I O7 in the code as re aired. 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 ASSOC Wceckeys, Inc_ Company Name And CS--362382 Type €ii{; 6,?,969 Name of Person Responsible for Construction License No. and Type if Applicable 352 Albany .: . _ ,z '.rri:se. d Street Address City/Town State Zip - Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:w (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 th_eJ' uance of the building permit. Is a signed Affidavit submitted with this application? Yes® No Cl SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)= 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.TotaI Cost $ (contact municipality)and write check number here 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 knowledge and understanding. ta....,+........N:., Please print and sign name Title Telephone No. Date n S Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: e � #�� 1. jr?._ 3 Name 'v City of Northampton 44. Massachusetts L DEPARTI4ENT OF BUILDING INSPECTIONS it •„ 212 Main Street • Municipal Building ..14 Northampton, MA 01060 1,.frs, is {+" 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: ask:=;rr, The debris will be transported by: Name of Hauler: <. 1<:x� , Signature of Applicant: VI rE I,zc:r�:-:Date: 2/16/202 The Common ittealth of Aln.ssachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114.2017 w►vitnthss.gor/dia 11•40kers'Caranlllensation Insurance Affidavit:BuildersiCuntractarsiElectricians!Ptu,nbers. TO BE I:11.ED Will 711E PE MIT 1'IM;AtIt1ICIRITY. Annlicsnt information Please Print l.t<.+.iblk Name(l3ttst,, ,€ utar,ir tk,„,:wl:,=iduul): Associated Building wreckers, Inc � IAddress:tSS: 3 2�- Albany Street City/State/Zip: Springfield: "A 01105 Phone (413) 732-3179 • Are you tt6 t-utpiuti-r?Chtel the sppetiorlatr but: Type of project(required): . 1 ash a etup :FiT wilts 3 emg:o}' cs(fit l acul'ax pm--t;madt. 7. 0 New Giinstruftk,n ::JD I am a,Litt proprietor on p rtnucsitip and have no etaplsry isY k`irtt inn fur Incin It_ e:noddinf any .eap3eity.[No wtaktn'(iarrey.instintrniv , 4ind.) 9. Demolition 301 ans a ba rsolNm,:doing all wort myself.INu u'urktra'cutup_illateltilttillAptired 4.0 I arh a tw n v+r act. w ell h hi tar aanttactor, xttlt3 x ail week Lin nn pnfleIty. I wit? I0Q Building addition s lien that sip malt-actors eilh a hurt u'orketa't rxJntuSalsaxr issauraa to an:soh: I I Electrical repairs or additions p roptimns x 1 r cs employees, i 2.E3 Plumbing repairs Or ad 1itielrts tun uart.'&ur staJ I h.i+e hired the soh-ettestamdiu.listed:cal tit.attutitid 44X!. j Tlaa c hip vmt --"on ft.c eatploy ee tics!hatc u-wkers':tray+,ivatsraruct. 13.�Rtx>f repairs tt.j it`r aze a cu veraliur and its officers ha-se esa d their rhvins:.f"s ctiniu xs pit bt€it e.. OtliL'i _ .. I(stl.a.-x we hate nu erstploye:s,[Nu wotkera`romp unsoraxix required.) "Any'applicft.t thai c ux:L bsax FL:tnWt titan felt out tiers thou ka lot drat io their wutler,':umia atslo:a policy infcxmatian tl°.neow nee Who sight:Tit thin affidavit indie'alinc thew arc duit p~ail a`tal and then hire o ttsicle etont;s.t:xi mtii.u'nrnit a nets affidavit ittrlianiis€z&nth, €'crrtt-t. a+sttLt e h xx i s s k:a nett::x€ts l f t s l:ii'tiu is SleVI she tt in,,,the name ref the aura-c:itrt:ru:i.ir an;!s ate w6 aJuer as not Ihuu&n1di:-s h tip' 1 out an employer that is presiding worArrs'compensation insurance for my employees. Below is the policy and job site information. itt~tsrance company`ante Great Divide Insurance Co. Policy#ur Self-ins.Lie.