22B-043 (37) BP-2023-0824
296 NONOTUCK ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
22B-043-001 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-2023-0824 PERMISSION IS HEREBY GRANTED TO:
Project# PARTITIONS 2023 Contractor: License:
LIVEWELL HOME IMPROVEMENT
Est. Cost: 5000 LLC 109600
Const.Class: Exp.Date: 10/19/2023
Use Group: Owner: NONOTUCK MILL LLC
Lot Size (sq.ft.)
Zoning: OI/WP Applicant: LIVEWELL HOME IMPROVEMENT LLC
Applicant Address Phone: Insurance:
33 LAUREL MOUNTAIN RD (413)409-2929 WCC-500-5024695-2023
WEST WHATELY, MA 01039-9604
ISSUED ON: 06/22/2023
TO PERFORM THE FOLLOWING WORK:
BUILD NON STRUCTURAL CUBICAL PARTITIONS
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:
r �
Fees Paid: $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
RECE!VEO
AN 2
y
The Commonwealth o Mass:ch
E Office of Public Safety nd Insp: tiontrPr OP BUILDING tNSP
Massachusetts State Buildin Code(780 • - NORTHAmprON, BCT►ONs
Building Permit Application for any Building of er than a One-or Two-Fame M:oiq'i'1
(This Section For Official Use Only)
rq�
Building Permit Number:1;{4 - OG•'1 Date Applied: Building Official:
SECTION 1:LOCATION
)c*jG Nnno fuck 51" F10 v'ce, MA 0 [Obi Non011Ck ' i It
No Rdgtreet C'ty/1 �o 1 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 Building2it Repair 0 Alteration It Addition 0 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 No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No
Brief Description of Proposed Work: Q v i to VI o n 5)(G/Civ Wq I cubical 'G Y 7 j f j ON 5
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 GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub 0 A-3 ❑ A-4❑ A-5❑ B: Business 0 E: Educational ❑
F: Factory F-1 0 F2 0 H: High Hazard H-1 0' H-2 0 H-3 0 H-4❑ H-5❑
I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-ID R-2 0 R-3 0 R-4❑
S: Storage S-1 0 S-2❑ U: Utility 0 Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB ❑ IIA 0 IIB 0 IIIA ❑ IIIB 0 IV 0 VA CI VB 0
SEC PION 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:
Public 91 Check if outside Flood Zone Indicate municipal!' A trench will not be Licensed Disposal Site if
required or trench or specify:
Private 0 or indentify Zone: or on site system 0
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach a-ea? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Constructor
Does the building contain an Sprinkler System?: tt.5 Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
lme and Address of Property Owner
Joseph Koc h apshl ( 13 L-• hiciiINS't to5f ht,yn frfol,, 1144 a I 7
Name(Pr t) No.and Street City/Town Zip
Property Owner Contact Information:
Oc ) nor - - 9LL-563- joeko('ha 5k; ( x0 00.cv►))
Title Telephone No.(business) Telephone No. (c ll) e-mail address
If applicable,the property owner hereby authorizes:
Name Street Address ity/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❑.
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 ip Discipline Expiration Date
10.2 General Contractor ;`
LjJkA/-Ptl E-fo 0 . 1-w) .iO4eV✓1e,t
Company Name
K.Pvi0 Schnell CS -- 104 6q0
Name of Person Responsible for Construction License No. d Type if Applicable
33 (oIUv'e1 /1/1pvn1gin POI (iti h°1341 ft"144 0 /03,
Street Address 913-q 0(/)q7_q City/ToOn State Zip
I I iH42, 0CL ce a//vD, PII k,vr1e 071 p ovevAlo tCQ✓n
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORIcERS'CQMPENSATION TNSURANCF.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 thej denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and
Materials) Total Constructio Cost(from Item 6)=$
"l W
1.Building $ v Building Permit F =Total Construction Cost x (Insert here
2.Electrical $ approp to municipal factor)=$ .
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minim fee=$r 0(contact municipality)
5.Mechanical (Other) $ Enclose check pay ble to
6.Total 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.
/Vqf v,qt7 Cps- ell4 ,qi o .1 c n ,el 46 q'GX_ f770 4 i t'-3
Please print nd ign na a T' Telephone No Date
(O S- ►- ,� c� Whafel ocifngn 6C glut viahorne01 prw l
Street Address City/own State Zip Email Address silt,
COM
il
Municipal Inspector to fill out this section upon application approval: % ',0 il • __VW;23_
,.....,�_ I Name Date
City of Northampton
'�' .R� 5� f.1�'N mow-, sjC
Massachusetts . ft�
s DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ,y
" Northampton, MA 01060 4Jy , .
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: L/ c'i II �y Aloy C l i'v) 3 ti q51 haprploo kce
Juor-'h4mpio ( NW
The debris will be transported by:
Name of Hauler: L iV() Veil �dni -P l i pird VeIinfA f
Signature of Applicant: Date: 612'4)-(2'
The Commonwealth of MaSSaChUSein
Department of industrial Accidents
r,=1100=7.
