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24D-089 (14) BP-2023-1255 64 NORTH ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24D-089-001 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-2023-1255 PERMISSION IS HEREBY GRANTED TO: Project# FOUNDATION REPAIRS 2023 Contractor: License: Est. Cost: 30000 THOMAS BACIS 070061 Const.Class: . Exp.Date: 03/06/2025 Use Group: Owner: HARRINGTON MICHAEL Lot Size (sq.ft.) NEW ENGLAND REMODELING GENERAL Zoning: URC Applicant: CONTRACTORS INC Applicant Address Phone: Insurance: 75 VALLEY RD (413)478-5272 WCC500601501 SOUTHAMPTON, MA 01073 ISSUED ON: 09/12/2023 TO PERFORM THE FOLLOWING WORK: FOUNDATION 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: 1 . . I„, ,.2 . 7:2915/ Fees Paid: $195.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner SF,° � p 1 T-e Co' onwealth of Massachusetts 17-. 2 2O7Boa,. of : ilding Regulations and Standards FOR , MUNICIPALITY B7ni,� Ma•sach .etts State Building Code, 780 CMR 5` ',nu,, 1 USE .Y*, ppli• tion To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 G'Ge0 NS One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 6,'`0.73— /.2-S.5 Date Applied: 14.1.M.) t , /lam __ 91Z-ZoZ5 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Proper ddress• 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street?yes 'v 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: Zone: Outside Flood Zone? Public ' Private❑ Municipal On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of e�cord: ea, Cyt 1_ eentai e,;v,, Cov7114APA 1144 0/6 ) Name(Print) City,State,ZIP 7 Sr' V4key (Z C1a'3-('71 say- 73ac,S 73 r' Iota;/,Co 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) Ill Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:_ Brief DescriptionAf_Proposed Work2: I-adnia?,O fr. Q.epa%ri /12e phi eZ is e, . Z ►'12 au( (Coot-(= *'Cr-O .S Zti SA.'r G SC. (L Fro rk e_ S74,'r c r1 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 Application Fee • 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x b 3.Plumbing $ _ 2. Other Fees: $ __ ___ 4. Mechanical (1-IVAC) $ List: T _ 5. Mechanical (Fire $ Suppression) Total All Fees: $^__-}.c- Check No. r�'' Check Amount: Cash Amount: 6.Total Project Cost: $ 3a, and 0 Paid in Fu 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor I,igense(CSL) CS, O 7 Q r,/ I 3 , / 2O 2 S o rf a S M , (�/ at C 1 S License Number �V Expirationn Date Name of CSL Holder 7 S \ r c 1 t O� 1 List CSL Type(see below) V No.and Street Type Description SOu1_1 am 0 `Cm /�/In I O-7- U Unrestricted(Buildings up to 35,000 Cu.ft.) ((1 9 I "u, J --_---_ -__ R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 1 LL SF Solid Fuel Burning Appliances 1 19-o�I ()Minodl9 ' Tt!r. I Insulation el hone E ai ress D Demolition 5.2- Registered Horne Improvement Con ractor(HIC) 14 p n q g 2_ 2 2.202y 1 i'y brTlac [1 , 'l)a CIS HIC Registration Number Expiration Date ic, HIC Compan Nam or HIC Re sttrra Name — 5 V 0.11 LN a r►e rein oli lil t o olta(l�f, 4 No.And S r et .JJ Email ddress City/Town,State,EIP 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 61 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 to act on my behalf,in all matters relative to work authorized by this building permit application. 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. "'1;r,.., I3ac,f /V ew Cni l arv ) tZer, ,id,►2g c( _ u r — .23 Print Owner's or Authorized Agent'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 0, 1 AMjro , s + "' Massachusetts w' 4 �Cftr C< til DEPARTMENT OF BUILDING INSPECTIONS , 1. w"' i. 212 Main Street • Municipal Building v 2' �j,. ' Northampton, MA 01060 d'l,j4 .IV" 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: N I Location of Facility: Vol t t_ct Cl i Yl 6 NA The debris will be transported by: 1p Name of Hauler: A ar'oriS 1 I OW, 1 Signature of Applicant: /�� Date: 9• /2• 2 aa3 \.--, The Commonwealth of Massachusetts t Department of Industrial Accidents a 1 Congress Street,Suite 100 Boston, MA 02114-2017 .-,..;....c...-:raw ww .r mass.gov/dia %%corkers'('ompensatiun Insurance Affidavit:Builders/Contra¢tors/Ekctricians{Plumbers. H)BE FILED W1 11 1 IIE PERM'lTINC:AisTHORITY. Applicant Information rR_Icaliat Please Print Leeibly Name(Elusincss.Organiiation.rindividual): N C w 1..In \alla I n Address: C 0 S City/State/Zip:_ Ov)-ka ., .4 Cle73 Phone#: S a q ^o 5 J0 Are act an rinployer'C hettk the appnuµriaLe box: Type of project trtrquired): i.rsi I ant a employer wish renphrectri(full anise part•ng:art.• 'r t_ 0 New construction 2T.....1 I ant a wile ptuptretur or pcutnrrhap and have no cmpkryuca w,urking fur nic in S_ErRetnodeling any capacity_[Nu worker,'lump.uuuranla ntlenni j 9. 