#: WCA1545165-22 Expirativrt.Date: 2/1/2024 Job site Address: 22 Lilly Street Cit y:State,''Li . Northampton, 01062 Attach a copy of the workers`tompt°rsa€oo policy declaration page(shots lag the polio aninaLi r and tapirs on date). Failure to severe coverage as requiro i under SiGL e. 152,*2MA is a criminal violation punishable by a fine up to$1,50000 ai tt'or one-year iinprisoornent,as well as civil penaktica in the form ofa STOP WORK ORDER and a fine oftup to$250.00a day against the r,,iolator.A copy of this Statement may be forwarded to the Office of Investigations of the DR for insurance coserage verilicatiori. I do hereby certi''under the pains and penalties of that the Information provided above is true and contort. Fred VanDerhoof, Vice President Sienature Date: Photef<• (173) 732-3179 Official use only. Do nor write in this arena,to be completed by city or town official f City or Town: Permit/License# Issuing Authority(circle trite),' 1.Board of Health 2.Building Department 3.City'fTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone 4: , Commonwealth of Massachusetts Division of Occupational Licensure '` Board of Building Regulations and Standards Constcdelion SW,rvisor CS•062382 51cpires: 10;3112023 ANDREW H MIRKIN p 299 TANGLEWOOD DR LONGMEAD©W MA 01106r, ra Commissioner d Ir1Clr7atd,. Construction Supervisor Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet (991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.govfdpl 44e ',/?//VKI/XKK'KW K' /7,4- K KYIKK-.1(7/4 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Typo; Corporation Registration: 169969 ASSOCIATED BUILDING WRECKERS, INC. Expiration: 08/24/2023 352 ALBANY ST. SPRINGFIELD, MA 01056 Update Address and Return Card. SCA 1 0 20M-0507 .>'1;119fi/C/9nAllPlePfSPAIA:Y8,'WO/MAW-M*3°n HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Of ice of Consumer Affairs and Business Regulation 169969 08/24/2023 0 Washington Street -Suite 710 ASSOCIATED BUILDING V/PECKERS,INC. ost n,MA 02118 ANDREVV H.MIRKIN 352 ALBANY ST. SPRINGFIELD,MA 01056 NoLitiwithout7ignaiu-----re Undersecretary ASSOBUI-01 DKELLEY ,4coRO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `--�' 2/3/2023 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 Denise Kelley, CISR NAME: AssuredPartners New England,Inc. PHONE FAX One Monarch Place,12th Fir (A/c,No,Ext):(413) 327-7517 (A/C,No):(413) 327-7517 Springfield,MA 01144 E-MAIL Denise.Kelley@AssuredPartners.com INSURER(S)AFFORDING COVERAGE j NAIC# INSURER A:Nautilus Insurance Company 17370 INSURED INSURER B:Great Divide Ins.Co. 25224 Associated Building Wreckers,Inc. INSURERC: 352 Albany Street INSURER D: Springfield,MA 01105 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR ECP2031158-13 2/1/2023 2/1/2024 DAMAGE TO RENTED 100,000 X X PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY X PRCOT- LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: E $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE� ONLY AUTOSNO ED BODILYO INJURY(Per accident) $ AUTOS ONLY _ AUTOS ONNLY (PerOacodentDAMAGE A _ UMBRELLA LL4B X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE X X FFX2036791-11 2/1/2023 2/1/2024 AGGREGATE $ 5,000,000 DED RETENTION$ $ B WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE YIN x WCA1545165-22 2/1/2023 2/1/2024 E.L.EACH ACCIDENT $ 1,000,000 MFICER/MEMBEREXCLUDED? N N IA andatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Pollution Liability X X ECP2031158-13 2/1/2023 2/1/2024 See Description Box DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Pollution Liability Limit:Limit Per Occurrence;$1,000,000:Limit Aggregate;$3,000,000 Please be advised the below listed certificate holder is listed as Additional Insured on a Primary and Non-Contributory basis in regards to the General Liability,Pollution Liability,Umbrella(Excess)Liability,and Workers Compensation policies listed above when being required by written contract.Waiver of Subrogation in favor of certificate holder for all above listed policies. Umbrella(Excess)Policy is written on a follow form basis over the above listed General Liability,Pollution Liability,Employers Liability(Workers Compensation),and the Auto Liability with Commerce Insurance,Policy#19MMZP4610. SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main Street Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 7 ?J ,J * d -,,rvi\,:k.30.,• 8= - ate oY ok v1/41 BUILDING DEPARTMENT DEMOLITION PERMIT SIGN-OFF SHEET Date: 2-g-aoacR Address: I J /l t j. f /1(PhC Building Use: G rrer: fIQ igOYCLAA.0 • Afc ' Phone: 536 -- ic?g7 (Nick) eActrOwner's Address: Qciv r UTILITY CUT OFF (Signature of Authorized Representative of Utility Department required) As required by the Massachusetts State Building Code (780 CMR), a permit to demolish shall not be issued until a release from the utilities is obtained, stating that their respective service connections and appurtenant equipment have been removed or sealed and plugged in a safe manner. Eversource (Gas) Signature Title National Grid (Electric) Signature , / Title y DPW (Water) - AUV • Signature o Title .? DPW (Sewer) (- � S tt�Q,Q�..._ b -l8 a2-- Q,t ,ten �jd�, , Signature Title lJ 9 DPW (Storm water b/ g"DD— 6 01Q Signature Titl 0 DPW (Tree Warden) _ 0-1Z9D--- Lux R ignat e Title ' ' DPW Director Si ature Title Historic Comm. Review Signature Title 7-4.(4, ,Q e�c. t— - c &3 —063 ASBESTOS REMOVAL All residential, commercial and institutional buildings are subject to Massachusetts Department of Environmental Protection (MassDEP) asbestos regulations at 310 CMR 7.15. Therefore, owners and/or operators (e.g. building owners, renovation and demolition contractors, plumbing and heating contractors, flooring contractors, etc.) need to determine al asbestos containing materials (AGMs), both friable and non-friable, that are present at the site, and whether or not those materials will be impacted by the proposed work, prior to conducting any renovation or demolition activity. Examples of commonly found ACMs include, but are not limited to, heating system insulation, floor tile and vinyl sheet flooring, mastics, wallboard, joint compound, decorative plasters, window glazing, asbestos containing siding and roofing materials and fireproofing materials. Failure to identify and remove all ACMs prior to its being impacted by renovation or demolition activities, can result in significant penalty exposure, and higher clean-up, decontamination, disposal and monitoring costs. A DOS certified asbestos consultant must be contracted to determine if asbestos is present and whether removal/repair is necessary. If the building is a state owned facility, contact DCAM and DOS. DOS provides a list of licensed asbestos abatement contractors and consultants. You may wish to inquire if a contractor has any history of violations. Only DoS licensed and DOS certified asbestos abatement contractors and consultants may be hired to perform asbestos related work in Massachusetts. Received by: Edward Nowak#15386 Owner Print Name Title Please see attached signed testing documents and report from Jees Enviromental - DOS Certified Signature Date tiff e u rof i n s EMLab P&K Report for: Ed Nowak JEES 22 Park Rd Charlton, MA 01507 Regarding: Project: Kashazis; Home Remodeling EML ID: 3002150 Approved by: Dates of Analysis: Asbestos PLM: 08-12-2022 Approved Signatory Renee Luna-Trepczynski Service SOPs:Asbestos PLM (EPA 40CFR App E to Sub E of Part 763&EPA METHOD 600/R-93-116, SOP EM-AS-S-1267) NVLAP Lab Code 500031-0 All samples were received in acceptable condition unless noted in the Report Comments portion in the body of the report.The results relate only to the samples as received and tested.The results include an inherent uncertainty of measurement associated with estimating percentages by polarized light microscopy. Measurement uncertainty data for sample results with >1%,asbestos concentration can be provided when requested. Eurofins EMLab P&K("the Company")shall have no liability to the client or the client's customer with respect to decisions or recommendations made, actions taken or courses of conduct implemented by either the client or the client's customer as a result of or based upon the Test Results. In no event shall the Company be liable to the client with respect to the