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29-076 (8) BP-2023-1244 62 ACREBROOK DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-076-001 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-2023-1244 PERMISSION IS HEREBY GRANTED TO: Project# FILL IN POOL 2023 Contractor: License: Est. Cost: 5400 TRUEHART PAVING LLC 106781 Const.Class: Exp.Date: 09/09/2024 KOLEMBA JUDITH & MICHAEL J KOLEMBA & Use Group: Owner: VALENTIN J KOLEMBA Lot Size (sq.ft.) Zoning: WSP Applicant: TRUEHART PAVING LLC Applicant Address Phone: Insurance: 134 NORTHWEST RD (413)246-8233 WCP0389W WESTHAMPTON, MA 01027 ISSUED ON: 09/12/2023 TO PERFORM THE FOLLOWING WORK: FILL IN INGROUND POOL POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.VV. 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 • . a Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner 0 SEA V%i The Commonwealth of Massa 'use t !I 4 O OR W Board of Building Regulations and S•: ,;� . ITY Massachusetts State Building Code, 780'.'''f+ '.4,, A, Or SSE Building Permit Application To Construct,Repair, Renovat 4 'i olish . Rev' ed Mar 2011 One-or Two-Family Dwelling qo, „N. This Sec�tion For Official Use Only `P Buildin Permit Number: 43 �" Date Applied: Cvt��n ��y7/,Z 9-a-2o23 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Addrgss: 1.2 Assessors Map&Parcel Numbers tat, nc,mbYDDk 1.1 a Is this an accepted street?yes X 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 Private❑ Zone: Outside Flood Zone? Municipal 4 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record:JO M 134 • J I I itik A Name J(Print) J"'v City, State,ZIP i kkL A4elvr -` )c. s�q— 3621 bvq 6 @ c c hr Y1 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 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': Aift VIA- (L PV4. qt,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: 0 Standard City/Town Application Fee 2. Electrical $ Z5b, 0 Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fecfr in Check No. 1 /Check Amount: 5 6.Total Project Cost: $ ,it co,00 0 Paid in Full 0 Outstanding Balance Due: 5 r.6e \ @ + , NfNe--it— City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS IT * `�- ." A 212 Main Street • Municipal Building Northampton, MA 01060 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS, DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC. 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work(Digital and hard copy). 3. Construction Debris Affidavit filled out and signed by applicant. 4. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance. 6. Energy Conservation Compliance Certificate(new/replacement windows). 7. Home owner's License Exemption Form (if applicable). 8. Note any Special Permit requirements(if applicable). 9. Energy Code—all new construction (Gut/Rehab) requires a HERS Rater Affidavit. 10. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. 4. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Superviso License(CSL)1 CS— ���`? 1 2-4 — C���s 1 License Number Expiration Date Name of CSL Holder W.-1 1 tt—1, S i A List CSL Type(see below) No.and Street '�/• Type Description /t ‘ �,1� D 1 /��� _ Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP 1 V V Restricted 1&2 Family Dwelling M Masonry _ RC Roofing Covering WS Window and Siding r I 7 2-7 ? SF Solid Fuel Burning Appliances '1 ( � J U C• I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address 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 0 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 r — R4'J 1 Nam- Lie to act on my behalf,in all matters relative to work authorized by this building permit application. LS LAD1 1< LEk13A /—/"2 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. Print Owner's or Authorized Agent'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" • The Commonwealth of Massachusetts Department of Industrial Accidents - • 1 Congress Street,Suite 100 Boston, M402114-2017 www.mass.govidia I'd,..fkers ['unionisation Insurance Affidavit:BitildersiContractor-sfElectricinns/Plumbers. It)HE t ILE) an THE PERMIT]Psi.: rf ADMIN. ApplicantInformatiOti Please Print Legibls Nartle(3thrhess.Urgantzation:Iniiividual): 112.tote4A f111,1-- PA V Address: I,3 ui LA511.4140k)6S7r City/State-lip: W1-1W 1 MA tt)—CI, Phone P: t3 2,3 3 A.yew an MAP, Chute OR ippnipriitc Type of project(requiredl: 1.0 i am a employer with 1 ,‘ employees(1411 minor part-time t.' 7. 