0 Det'tiolition 31:1 I am a homeowner doing all wort.myself_fNu.actors'Lonlp.irisUtatitec requaird..] 4.0 I ant a homeowner and will be hirutg, r.t- 1.. 1 t) Building addition n to cuctduct all a urlC un my pratpc7h_ i will encore that all contractors either have workers'compensation tmurarice is an:stile i I.[J Electrical repairs or additions proprietors v.ith no employees. 12.0 Plumbing repairs or additions .."..r3 I ant a general can trout and J have hued the rub-conttacturs inted on the attached sheen.. "" There sub-contracrurx have employees and hate sna hurlers'. p.tnsurancr. I Roof repairs n: 14.0 Other t 0 We a a coo aYion and its utf.certi him:txen no d their right of ratseraraw Idn per OI c. IS`!i I(4 i.and we Iasi no cauploycra.[No vomit:PC cam, nauranee rryuiaetil 'Any appticaltt.that ch cks box Pl mini also fill out the ve:turn brim.,abxtwing their wutkess•curapcn,ation pal.,, u l rin:;rt,an, t Hutnaow'ts.rs nIt,,subunit this aff'tdatit indicating they are dgeng all.work and tbam hire outside contra.toes moat .abrrut a rt.,afti.l.tstit iralu:.itrng rua tCunlractur',that check tiles to must alu..-I.etf an aJJitiunai abLtt slat n trig the name of the abrt:iaartr-a:torr,and slate ttittthrr Or rat thu.,c cntitic'_t hate employees. If the antt-tunitatlnra!Luc elMill ,xa.theynalstprosId.'thy:w workers'comp.puhts-nlunhcr I am an employer that is providing wanders'c ompensation insurance for my employers. Below is the policy'and job site information. Insurance Company Name'- A.M M 1 t u a. A.Policy#car Self-ins.Lic.#: �-So 0"60D LOIS-20�3 A Expiration Date: 9` it' oar Z LI Job Site Address: V f (vorl,k S f`al City/State+7.ip:_N 1- L.,M/A__U I G b C Attack a copy of thr workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under NiGL t;_ 152.§25A is a criminal violation punishable by a tine up to$1,500.(Xl and/or one-year imprisonment.t.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 l rwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ' the,pa- and penalties of pentary that the infnrmatitin pror4ded above it true and correct Si tattle: ...— l)aic 9 ' / 1 .2C)-3 phone 4: ( 411) S a'A - o g-O Official use only. Du not write in this arlra.to be completed in city or town official City or Tows: Permit/License q Issuing Authority(circle one): I. Board or Health 2.Building Department 3.City'1T'awn Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Plane#: tee. 11 DATE(MMIDD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE kin...--- 09/12/2023 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 polioy(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 Susan Fleury NAME: King&Cushman Inc. PHONN.Extt: (413)584-5610 FAX No): (413)584-9322 P.O.Box 447 E-MAIL sfleury@kingcushman.com ADDRESS: 176 King Street INSURER(S)AFFORDING COVERAGE NAIC k Northampton MA 01061 INSURER A: Northfield Insurance Co INSURED INSURER B: Scottsdale Ins Co New England Remodeling INSURER C: AIM Mutual Ins Co General Contractors,Inc. INSURER D: _ 1 75 Valley Road INSURER E: Southampton MA 01073 INSURER F: i COVERAGES CERTIFICATE NUMBER: CL2391205477 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. 9 INSR TYPE OF INSURANCE AWL SUER POLICY EFF POLICY EXP W LIMITS LTR INSD VO POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) H X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 10,000 A WS514639 10/23/2022 10/23/2023 PERSONAL&ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000 POLICY JECT PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _- ANY AUTO BODILY INJURY(Per person) $ ONED SCHEDULED BODILY INJURY(Per accident) $ -(i W AUTOS ONLY AUTOS --.-.) HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) ____1 $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE XBS0176810 12/06/2022 12/06/2023 AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER -__ Y/N 1 C ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WCC5006015012023A 09/04/2023 09/04/2024 E.L.EACH ACCIDENT $ , , OFFICER/MEMBER EXCLUDED? (Mandatory 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 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main St AUTHORIZED REPRESENTATIVE J) Northampton MA 01060 "t` ,y _-,{. —�F'�• $ I I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD LudLV,S�9 ..avAo o ed115 I 1 v I 1 Ne' ,. ,. ,._., .a_iiimis!"--.......„„ me_-d_- C, �_ 1 1 - 1 o i '449 -;v/ri-S a A et 5 re LonaceA 7n9uaa‘6 L tiN /`e ' 1 1 vr-ei A)ora ii v.L. is -s HA Q0 -r) C(,\'. 5.0k? ,/i c- -"Arun Si 1 QV%1 Up,,.i..ve c.,no3 Mau 'h i i bL S v f_ 0 )9/ 1 '1)b-i - poio 00 'i IS ' uo.Ia f ''''1o3 u ‘u,'$to 40 u9.49?5 i L 1 /) LSUI ' , Li , Q1 1 'Ct r s oz. ...L9v