Test Results except for the Company's own willful misconduct or gross negligence nor shall the Company be liable for incidental or consequential damages or lost profits or revenues to the fullest extent such liability may be disclaimed by law,even if the Company has been advised of the possibility of such damages, lost profits or lost revenues. In no event shall the Company's liability with respect to the Test Results exceed the amount paid to the Company by the client therefor. Eurofins Aerotech Built Environment Testing,Inc.an affiliate of Eurofins EPK Built Environment Testing,LLC d/b/a Eurofins EMLab P&K EMLab ID: 3002150, Page 1 of 3 Eurofins EMLab P&K 1501 West Knudsen Drive,Phoenix,AZ 85027 (800) 651-4802 Fax(623) 780-7695 www.emlab.com Client: JEES Date of Sampling: 08-10-2022 CIO: Ed Nowak Date of Receipt: 08-12-2022 Re: Kashazis; Home Remodeling Date of Report: 08-15-2022 ASBESTOS PLM REPORT Total Samples Submitted: 8 Total Samples Analyzed: 8 Total Samples with Layer Asbestos Content> 1%: 0 Location: NW-WC-1,Cottage Window Caulking Lab ID-Version$:14449254-1 Sample Layers Asbestos Content White Caulk with Multilayered Paint ND Composite Non-Asbestos Content: < 1%Cellulose Sample Composite Homogeneity: Good Location: NW-WC-2,Cottage Window Caulking Lab ID-Version$:14449255-1 Sample Layers Asbestos Content White Caulk with Multilayered Paint ND Composite Non-Asbestos Content: < 1%Cellulose Sample Composite Homogeneity: Good Location: NW-FT-3,Closet White Blue VAT ( (3a```) Lab ID-Version$:14449256-1 Sample Layers Asbestos Content Off-White Floor Tile < 1%Chrysotile Black Mastic ND Sample Composite Homogeneity: Moderate Location: NW-FT-4,Closet White Blue VAT (NoT I,oc.a.4.e 9. : ‘36.rn) Lab ID-Version$:14449257-1 Sample Layers Asbestos Content Off-White Floor Tile < 1%Chrysotile Black Mastic ND Sample Composite Homogeneity: Moderate The test report shall not be reproduced except in full,without written approval of the laboratory.The report must not be used by the client to claim product certification,approval,or endorsement by any agency of the federal government.Eurofms EMLab P&K reserves the right to dispose of all samples after a period of thirty(30)days,according to all state and federal guidelines,unless otherwise specified. Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually.ND means no fibers were det ted.When detected,the minimum detection and reporting limit is less than 1%unless point counting is performed.Floor tile samples may contain large amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to low r the detection limit and to aid in asbestos identification. $A"Version"indicated by-"x"after the Lab ID#with a value greater than 1 indicates a sample with amended data. The revisi n number is reflected by the value of"x". Eurofins Aerotech Built Environment Testing,Inc.an affiliate of Eurofins EPK Built Environment Testing,LLC d/b/a Eurofins EMLab P&K EMLab ID:30 2150,Page 2 of 3 Eurofins MLab P&K 1501 West Knudsen Drive, Phoe ix,AZ 85027 (800) 651-4802 Fax(623) 780-7695 .emlab.com Client: JEES Date of Sampling: 08-10-2022 C/O: Ed Nowak Date of Receipt: 08-12-2022 Re: Kashazis; Home Remodeling Date of Report: 08-15-2022 ASBESTOS PLM REPORT Location: NW-LI-3,New Bathroom Flooring (tvoT 10(4+-'Ni- 15a e'Ps) Lab ID-Version$: 14449258-1 Sample Layers Asbestos Content Beige Linoleum with Felt Backing ND Composite Non-Asbestos Content: 30%Cellulose Sample Composite Homogeneity: Good Location: NW-LI-4,New Bathroom Flooring (Na T (c Gu-4—t-C 1 v` �""v1' Lab ID-Version$:14449259-1 Sample Layers Asbestos Content Beige Linoleum with Felt Backing ND Composite Non-Asbestos Content: 30%Cellulose Sample Composite Homogeneity: Good Location: -ARIMPIIMMage Wall Wallboard Lab ID-Version$: 14449260-1 Sample Layers Asbestos Content Brown Fibrous Material ND Composite Non-Asbestos Content: 99%Cellulose Sample Composite Homogeneity: Good Location: N W-WB-4,Garage Wall Wallboard Lab iD-Version-I: 1444926I-1 Sample Layers Asbestos Content Brown Fibrous Material ND Composite Non-Asbestos Content: 99%Cellulose Sample Composite Homogeneity: Good The test report shall not be reproduced except in full,without written approval of the laboratory.The report must not be used b the client to claim product certification,approval,or endorsement by any agency of the federal government.Eurofins EMLab P&K reserves the right to dispose of all samples after a period of thirty(30)days,according to all state and federal guidelines,unless otherwise specified. Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually.ND means no fibers were dete ted.When detected,the minimum detection and reporting limit is less than 1%unless point counting is performed.Floor tile samples may ontain large amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lows the detection limit and to aid in asbestos identification. $A"Version"indicated by-"x"after the Lab ID#with a value greater than 1 indicates a sample with amended data. The revisi•n number is reflected by the value of"x". Eurofins Aerotech Built Environment Testing,Inc.an affiliate of Eurofins EPK Built Environment Testing,LLC d/b/a Eurofins EMLab P&K EMLab ID:3010 150,Page 3 of 3 CHAIN OF CUSTODY ti,eurofins WEATHER IFca heal Snow wLalCrar ""` WLVW.EMLabPK.cnm EMlab P&FS _, Lighht-Nne= -!. - ' Non.Cuhunbte Ir �����(������� :.�� li.ii Marlton,NJ:3000 Lincoln Dr E.Sta.A,Marlton,NJ 08053"(868)871-1984 Moderate ; Spore Tapa, O O 3OO Z 1 S O �t* Phoenix,AZ:1501 West Knudsen Drive.Phoenix.AZ 85021'(800)6514602 Heavy _ Trap Swill,.Bulk SSF,CA:6000 Shoreline CL Ste.205,S.San Francisco.CA 94080'(868)888-6653 CONTACT INFORMATION Com LEES(I 5386) dm�.22 Park Rd Chariton,MA 01307 i I F Contact Ed'Nowak _.—.,..�..__.._.... _- _- t y� Speciallnstuclions -""ti'10 ��3\:, Nl rr �) I g P„..., 5CHF523 5923 a1 PROJECT INFORMATION TURN AROUND TIME CODES-(TAT) g . E a C STD-Standard(Default) Rushes rocerved aflor 2 m 1l Ni 11 Pro ec or on weekends,will be E u nm yslkm, L1\ \ - ND-Next liusinese Day considered received the 9 1 ' i - + g I 1 $ IIr��� w S $ Ptux41 �� ,„1 1 1\ SD-Same Business Day next buslnets day.Please a,, a § a3 a ui i I I oPONurnbe i yl, .'y Ey: `. 1jtyy{�+ WWeekandlHolidaylASAP weds. a• .I 4 - a %, ,o 4 I Sample Total 7f 1 A O 6y s i( dam-. TAT Nfl7ES aix G a SAMPLE ID DESCRIPTION T Votume4Area 5 $ia ■ �$ Below) (� 1 (as a ,Ncable) (time or tlay,Temp,RH,sh.) w O 8 8 d' u 12 o( y 2 ] i d 4. "'' . It I .. 111 i 1.A IR NAI1 [�i. I • _____ _ _ 1 SAMPLE TYPE CODES RELINQUISHED BY DATE&TIME �\ RECEIVED BY DATE&TIME BC-BinCassette� CP-Contact Plata T-TB --_.„O.Othen t `\' `� J l j[;u l. 4-v-t r� 'y`\1{'tom. Al S-Andersen ST-SpweTrap SW•Swab :1 r .. , SAS-Surface Air Sampler B-Bulk SO-Soil er50 of NP-Non-potable Water „P-Potable Water 0-Dust ;,• "^,- CITY OF NORTHAMPTON, MASSACHUSETTS PENDING APPROVAL 2 DEPARTMENT OF PUBLIC WORKS 22 LILLY STREET ,� ��-!4j 125 Locust Street . .� �" Northampton, MA 01060 Trench Permit Number: 2023-063 413-587-1570leci• "- Fax 413-587-15T6 Date Approved: f'j Z � �. Expiration Date: I( 'for Citv Use Only) EXCAVATION/TRENCH PERMIT Pursuant to G.L.c. 82A and 520 CMR 14.00 et seq.(as amended) This permit must be fully completed prior to consideration. Submit completed form with permit fee to Northampton Department of Public Works, 125 Locust Street,Northampton, MA 01060. This permit is issued under the provisions of M.G.L.c. 82A, 520 CMR 14.00 and applicable sections of the Revised Ordinances of the City of Northampton, including,but not limited to, Section 285-21. Fee: $250 Check#:63813 Date Issued:8/22/2022 Name of Applicant Primary Phone# WRIGHT BUILDERS 413-586-8287 Street Address Emergency Phone # 48 BATES STREET 413-923-2870 NICK City/Town State Zip Email NORTHAMPTON MA 01060 nwright@wrightbuilders.com Name of Excavator Primary Phone# ASSOCIATED BUILDING WRECKERS 413-732-3179 Street Address Emergency Phone# 352 ALBANY STREET City/Town State Zip Email SPRINGFIELD MA 01005 Name of Property Owner(s) Primary Phone# KATRINA KARKAZIS 415-810-8481 Street Address Emergency Phone# 22 LILLY STREET City/Town State Zip Email NORTHAMPTON MA 01060 Insurance Certificate# Policy Expiration Date ON FILE Name&Contact Information of Insurer ON FILE Dig Safe#& Start Date from Dig Safe Ticket: 2022-330-8521 .�vl - �r€ - aq 9 ii !z Project Description/Location of Work. Provide the following: ® Description of purpose and exact location of proposed work including description of what is to be laid or repaired in the proposed trench (e.g. water pipe, sewer pipe, drain pipe, gas line, power line, communication lines, etc.) ® Sketch or drawing showing all proposed work. ®Anticipated Start of Work Date. Description: 22 LILLY STREET DEMOLITION OF EXISTING BARN/CARRIAGE HOUSE EXCAVATING SLAB- UNDERGROUND CONCRETE NO OTHER TRENCHING/JUST DEMO Check if applicable: El Emergency ® Work on Private Property ❑ Work in Public Right of Way ❑ W• ork within State Layout(attach State Permit) ❑ Work within 50' of a Public Shade Tree(see attached Public Shade Tree Regulations) ❑ Tree removal required(see attached Public Shade Tree Regulations) ❑ Tree protection,trimming, or root pruning required(see attached Public Shade Tree Regulations) ❑ W• ork within 100' of a wetland or 200 Ft.of a stream or river (attach Permit) ❑ Work within floodplain (attach permit) ❑ Public Water/Sewer/Drain Entry Permit(attach permit, if available) ❑ Driveway Permit(attach permit, if available) ❑ Pole and Wire Petition(attach approval) Pg.2/4 To be completed when approved permit is picked up. By signing below,the applicant acknowledges and agrees to all the conditions of approval stated below and validates this permit. f//177-e Applicant Date For CitY Use—Do not write in this section Department Approvals/Comment Water: 8/22/2022 Sewer/Storm Drain: 8/29/2022 FPC: 9/8/2022 Streets: 8/29/2022 Traffic Signals: 8/22/2022 Subject to 5-yr. pavement moratorium Road last paved: 2003 ❑ Special Conditions: _ Fee ® $250 Permit Application received(Check payable to the City of Northampton) ❑ Waived. Reason: ['Tree mitigation: Permit Ap : '1 f - Director of Public Works Date Pg.4/4 id take a ride by the site and from what I could tell there is no power to the garage behind 2. Unfortunately, the clearance for no power will have to come from the local wire inspector .. as any garages/barns are fed from the house panel. ?ase reach out to Roger Malo for this letter a a.jasinski@nationalgrid.com CITY of NORTHAMPTON c, �''`� PUBLIC HEALTH DEPARTMENT (24• Public Health Director Memdith O'Leary, RS !� Municipal Building• 212 Main Street Northampton,MA 01060 - Phone(013)587-12/4 Far(413)587-I221 Pabliclitalth http:/www northamptonma.gov/245'Health Prevost.Proem helm WITNESS OF EXTERMINATION Dale .2- i- - )- 3 Time /�y /t't Property Owner: Property Address: J .) Lr/t(/ C! ,-(Q/MCe _,l/(,r el IQ G Exterminator: cC/4,4.-�r1 ALtc, p t; Company: Hdre Ace /30.. i .Ci /.. >-'a.---, Company Address: 6 f C!1l.r3 ,CT/,ze L /7"treerCt At CI r) ,d')t.J Rodenticide/Chemicals Applied 2-r,t,G� /2 1¢G(� t 00 r A 3ro i41 FGto Li 44 P 1)1/4/51— Reason for Extermination: Q,61 tQ1/a u_p 0 ,i`]L h f 7 a 4 611 Ii—C r1/ (JJ ht.,S'71 Q—_ / RN (IAy 2rtd 1 CAS..- p la-s f-- t Pc'Ss d lI e rel.'4-4-- '2-1 Pl'sf-r it/ Comments: / IT U. f- ��,TL-1 t— 1..., - ///�{ { //( f r'i&..[� Wi't-i-Y i/I1 (��{'-7 4,4 - .17- )-3 / ,..?-0 to ck I hereby certify,under the pains and penalties of perjury,that Ito the best of my knowledge and belief,have applied the above noted pesticide in accordance with M.G.L.Chapter 132B and any other applicable law or regulation. ❑City Water ❑Well 0 Septic System If applicable DYes 0 No Board of He h Representative Si nature of E minator *Demolition best practices relating to fugitive dust and debris must be adhered to in accordance with MGL Chapter l 11,Section 122. 