0 New construction 1 am a sole propnetururpurtherdup and have Ito Vorloyee,working for Me In /C. 0 Remodeling, cirri eaNeity. w miters'currip.insurance regimen.) 9. 156 Ottitt0IittOil 30 I AM a hurneuwIlAl tiotriN all wart m)self.iNoworkers'comp_InAtJAIMAX la I am a honseuwara arid skill be&rms.contractors to conduct all work on my propert3. I will I Building addition ensure that all coseractura either have.worrivers'compensation intionmer 11.0 Electrical repairs or additions proprietors with nu employas, 12_0 Plumbing repairs or additions $C3 I am a moral cormactin and I ha.e hued the Nub-contractor%hoed on the attached sheet 13.0 Roof repairs These sub-euntraelors haw imployerts and hai‘e workers'comp.insurance.: 14.C3 Other 1V-15\c15\4-AA-ek -Y" Oa We are a umporrinon and its officers hai c exercised their right Of exemption per hilfel.e. I!v.?,§1(41.rind xe hates nu anpluyeeN.ISo workers'comp.insurance required.] *Any applicant that cheeks box al mint aboa fill vat the section below showing their wen-kers'conmensathin palw trtieVIEIAKIAMI Iknnarn .who submit this affidavit ratheatinu they are doing all work and then hire outside cormackats man sahnot a net.ttlidat,itaralt...-.allts m.sch IC:Lontractor%that check this box.a:mil attached an widitional sheet show in g the name at the 6ab-zontractots and state whether tyr not thu*c tattitict-luse ....inployees if the sub-eanaractors have eisluin ,thiy mud provide their workers'cramp.policy latanki. am an employer that is providing ovorkers'compensation insurance for my employees, Below is the policy and job site information. Insurance Company Name: F I 'JCL p&t,17.4e\s Policy#or Self-ins.Lie.#: VNGI©0 3 11 \Ai Expiration Date: 1 I r2S f 2/071 Job Site Address: 1.9-7_..." CityStateZip: ‘\) cm., MA b b192---- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as req 'LIMA'under MGL c. 152,§25A is a criminal violation punishable by a fine up to SI.500.00 atttibt"one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 coverage verification. I do hereby c• under the'pi ins a tenalti s of perjury that the information provided above is true and enrrecr. — — 1-0 2.3 Siena ture- Date: Phone#: 1:3 Official use only. Do not write in this area,to be completed city or town official City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 1.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton ix./,, jMassachusetts a 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: U _ 1 1‘;.-kN Location of Facility: bc.e i-1-6 1 k`^tr 3 V i The debris will be transported by: Name of Hauler: /1- 'AVI lC� e\--4,41 1 't 1 —24)2..3 Signature of Applicant: Date: 3o, l� City of Northampton t4‘ Massachusetts +" $ c I # A:k0; DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building3k, �'. Northampton, MA 01060 `S' HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born (insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20 . (Signature) ' 1 � DDlY AC RO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE (7M0/ 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 Elizabeth Carballo,CISR,CPIA NAME: Finck&Perras Insurance Agency Inc. PHONE Extl: (413)527-5520 FAX(PJC No): (413)527-5970 6 Campus Lane ADDRESS: bcarballo@finckandperras.com INSURER(S)AFFORDING COVERAGE NAIC# Easthampton MA 01027 INSURER A: Main Street America Assr Co 29939 INSURED INSURER B: NGM Insurance Company 14788 Truehart Paving LLC INSURER C: 134 NORTHWEST RD INSURER D: INSURER E: WESTHAMPTON MA 01027-9511 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2372007352 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 INVD POLICY NUMBER SMM/DDIYYYYI_(MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RETED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) S 500,000 MED EXP(Any one person) s 10,000 A MPP0389W 07/10/2023 07/10/2024 PERSONAL 8 ADV INJURY S 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY PRO JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER EPLI s 10,000 —^ 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) S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y!N 500 000 ANYETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ , B OFFICER/MEMBER EXCLUDED? Y N/A WCP0389W 07/28/2023 07/28/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Proof of Coverage 62 Acrebrook Drive, Northampton,MA 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 //11 Northampton MA 01060 �'/;e`Y{C.( ,c�1Az&(O I / ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD