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38A-039 (2)
BP-2023-0969 32 LAUREL ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38A-039-001 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-2023-0969 PERMISSION IS HEREBY GRANTED TO: Project# BATH RENO/CLOSET 2023 Contractor: License: Est. Cost: 17925 MATTHEW FABRY 118003 Const.Class: Exp.Date: 12/20/2026 Use Group: Owner: FORTIER RHOADES NANCY & DAVID Lot Size (sq.ft.) Zoning: URB Applicant: ROOTS CONSTRUCTION LLC Applicant Address Phone: Insurance: 98 PLAIN ST (413)667-7424 ROWC405015 EASTHAMPTON, MA 01027 ISSUED ON: 07/28/2023 TO PERFORM THE FOLLOWING WORK: BUILD NEW WALK IN CLOSET AND RENO 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 VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fees Paid: $116.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner f-lt: :IVED The Commonwealth of Massachusetts Board of Building Regulations and S dares JUL 2 Q 2023 MUJNIC ALITY Massachusetts State Building Code,7 CMR U E Building FoR PermitRe Wised ar 2011 Application To Construct,Repair,R nov GUIIDING INSPECTIONS One-or Two-Family Dwellin NO11THAMPTON,MA 01060 This Section For Official Use Only Building Permit Number: 6P'-• i Date Applied: I. . 1. 1' • 7/ )/a-1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 32 LAu euL ST 1.la 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 disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: DAV►0 ,r^ri ct2 No41VI -Ph,.-, 1/L4A O 1 OG 6 Name(Print) City,State,ZIP 32 L A.Ure i 5' -�- L i3 SNINE ZSv-33ciy 014'ht13-310 z),4144 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building M Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: 6vi1c( Alcoa C..41rc-IA) CIv}d. M�r.(It �'JA acM SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 2i q zc. nV 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ gro0 , UJ ❑Total Project Costa (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No.10:19 Check A oun . I ((A h Amount: 6.Total Project Cost: $4 7 Z y. 06 paid in Full ❑0 tandin Due: SECTION 5: CONSTRUCTION SERVICIES 5.1 Construction Supervisor License(CSL) f 1 ,0 0-3 1 2/v /2 6 ,4l e(,) R C L, ril FA 13 fL l License Number Expiration Date Name of CSL Holder Cr S Pt R`44 S T list CSL Type(see below) No.and Street Type Description En�-ti4ft l p�vn , M4 U' 0 Z i U Unrestricted(Buildings up to 35,000 cu.ft.) / R Restricted 18/2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding G1S-667-7'f 2y Qao1-scvnitmcti�t 113 SF Sol tioelBturningAppliances y'�Y},/ cum I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) se- e (Z, �132y 2C>gOu 6 ?�Zo12� HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name el? plAtn ST Rou+ScwSt(t) tityth309944,1.c0,y No.and Street Email address East i.q,"+ v AAA c) l 0 2 7 L 13--6 6 7- 7cl Z ty 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 IDV No .O 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 go0745 L L to act on my behalf,in all matters relative to work authorized by this building permit application. ID -U(0 P-acf-i /' 7//o/L 3 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER1 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. -7/Cb/23 nt ner s or Aut orize ent'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 Massachusetts ��? •`cj<< p 4, f,; * 1 4 DEPARTMENT OF BUILDING INSPECTIONS �`• 212 Main Street • Municipal Building yO :C1� Northampton, MA 01060 rg�; ..vo;.�0 CONSTRUCTION DEBRIS A*FIDAVIT (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: V' 4 f l2'tY(It4? Z 39 C21S R4 f�i. A4� ./trv. 010 6 o The debris will be transported by: . Name of Hauler: A1ft Frl-3RY Signature of Applicant: . Date: 7 /C3 Z 3 The Commonwealth of:11fassachusetts __ I E. Department of Industrial:Accidents . M= 01 1 Congress Street,Suite 100 WOW Boston,MA 02114-2017 www mass.gov/dia %miters'Compensation Insurance Affidavit:Buildersl('ontractorslEketriciansiPlumhers. Tt) THE PERMUTING At'THOWTI. Applicant Information h I Please Print Leiih Name (Busutess Organulttton ltxlrvielttal): i pp o 07 S (O/I)1/�r'u CTI„Di t"L C Address: 61 (OI A. S T City/State/Zip: Efi t( ,. 010 2 7 Phone#: '-I 13- C 7- 74 a y Are yen an rmptoser?Creek re appropriate hot: Type of project(required): 1. !am a cmipkrva with employees(tali and or part-tune►_' 7. ❑ New construction _sl—J I am a ok proms:tor or purtnc-n cm h.p and tease nu einpkry 'socking for me at $. 3em odeling any capacity.[No workers'cutup.insurance ro wriid_I 10 I am a home-outlet doing all work my ell.[No wod.as'comp..rnwrance rcgwrcd j 9. [I Demolition ID Q Building addition 4.0 I am a h unenuner and w III be hiring corarrctun to conduct all work on my pro pert).. I K ill mom:that all contracture either lase Kod c-n'compensation insurance ur are sole I 1 a Electrical repairs or additions proprietors rah no employees_ 12.0 Plumbing repairs or additions SCI I am a general contractor and I has c hued the sub—contractor,hated an the anadncul sheet_ Thew sub-contractors tease employees and has c*tickers' cup.insurance. I ❑Rowf tepairs 6.0 Vie arc a corporation and its officers has c cxcrcnsed thee right of exemption per Mt&L c. 14_ Other IS?..§1i4►,and Kc has.:nu employees.[Nu workers'comp.insurance rcqutrcd.I •Any applicant that checks box a I must also till out the section below show mg their*vitas'compensation policy information_ *I amm%nem who submit this at[uujrs it indicating they are doing all Kirk and then hire outside contractors must subnut a new atfadas it indicating such. :Contractors that check ilia box must attached an additional sheet show Ong the name of the sub-contractors and stale Whether or not thou:entities base employees. It the sub-contractors ha se crrtployns.they must pro%idc 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: ef4511i r 14A1Zo,r:l _ Policy x or Self-ins.Lic.#: eb WC OS-D Expiration Date: Lai3/Z,/ lob Site Address: 3 Z I A-0s`c ( S City/State/Zip:/llot i ;44�4 iU. 9 b([�6 G Attach a copy of the workers'compensation polity declaration page(shoveling the policy atrmber expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishabk by a fine up to 51.500.00 andlor one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a tine of up to 5250.00 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 cent under the pal and penalties of perjury that the information provided above is true and correct Signature: Date: 7/ )/C Phone#: Lit .) - 66 7 Official use only. Do not write in this urea,to be completed by city or town official City or Town: Permitll.icense# Issuing Authority(circk one): 1. Board of Ilealth 2.Building Department 3.('it'.'Town Clerk -1. Electrical Inspector 3. Plumbing Inspector 6.Other ('intact Person: Phone#: Commonwealth o1 Massachusetts Division of Occupational Licensure ._ Board of Building Re ulations and Standards �`��I1 Constiactlon Srvisor CS-118003 : ..riime,., spires: 12/20/2026 4. 1 MATTHEW R CHARD A F 98 PLAIN STIIEET EASTHAMPTC N MA 010 u 1 lt, J blot i. • THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:LLC Registration Expiration 208046 03/20/2025 ROOTS CONSTRUCTION i MATTHEW R.FABRY 98 PLAIN ST i ,�...,(,;' ,.w6ldt EASTHAMPTON,MA 01027 ,",.. Undersecretary '`, �RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DWYYYY) 5/12/2023 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 f.ONI ALT NAME: John Camerota Dale A.Frank Insurance Agency Inc (P2ONNo'EA: (413)665-8324 FAX No): 2 Amherst Road E-MAIL ADDRESS: John@dalefrartkinsurance.com INSURER(S)AFFORDING COVERAGE NAIC t Sunderland MA 01375 INSURER A: MAIN ST AMER ASSUR CO 29939 INSURED INSURER B: NORGUARD INS CO 31470 Roots Construction LLC INSURER C: 98 PLAIN ST INSURER D: INSURER E: EASTHAMPTON MA 01027-2512 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE H INSD WWI POUCY NUMBER POLICY El- POLICY EXP X COMMERCIAL GENERAL UABIUTY (MM/DD/YYYY) (MM/DD/YYYY) OMITS EACH OCCURRENCE $ 1,000,000 UAMAOE I V HtN I tU CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A MPJ4855Q 04/13/2023 04/13/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY Mira C LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ —OWNED —SCHEDULED BODILY INJURY AUTOS ONLY AUTOS (Per accident) $ —HIRED —NON-OWNED PROPER I Y UAMAt t AUTOS ONLY _AUTOS ONLY (Per accident)— $ $ UMBRELLA UAB OCCUR — EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION PER Cl H- AND EMPLOYERS'UABIUTY Y/N STATUTE ER ANY B OFFICER/MEMBER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N/A E.L EACH ACCIDENT $ 100,000 ROWC405015 04/13/2023 04/13/2024 (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 XINMR A INMRC MPJ4855Q 04/13/2023 04/13/2024 Tools 10,000 MSIME DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Matthew Fabry ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Jo{,....C .*troici, 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton 32 LAQn-FI S �- VI C`oS .0 t2 tr‘