1401 ,1: l c s \) Q czVI<T- File #BP-2022-1166 c/)9/ ()I . APPLICANT/CONTACT PERSON:WRIGHT BUILDERS 48 Bates St NORTHAMPTON, MA 01060413586-8287 PROPERTY LOCATION 22 LILLY ST MAP:LOT 17C-283-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Perm' ' -d out Fee Paid 30.00 Type of l ons - ion: demo garage/carriage house New Construction Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved )( Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Perm it With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed XOther Permits Required: Curb Cut from DPW Water Availability SewerAvailability Septic Approval Board of Health Well Water Potability Board of Hea lth Permit from Conservation Commission Permit from CB Architecture Committee X Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay • Q t Si: ature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission,Department of public works and other applicable permit granting authorities. • * Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. r hf / / ems cv, thdrr?J `_- _ - gym ,Job Th Commonwealth of Massachusetts oard f Building Regulations and Standards FOR assa husetts State Building Code, 780 CMR MUNICIPALI SEP USE 1i1 ri ermi App cation To Construct,Repair,Renovate Or Demolish a Revised Mar 20 1 One-or Two-Family Dwelling i OF Still DING INSPECTIONS This Section For Official Use Only "."111T1 IA\1,70N.MA 0 tOo0 Building Permit Nranbci. Q v /U(i Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 22 Lilly Street Florence, MA 01062 17C 283-001 1.la Is this an accepted street?yes x no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: URB Return area to grass 10,890 SF.25 Acres 82.5' 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 50' 82.5' 4' 10' 20' 32' 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Di Private 0 _Zone: Outside Flood Zone? Municipal IE On site disposal system Cl Check if yes® SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Katrina Karkazis Florence,MA 01062 Name(Print) City,State,ZIP 22 Lilly Street 415-810-8481 karkazistaymail.com No.and Street Telephone Email Address New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition ❑ Demolition ID Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': Demolition of the garage/carriage house on back of property.There will be no new structure in its place.Only the carriage house/garage. 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 $ ElStandard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: 22 Check No. ikkheck Amount: "/�., ° Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: Demo Permit Fee - $30.00 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-065521 1/25/2024 Steven Barrett License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 97 Federal Street PO Box 503 No.and Street Type Description Belchertown,MA 01007 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances (413)586-8287 sbarrett@wright-builders.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 101536 6/25/2024 Wright Builders, Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 48 Bates Street nwright(a).wright-builders.com No.and Street Email address Northampton,MA 010R(1 (413)586-8287 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 l No ❑ 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 Wright Builders Inc to act on my behalf,in all ers relative to work authorized by this building permit application. Katrina Karkazis 9/'-/le 2- Print Owner's Name(Ele onic S. ) Date SECT N 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 to to the best of my knowledge and understanding. Wright Builders Inc y/r/2p Z2 Print Owner's or Authorized A s Name tectonic 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.)