1 Congress Street,Suite 100
4
%., i
litE,, Boston, MA 02114-2017
, ,.....9 i—
t.... , ..„.„, WWW.inass.govldki
' IV t&kers'Compensation Insurance AMdavit:Builderstetistinetors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
,,
Name(auitic ssa,OrguntiationAtutteicluall: 47,..:1ti`JEI.A1t il ,,,,V,Gyn
Address: uie 33 • o I A/1 't id........ ._ , , , .„ , . , . . , , „ ._ „_
•
City/Statc,1Zip:ILIACileLy 1,ALLA12 10311 Phone it- CI .13- troc-t ),.9 ) °/
Ate ysis toe employee Cheek do app4priate hoc Type of project(required):
I. i AM a employer with,,,,,,,,I, yo (__,,enagloes full andecit pinks arigo
I. 7, CI New construction
2 I ant it sok,proprietor or partneratop anti have no employers working for me in 8. Remodeling
any cliFiacity.(No*eaten.'comp,intiunince required4
9. Demolition
30 I ant a homecoanow doing all wart myielf.(No workers comp„irradiance nantiroir
aw ui
a.C3 i ion a homeowner and wilI t hiring contiveton to conduct silt work on my pro la c3 B lding addition
perty. I will
ensure iSdi all COlthiCICAN either have wearitera'cenipmisation insuranix ne are sole ll.C3 Electrical repairs or additions
prrirriettrrs with no employeeri.
110 Plumbing repairs or additions
sCi I Ain a general cLaarraclur and I have hired the iwb-entstrowirs Listed on the attached sheet.
130Roof repairs
Thew sub-contractors have employees and have workers'comp.inautance.l
14,100thet
6.0 We art a corporation and it,officer%have exercised their right of exemption per k461.-c.
1(4 and we have no employees.[No aeorkeri'comp inawance required.]
*Amy applicant that cheek*hot:.;I mmt also;Ili out the section befo-Wahinying their to;;ittS.COtopetu"--ation policy information.
Hointiowneni who submit this affidavit indicating rites ant doing all work and then hire outside contrailom alum*ablaut a new affidavit etsdicaing auch.
:Contractors that check this bov moat aro:lied an additional sheet show tog the name of the adh-etrunactoca and suit whether or not those annum have
employee, If the wh-oaltra,:turN hav=e milfluyix-N.thay moat pros icie their *orkera"own!),policy atanber.
lam an employer that is providing wor4ers'compensation insurance for my employees. Below is the policy and jab site
information. ,
Insurance Company Narne: A TA4_ ,A, rzvic ( _
,--,
Policy#or Self-ins,Lie,#: l. *--- QQ5jQfJfj33
Expiration Date: (4/51).771
Job Site Address:2,9,6 Aionolu( k 61- cityistatezip:_riny,e0C 1 06 ).
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGE c. 152,§25A is a criminal violation punishable by a tine up to$1,500.00
anti/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 c rah,under the tins and penalties of perjury that the information provided above is fru and COrtYCL
Signature: 6 °.-..- el —2
Date: C /4'7—
Phone#: if 0 --- i110--11-77 0
Official use only. Do not write In this area,to be completed by city or town offichtt
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 0:
""'.'1 KEVISCH-01 LZAPKA
A�CORL7" CERTIFICATE OF LIABILITY INSURANCE DATE511/2/11/2 23YY)
023
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
Whalen Insurance Agency PHONE FAX
71 King Street (NC,No,Ext):(413)588-1000 (A/C,No):(41 3)585-0401 .
Northampton,MA 01060 l"D p1Ess:infoeWhalenlnsurance.com •
INSURERS)AFFORDING COVERAGE NAIL X
INSURER A:Main Street America Assurance 29939
INSURED INSURER B:AIM.Mutual Insurance Co.
LiveWell Home Improvement,LLC INSURERC:
33 Laurel Mountain Road INSURERD:
West Whately,MA 01039
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSLED 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 E FF POLICY EXP
LTR INSD WVQ- POLICY NUMBER „MIDDIYYY► (MM/DD/YYYYI, LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000
CLAIMS-MADE X OCCUR MPJ8858A 3/28/2023 3/28/2024 PREMISES f REoNcTEr°enao S 100,000
MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000
X POLICY j Tef LOC PRODUCTS-COMP/OP AGG $ 4,000,000
OTHER: CT
$
COBINED
AUTOMOBILE LIABILITY ((Ea accident)INGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULEDTO BODILY INJURY(Per accident) $
AUTOSIRE�ONLY AUpTNOSW�.�Ep
AUTOS ONLY AUTO ONLY �OPERdent) E $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
B WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE I WCC-500-5024695-2023 4/5/2023 4/5/2024 E.L.EACH ACCIDENT $
100,000
�QppFICER/MEMBER EXCLUDED? I N/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
I
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Certificate issued as evidence of coverage
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
ACCORDANCE WITH THE POLICY PROVISIONS.
Main Street
Northampton,MA 01060
AUTHORIZED REPRESENTATIVE.
ACORD 25(2016/03) cq 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered mars of ACORD
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