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18C-095 (3) BP-2023-1218 20 FRANCIS ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 18C-095-001 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-2023-1218 PERMISSION IS HEREBY GRANTED TO: Project# WATER DAMAGE REPAIRS 2023 Contractor: License: Est. Cost: 100000 PRIME HOME IMPROVEMENT 116599 Const.Class: Exp.Date: 05/23/2025 JOHNSON AMALIA IOANNIDOU &CLIFTON Use Group: Owner: MCLURE JOHNSON & Lot Size (sq.ft.) Zoning: URB Applicant: PRIME HOME IMPROVEMENT Applicant Address Phone: Insurance:, 108 NELSON ST (413)222-9776 CHICOPEE,MA 01013 ISSUED ON: 09/07/2023 TO PERFORM THE FOLLOWING WORK: REPAIRS DUE TO WATER DAMAGE 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 ,2 . Fees Paid: $650.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner RECEIVED C SEP - 7 2023 i The Commonwealth of Massachus tS pEPT.OF BUILDING INSPECTIONS W Board of Building Regulations and Sta dar& NO THAM TON.MA 01060 FOR Massachusetts State Building Code, 78 cm IPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 6 'o "*.Le Date Applied: 410 7055 /n2 ` "72OZ3 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers ZO FP iuci S Sr. 11100,q 4729/1 eh, 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 1 Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Recoorr 1: CLtF1-ott J oMNSoA ' NOVNAIriPTON, /J1i9 O'060 Name(Print) City,State,ZIP ZD PRxm,crs SrR&r (20z)966-p194# To, uc , cmae&PLtrL,Cam, No.and Street Telephone Email Ad ess SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) ll' Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units / Other 0 Specify: Brief Description of Proposed Work': //OtA 111W jai;17�/2,tpcc. 171).5(.4ccTz-O/1) DRyajgti, joR F CLoOR.ivOBCirNG REPG2CED. ELecrA zf9L 61 DLLIniQZ7i/& ACG/1/G t11)&419064 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 56 ODD 1. Building Permit Fee:$ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ Z.5;000 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ Z 5-, 060 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. 143 Check Amount: (,t gash Amount: 6.Total Project Cost: $ )00 000 )0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1/�Construction Supervisor License(CSL) C5 d/16,�f�J (j5/Z3/2� vi Z Inrdl,l�'C, FiLzPP a/Vf License Number 7 Expiration Date Name of CSL Holder List CSL Type(see below) U IDS flJGcory S7- No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) CH£Co PCE f MA,/ 0 O1 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered HomeA Impr. me�nt�C/onte - 1-1 14 17 Zcz _ S-A 4 E J r-i r/lJ�/ me HIC Registration Number Exp. ati n 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 re No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT tas Owner of the subject property,hereby authorize C"`fbtit' 36621i1. to act on my behalf,in all matters relative to work authorized by this building permit application. eirOwner's Name(Electronic Signature) r 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. Pkint Owner's or Authorized Agent's Name(Electronic Signature) -1211111Miwangmenigumetzuminis 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/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) 'al 03 (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) ) $DO Habitable room count Number of fireplaces ► Number of bedrooms Number of bathrooms ` . Number of half/baths Type of heating system 13AS6:1PORnd )46i'Wq TEK Number of decks/porches 8 Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton �O � SAS SIC �•2r n Massachusetts e 1 w; K s. f , , ' DEPARTMNT OF BUILDING INSPECTIONS( fr1. 212 Main Street • Municipal Building yvd a� Northampton, MA 01060 ssd ;�00 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: The debris will be transported by: Name of Hauler: A15 DLt.{'ipsrcRS Signature of Applicant: �4/ 4 l �� rOrt-L 712 3 The Commonwealth of Massachusetts rl, Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Pc l W, ODw,.Q `jvk rr,Nreivvm� Address: I og `elsp� S City/State/Zip: CL1 c e•e, Z)LV Phone#: Ti; •2Z2 .-11114 Are you an employer?Check the appropriate box: Type of project(required): 1.1=1 1 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.12I am a sole proprietor or partnership and have no employees working for me in 8.,n Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10❑Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will -ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide 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: Policy#or Self-ins.Lic.#: Expiration Date: +1.10b Site Address: villb City/State/Zip: 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 •µ Revised 02-23-15 www.mass.gov/dia t" ,Sign Envelope ID:FIAECOC1-6112-4E45-9839-9B22FCE95C73 RESCON a RECONSTRUCTION SERVICES CONTRACT RESTORATION & CONSTRUCTION 833.4RESCON i www.GORESCON.com 1. EXHIBIT 3 .:-:.;..:..:: :.:: Payment Disbul•sement anti NI t a e Ini'oi•maltion Owner: CLIFTON JOHNSON Contractor; RESCON®RESTORATION&CONSTRUCTION 38 Crafts Street Loss Site 20 Francis St Newton,MA 02458 Address: Northampton,MA 01060 License: #106438 Job#: SPR2300I9R DOL: 01/25/2023 Date: 04/12/2023 I authorize my insurance company and/or mortgage company to issue payment on my behalf in the above referenced project directly to Contractor for the amount shown on the final estimate(s)or the invoices sent to my insurance company from Contractor. I understand that]am responsible for any services or repairs or additional improvements made at my direction that are not covered under my policy; to be paid in full to Contractor