_ 840 SF (including garage,fmished basement/attics, decks or porch) Gross living area(sq.ft.) 0 Habitable room count 0 Number of fireplaces 0 Number of bedrooms 0 Number of bathrooms 0 Number of half/baths 0 Type of heating system 0 Number of decks/porches 0 Type of cooling system 0 Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Demo Permit Fee$30.00 City of Northampton Massachusetts *x- %. At t ;t � DEPARTMENT OF BUILDING INSPECTIONS yJ Dx- arelt ` t ' 212 Main Street • Municipal Building Northampton, MA 01060 �sph, 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: 686 Main Street Holyoke MA OR Valley Recycling 234 Easthampton Road Northampton MA The debris will be transported by: Name of Hauler: J&J Trucking OR Associated Building Wreckers Signature of Applicant: Nicholas Wright Date: 8/8/2022 The Commonwealth of M1�assaehusetts jr Department of Industrial Accidents ,.1,,,,. f4� I Congress Street,Suite 100 Boston,AL-I 02114-20'17 r www.mass.gov/din I1 o/kers'('umpensatiun Insurance Affidavit:Builders'ContractursfEkctricians/Plurnbers. TO BE 111.E1 N1 ii ii'111IE PERMIITING AI!'l IIOR l't. Autwlicant Information Please Print I.eeibh Name Iliwanc i)rganiaationlndn du:alp:: Wright Builders Inc Address: 48 Bates Street City/StatettZip: Northampton, MA 01060 Phone#: (413)586-8287 Art?ea an tinplin re Check the appropriate bon: Type of project(required): 1.©I am a early..ct V.iiti 23 catgrk+►res Ititll:and car part-titnc'I.' 7. 0 New construction '.D lam a sole pcvprteatm.or rattier ship and luxe mi eratploneis workinm Ilm one is 8. Q Remodeling aan.apacaty.[\v.µ orlier.'.tmrtp.insurance ntiluired..l �J 9. El Demolition 3.D I am a Itunos'a onor idoin'-1"all oscii&rnoscli.(Ni thotl..rs"a unfit.insurance nxl7titra�l t 10 0 Building addition .1.1:1 lam a ltonovxanen and xs ill trc lining tvrncniun ill,lVeltilliet all wank on no ptorvas.. I will •nature that all.wntruiurs citlu.t hall C wwiLt-n"cuagirnantkat insurance av axe sole I I.a Electrical repairs or additions proprietor,w itlo no eanplcotia.s. 12.0 Plumbing impairs or additions 1'el1 ant a ntenoral contractor and I has.:hired the sub-cuntnai tarn listed on theattached slktimt.. 13 Roof repairs s__ these sub-contractor..lone ctnplun,ccs and have µ Oilers'comp.uuutan...: 14.D Other 6.11 Vi i..are a m.p.h..and its'officer.haxc exercised tl ain nt It ut.xenptatmt per S,1(iil-c. 1522.lI(4)ainlaClla.:Cal.Ntr}lunian.No w'urlvea] comp.insurance reyWn.41.1 'Any applicant don clrnelu Lox.I nnunt also fill out Cite s.etiaat t!cloxm shoo.inn their Murl.si i.nmpernation policy iadnaanation_ +litwncowncr.also Sabo a this attida,it ittdicaviun the.are dnintr all wort and Bonn hire outside.avttracturrs mint sahntit a rc s aftlidas it indicaiine such. lC"unts-actor.that ALA inns bon inert atia.laat an additional slo+.t slxrw inn doe name oldie sult~cvmtlra..tocs and state v.holh.r 4-XI not base.units..-.Lase cnnplovecs._ lithe sulreorutracttms lino..nrgelosees.they must ptt+sid.their workers"svanp.totli.M:norther.. I am an enrplvt'er that is providing ororbers"compensation insurance for emir'employees.es. Below is the policy and job site in firrmottion. In--.wane Company Name: A.I.M Mutual Ins Co _ Pt.-hey#or Self-iris.Lie.#: 1 MCC-200-2000534-2021A Expiration Date: 3/1/2023 Job Sore Address: 22 Lilly Street �€nrj .- r- I)d M +' `l) City Stat&Zip: Florence MA 01062 Attach a copy of the workers"compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under NIGL 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 jinn of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement tint,, be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certlfj•ander the pains and pearrrititts of 1'that the information provided above is true and correct Signature: Nicholas Wright 9/ 2�z iy l..: 8/8/2022 Phone#: (413)586 8287 Official ir-.c onit`. Do not write in this area,to he completed by city or mart official_ ("it". or 1 casta: Perniitoticense At Issuing.ltatliuril\ Icirclu ont-): I. Hoard of IIC.tlth 2. liuildiut,;t Department 3.('itr Fun it Clerk 4.Electrical Inspector 5.Pluutltini Inspector is.Other ('Canino Person: Phone#: