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25A-093 (7) BP-2023-0808 22 COOLIDGE AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25A-093-001 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-2023-0808 PERMISSION IS HEREBY GRANTED TO: Project# SIDING 2023 Contractor: License: Est. Cost: 18148 KRIS LARANGE 1 I G300 Const.Class: Exp.Date: Use Group: Owner: BRAZENALL JENNIFER MULLINS Lot Size (sq.ft.) Zoning: URB Applicant: KRIS LARANGE Applicant Address Phone: Insurance: 18 NORTH ST (413)824-0609 GRENFIELD, MA 01301 ISSUED ON: 06/22/2023 TO PERFORM THE FOLLOWING WORK: NEW 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: Fees Paid: $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner Ilia ill /, The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR l Massachusetts State Building Code, 780 CMR MUNICIPALITY \ 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 Building Permit Number: 8P—..3 C�d O b' Date Applied: �. : , 1. I Tptrii Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1,1 Prime Primerly Addren: M-Ct3-OO ssessors Map&Parcel Numbers C1 Li a Is this an aWepted 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: �y Private 0 Zone: _ Outside Flood Zone? Public P Check if yes❑ Municipal 9 On site disposal system 0 SECTION 2: PROPERTY� \ OWNERSHIP' 2.1 Own*of Record: \\ NIN'�\G* \-c)r . r'{ C) O�en � trr d1 rS Qxr,�er,o► .� 0 Name(Print) City,State,ZIP E) (`col'%lie IANa e- NIS)5a-o9/1- jbc,-7p.n.\1� ;�,Cow. No.and Street Telephone Email d ess SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied IV Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units ``Other 0 Specify: tBriiefDescription of Propo Work': V.;y.,00M QXt. �h Si ... � ltvi6Vi �.vbiiveK- rtiOJf 1A-rap 14, `rl�j ll 11f)`1 o.eu V1 t si Ah . �`!! V 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: ❑Standard City/Town Ap lication Fee 2.Electrical $ ❑Total Project Cost'(Ite 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Feelj$ o Check No0\�1 Check Amount: Cash Amount: 6.Total Project Cost: $ ?�1� 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 11 k. A D ,` D e pl S— V, et�E Gvra License Number Expiration Date ame of CSL Ider ' 1 15 �rs� List CSL Type(see below) �J No.and S Type Description c^�w��,,� ,e\ ` \' O`so\ U Unrestricted(Buildings up to 35,000 cu.ft.) 1 l� ` ` R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding ( '� �•' , SF Solid Fuel Burning Appliances jk10►TGt�,Q"��O qY��1 ,CD�^rl I Insulation Telephone D Email-iddress D Demolition 5.2 Registered Home Improvement Contractor(HIC) 'pp 3 Q a p K(-►s l�, G HIC Registration Number Ex irati n Date HIC Corn an ame or HIC egistrant Name Vbi kl Prot,v (Ot a� wx,l ,Co wl and St Erna dress O n es rir o� )1 6113) -cco City/Town, State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AE141DAVIT(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 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 \4f\< ,LA rck to act on my behalf,in all matters relative to work authorized by this building permit application. ..4—.�1 7/ 7/Z3 P Owner's Na ne(Electronic S ature) 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. V-4.-‘G Laa qi(e/Dori Print Owner's or Authorized A nt's Name(Electronic Signature) ate 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" :.Z\ ..___._., The Commonwealth of Massachusetts 1' - = 1 Department of Industrial Accidents r slit_ =ii .-- r. 1 Congress Street,Suite 100 ia= Boston, MA 02114-2017' ` - ~ ww>< mass.gor/dia Ilo kern'('ompt•n.ation Insurance A(iids%it: Builders/('onfractorsInectricianvPlutnbtr.. 10 et.FII.F.b N 1111 1111- 1'F.1ts rum; Vt'TNOW7"1. Applicant Information Please Print Eeiibis Name I Business'(hgnnetation indiviidiial) KPlie L_.qcCvn _ Address: lib N0 Si- City/State/Zip: Gt`,-Ctr .e M1\ 0%501 Phone ,-. till thO(&YEj Are yea nut employ r r.'t heck flu apprupnaie•hot: Type of project(required)_ I.Q I aril a employer with cnysioyres Ilull:ietstin part-timeI• 7. 