upon agreement of such services. This summary serves as a reference for payment procedures and Contractors payymeqpoliey. Your assistance may be required throughout the project to collect information for the purposes of acquiring draws and/or final paint/front your mortgage,insurance or other third-party company. -Though we accept third-party payment insurance, roe management,etc)as our Client you are responsible for ensuringthat Ilg�n�lnitials g P p Y P y (� property rtY B p ((�J these payments arc issued and processed on your behalf in a timely manner. Contractor will assist in this process as necessary. -For projects greater than$10,000 an initial draw may be required before the project can be put into production and a second draw Aitials may be required during production. Your assistance will be required to ensure we receive the draws in a reasonable amount of time GArin, so that production is not put on hold. -We will invoice your insurance company and/or mortgage company directly for services provided. Payments for such invoices Client Initials MAY OR MAY NOT BE issued directly to us. As our Client,It is YOUR responsibility to ensure that checks received by you (payable directly to you or co-payable to both Contractor and yourself)are distributed in the correct manner.Please carefully review ALL payments that you receive from the insurance company to determine the intention for that payment.Co-payable checks to Contractor and yourself arc due in MI to Contractor,but non co-payable checks may be intended for more than one vendor. It is your responsibility to forward any payments made directly to you which have been intended for our services. If you need assistance reading estimates or determining the purpose of an insurance check,please contact our accounting office and they will be able to assist. Please use the template below to collect pertinent information that will help with the progress of the project. Without this information Contractor may be forced to delay the project in order to acquire the necessary funding and draws. Primary Mortgager: Contact Name: (fir;11 1"i''.'s'i`'' Loan#: Contact Phone: (i t al'I'!"Ak) By signing below,Client gives permission to said mortgage company to discuss claim payment information associated with the above referenced loss with Contractor. Your privacy is protected and the information given to Contractor is strictly for the purpose of obtaining mortgage company endorsement for checks payable for services rendered by Contractor. .M. itMi?iry'M.: OWNER CONTRACTOli. 000usr9ned by: RESCON®REST ' N&CONSTR -' I N atNin. j6(kAA.SOW Signed: Signed: � %: -JUdN9h o3ovc tA9o... Print: Clifton 7ohnson Date: 4/27/2023 $($.2 �Print: ' i 'go6 i S- • Date: AcoR ° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 2/16/2023 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 NAME: Lindsey Pitts Arthur J. Gallagher Risk Management Services, LLC PHONE FAX 1050 Crown Point Parkway (A/C.No.Ext1: 678-393-5299 (A/c,No): Suite 600 ADDRESS: Lindsey_Pitts©ajg.com Atlanta GA 30338 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURER A:Scottsdale Insurance Company 41297 INSURED RESCONS-01 INSURERB:Hartford Fire Insurance Company 19682 RACI Intermediate Holdings, LLC dba RESCON Restoration & Construction INSURERC: 38 Crafts Street INSURERD: Newton MA 02458 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:109099288 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTRINSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY Y VRS0006329 1/1/2023 1/1/2024 EACH OCCURRENCE $2,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $1,000,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY X PRO- LOC PRODUCTS-COMP/OP AGG $3,000,000 JECT OTHER: Deductible $100,000 B AUTOMOBILE LIABILITY Y 83UENOD1185 1/1/2023 1/1/2024 COMBINED SINGLE LIMIT $Y 000,000 (Ea accident) X 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) A X UMBRELLA LIAB X OCCUR Y VES0003958 1/1/2023 1/1/2024 EACH OCCURRENCE $8,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $8,000,000 DED RETENTION$ $ g 'I WORKERS COMPENSATION 83WEOD1184 1/1/2023 1/1/2024 X AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A -- — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 B yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Contractors Pollution Liability VRS0006329 1/1/2023 1/1/2024 Aggregate/Per Claim $2,000,000 Professional Liability Deductible $100,000 Environmental Impairment Liab. II DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) NAMED INSURED SCHEDULE: A.R.S. Services, LLC ARS Restoration Specialists, LLC A.R.S. Restoration Specialists, LLC Blaine Oney Construction Company, LLC DBA RESCON Restoration&Construction Firestar, Inc. Parker Young Construction Inc. Parker Young Construction, LLC See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Sketch: SKETCHI, Level: Basement Insured: JOHNSON, CLIFTON Claim#: 017100652-011 �1 ---4 � -e � -• Basement Is' • I—,. MEM Drop Cell inl ma■mow wraha MEI Basement was completely flooded with water. ~-I?s Sketch: SKETCHI, Level: Level 2 Insured: JOHNSON, CLIFTON Claim#: 017100652-011 ,_-5.__, Is-1 --~ 4./ '.1 1 ij I Storage Closet - \ IT Right Bedroom _ \4 A+ ___ii- 1---,,_. \ Left Bedroom .. . 1 _, mi. _'_ Landing — I ail SF 1 1/1®'1 _ \ ii Sketch: SKETCH!, Level: Main Level Insured: JOHNSON, CLIFTON Claim#: 017100652-011 _4_---1 /M S �J J, 1 FPI) I — i r :--1-1'S"mil•= " • / 3'=- 1 �If f i _ a �, Kitchen t i Bedroom 1 . Show _L 1 f Re bL . .__..,............... room 1, _ 1 , , - 11 , Rear Fntry I j iV a. I _ c.11" 1