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23A-302 (3) BP-2023-1098 150 NONOTUCK ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23A-302-001 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-2023-1098 PERMISSION IS HEREBY GRANTED TO: Project# CHIMNEY 2023 Contractor: License: Est.Cost: 13631 FIRESAFE CHIMNEY SERVICES INC 105507 Const.Class: Exp.Date: 01/19/2024 Use Group: Owner: GRUBINGER DOE ALLAN &LENORE Lot Size (sq.ft.) Zoning: URB Applicant: FIRESAFE CHIMNEY SERVICES INC Applicant Address Phone: Insurance: 277 PALMER RD (413)436-7946 7pjub06033546 WARE, MA 01082 ISSUED ON: 08/16/2023 TO PERFORM THE FOLLOWING WORK: CHIMNEY REPAIRS 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: • . i ! Q �,� Fees Paid: S91.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner RF The Commonwealth of Mass. huse's //'v FOR Board of Building Regulations • d S S . dards W Massachusetts State Building ode, 7:0 C' �40l 1 ICIPALITY USE Building Permit Application To Construct, ' NI aiP, ' - •vate Or 1.3e ish a R- sed Mar 2011 One-or Two-Family Dwe 't f qT tioizo �"��JJ This Section For Official Use • 6-7-0 /N,c,p Building ermit Number: 6 0 ?3 - /d/! Date Applied: •'44 o�q��oA,9 ltv1i•-) 2.; B-iG- Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 15 0 fl OnarC t-1.A 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 disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 ner'of Re d• �llarl r1 Dire rI s.., rrn0 ofOUa Name(Print) City,State,ZIP t el na(1ct t ICI( Si- CM f3)S7-i& p rYArna 496) vne_. (011r, No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s)/ 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other pc Specify:eh flint (tf Y ur Brief Des • tion of Proposed Work2: Pe.._ u cad. c�t m e� 1�� cLY�d (�?1��k, SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 13L 31.c 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee SU 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 0 2. Other Fees: $ 4.Mechanical (HVAC) $ V List: 5.Mechanical (Fire $ Suppression) V5Total All Fees:rr$,, c(I ' Check No.‘1(A heck Amount: b Cash Amount: 6.Total Project Cost: $ 13(131, u) 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 10 SS ' t 4 a `) QS lL(_`I Q License Number Ex irati Date Name of CSL Holder J }. tip H, 1 ��� Po ax LID List CSL Type(see below) S I' No.andStreet► Type Description S -t,h cidr c 1„�') i/1 O I O 7 t 1} U Unrestricted(Buildings up to 35,000 Cu.ft.) 17 R Restricted 1&2 Family Dwelling City/Town,State,ZIP r-, ',� M Masonry I Lm®/1t re S ►11 May st Leo S (JO RC Roofing Covering J F- / WS Window and Siding L p 0 Solid Fuel Burning Appliances CLlf 13)L1 3C�^ 7 I Li(� I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvementt Contractor(HIC) 1550 Lf L.�CI CQ051�s E ( C►1 L y JS r� u S HIC Registration Number E piration Date HIC C papy Name HIC Regi�t�Name -7 a rz[a easgandn3Q.0 ineWesilirn,ILyi?r th S,c6w No. d Street Email address Lire rn� Ologa 0113 g3k- gg1,9 City/Town,SState,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 /15CNo 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 ;(`eSet C- ` AIL Seim G2 S to act on my behalf,in all matters relative to work authorized by this building permit aiplication. PACLn UCye Print Owner's Name(Electronic Signature) 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. Lif‘ Print Owner's or Authorized Agent's Name(EleO> ro c 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 �w�S " ` f *F f �• DEPARTMENT OF BUILDING INSPECTIONS y 4 .. -. 212 Main Street • Municipal Building vti. Northampton, MA 01060 ssryX 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: QWl.f‘rC � C � 1L E -k- 1n(\14) okOga The debris will be transported by: Name of Hauler: cIV Gc>4242 C- `Lin y ei Signature of Applicant: Date: *id 3 _ The Commonwealth of Massachusetts l` ,� Department of Industrial Accidents 1. '= 1 Congress Street,Suite 100 _i i=�;�` Boston.MA 02114-2017 `< www nass.gov/dia 1$urkers'Compensation Insurance Affidavit:BuilderslContractors/Electrkiwns✓Plumbers. Ill ui:.I ILED WITH THE PERMITTING Atrnu)RTIN. Applicant Information �c Please Print Ieeibly Name(KusmcsuCkanration`Individual) kiMOr CAA_Levi(\L1 C, y ti LCQ_S Address:c2 11 Pa.\, r 1 City/Siate/Zip: (..1`) j e 6 (\c‘A CA3 t) phone#: C q l 3-)i- —19.L 4 -- ArMeyw as eirlrya?Cheek the appropriate bone Type of project(required): d'irl I am a employer aria_ 1.___employees(full andiur put-tune).' 7. 0 New construction 20 I am a soh myna-war parmnekipand haw no employees working for me in IL CI Remodeling any capacity.[No workers'camp insurance noywnd_) 9. [❑Demolition 30 I am a homeuwn-r doing all work myself_(NNo i errs'cum..insurance u quirerl.l" 10 0 Building addition 4.0 I am a homeowner and will be hiring aurorsolorsto curium all VI.toll.on my pruperh. I x itl ensue that all cwtractun either terve nutters'eterprrnaUtwt m%urance or are sole 11.0 Electrical repairs or additions proprietors with no empty WIN 12.0 Plumbing repairs or addition i f 1 I am a general contractor and I hake hind the srrbtontractom hated on the attached.keen. 130 Roof airs tt.—+h Thew sub.cuntractum have cruployrrs and hake workers'cutup.mMurmke_• C 6.0 are a comm.-Amu and its officers have oxen is<d their right of c nr 1l u per 14. of cr .V t 1 152.fi 114),and vet have nu employees.(No coitus'cow_instance required] •Any applicat that tdro a boa#1 mutt ale fill ate the section below ahuwiri lair we kern'currtpernliw policy iakanntior_ +Ilutueuveacrs who submit this affndava iodic:Nies airy ate&ins all work sad ties kite uruide uo_ttatsors nowt Id act a WV affidavit indicating suck 'Contra kris that check this hoot must annelid an addttioral abaci Amanita Hems emit rub-cotaracmrsand goo whether err rot three stints have employees_ If the sub-contractors have etoployoca.they must provide their workers'conmp policy number. I am an employer that is providing worlers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:T(CL,V'elR V`5 !r Policy#or Self-ins.Lie.#:-1 Pi)it B`�C733'341Q Expiration Date: Si i I a 4 Job Site Address: 150 1 Ibr\6-'l.lLV1 ST Cityr'Statelzip: rtr_WrYNC_LLt rnP Li(1)L.Q.) Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL 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 form of a STOP WORK ORDER and a fine of up to$250.00 a day agate 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 nerd the pains and peaai►ies of perjury that the information provided above is true and correct Signature: Date: q l O I Phone#: l— 104 302- L !y(-1) Official use only. Do not write in this area.to be completed by city or town official ' City or Town: Permit/License# honing Authority (circle one): I.Board of health 2.Building Department 3.('ityfl'onn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other IIContact Person: Phone#: 111 - Commonwealth of Massachusetts \ 1.5Division of Occupational Licensure ' Board of Building Re_ ulations and Standards rds Constructi u e r Specialty• tPi r s. CSSL-105507 spires:01/19/2024 JAMES J WALLING 40 HIGH STREET P.O. BOX 40 ` SOUTH BARRE•MA 01074 4r4 .I,tr� 'J Commissioner o ' . THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration ,; i7,, 1 re Type: Corporation FIRESAFE CHIMNEY SERVICES Registration: 182449 277 PALMER RD UNIT 2D Expiration: 06125/2025 WARE,MA 01082 u r .1r, l.�� S�8 ti� Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 182449 06/25/2025 Boston,MA 02118 FIRESAFE CHIMNEY SERVICES .71 "JAMES WALLING JR -. ` 1 277 PALMER RD 4: _ /,,,,,...Ya l.140.4. WARE,MA 01082 Undersecretary of w' signature ACORO® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/08/2023 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 Jessica Pierce NAME: .._.. - _. BRABO INSURANCE /ac°.No.Ext1: (508)830-3800 FAX (A/C, E-MAIL - -.....- __._.. ADDRESS: JP;"'lerce 0t7braboinsuranCe.COm 65 Cordage Park Circle INSURER(S)AFFORDING COVERAGE NAICS Plymouth MA 02360 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B FIRESAFE CHIMNEY SERVICES INC INSURER C: INSURER D 277 PALMER RD INSURER E: WARE MA 01082 INSURER F: COVERAGES CERTIFICATE NUMBER: 919481 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. INSRLT ADDLTYPE OF INSURANCE INSD WVOSUBR POLICY NUMBER (MM/DDPOLICY/YYYY) (MM/DD/YYYY) LIMITS LTR INSD WYD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ i CLAIMS-MADE j I OCCUR PREMISES(EaENTED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ - OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLALLAB OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 7PJUB0G03354623 05/12/2023 05/12/2024 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main Street AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ��--, FIRECHI-01 JPIERCE ACORU MM/D(DATE D/YYYY) CERTIFICATE OF LIABILITY INSURANCE MMD23 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 NAME: Brabo Insurance Agency PHONE 508 830-3800 FAX 508 746-1540 65 Cordage Park Circle (A/C,No,Ext):( ) (A/C,No):( ) Plymouth,MA 02360 ADORIESS:info@braboinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Northfield Insurance Company INSURED INSURER B: Firesafe Chimney Services Inc. INSURER C: 277 Palmer Rd,Unit 2C INSURER D: Ware,MA 01082 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDD/YYYYI (MM/DDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR WS551038 7/15/2023 7/15/2024 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY jECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ 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 YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I 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 I 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 Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main St 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