0 New construction I am a sole proprietor or partnership and hoer no empkweas%inking for cur in91 S. Q Remodeling any capiaert n y (No workers'comp.insurariez rcyurnal_) 30 I am a homeowner doing all Nark myself.[No worker'comp insurance required]' 9. ❑ Demolition Cl4.0 1 am a hones.% and will be humg contractors to conduct all work on my pnrperty_ 1 wit i U Building addition ensure that all contractors either hose workers'compensation insurance or are WIC i I.p Electrical repairs or additions proprietors N ith nu e'mplosees. 12.0 Plumbing repairs or additions S I am a general contractor and I ins a hired the sub-contractors toted on the attached sheet. 13.[J Roof repairs These sub-contractors haw employers and have workers'comp.insurance..- ``_ , i 14.( Other1�iPiO 1 ihA 6.0 we are a corporation and its officers has a exercised thou right kit-exemption per MU c. v l!2.[1i4I.and we base no employees.INo workers'comp.Insurance requited.' •Any applicant that cheeks boys aI must also till out the section below show ing their*utters'eunr)unsatiun policy information t I neusiners Abu submit tlus atidesit indicating they are doing all wort and then Lure outside contractors must suhrmt a new attidas it indicating such. ',Contractors that check thus box must attached an additional sheet showing the name of the sub-contractors and state w hither or not those entities base cniplosec, It the sub-curatractors base employees.th,_ most prosaic thri .+,,rk:r,'sot:ip puhcy nianber. I am an employer that is providing workers'conipe•nsation insurance for my eaiplurees. Beloit'is the polity and job site information. insurance Company Name: I _ Policy#or Self-its. Lic. #: Expiration Date: Job Site Address: ,CitylStateiZip: ___ Attach a copy of the workers'compensation police declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, 425A is a criminal violation punishable by a tine up to S1,500_00 andior one-year imprisonment.as well as civil penalties in the form of a STOPIWORK ORDER and a tine 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 cover et %rrlticalum. I do hereby t rider the pain. d (ties a rjurt'that the information provided a ore is true and correct. swil.auic Dal,:4 cp16aoas Phone ::`mil► t 7d� 0009 Official use only. Do not write in this urea,to be Completed by city or town official ('its or Town: Permit/Licettse!M Issuing Authority (circle one►: I. Board of Health 2. Building Department 3.( its Town('jerk 4. Electrical Inspector 5. Plumbing inspector b. Other ( ontact Person: Phone a: City of Northampton r • Massachusetts t� DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 • ` 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: The debris will be transported by: Name of Hauler: N vrix\ E./1 Si nature of A licant: p_ 1 Date: 6/�� _ g pp ACo® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 06/20/2023 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 Tracey Kuklewicz NAME: A.H. Rist Insurance Agency, Inc. (PAHONNo,Eat): (413)863-4373 FAX No): (413)863-9658 159 Avenue A E-MAIL ADDRESS: P.O.Box 391 INSURERS)AFFORDING COVERAGE NAIC# Turners Falls MA 01376 INSURERA: Main Street America Group INSURED INSURER B: Kris Larange INSURER C: 18 North Street INSURER D: INSURER E: Greenfield MA 01301 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2362004833 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 W LIMITS INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $DAMAGE T 1,000,000 CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence)REN $ 500,000 MED EXP(Any one person) $ 10,000 A MPP5898N 06/04/2023 06/04/2024 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) 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) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 Jennie Brazenall ACCORDANCE WITH THE POLICY PROVISIONS. 22 Coolidge Ave AUTHORIZED REPRESENTATIVE Northampton MA 01060 14.11044 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD