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38D-044 (3) BP-2023-1451 28 HARLOW AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38D-044-001 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-2023-1451 PERMISSION IS HEREBY GRANTED TO: Project# CHIMNEY LINER 2023 Contractor: License: Est.Cost: 9954 FIRESAFE CHIMNEY SERVICES INC 105507 Const.Class: Exp.Date: 01/19/2024 Use Group: Owner: ROBERT LOCK 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: 10/18/2023 TO PERFORM THE FOLLOWING WORK: RELINE CHIMNEY WITH LINER 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: f ,I ' • • . . T ,8 • , Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner rn The Commonwealth of Massac usettR E C E I " E D W Board of Building Regulations and tan rd FOR Massachusetts State Building Code, 80 CMI� MUNICIPALITY U CT 2023 USE Building Permit Application To Construct, Repair, enovate Or Demolish a Revis d Mar 2011 One- or Two-Family Dwelli g _ — z -tm_n�NC iuorrCTto�S This Section For Official tllse On ,.T ia1.,n�oh rya oioso ..-;.---- Building Permit Number: 60-A.3' ld16'f Date Applied: 4,,...., a5, //,/ /6-16 7.3 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Pr.opetr y Ad ress:� 1.2 Assessors Map&Parcel Numbers QoorInk1.1 a�IsSthis 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 ❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.tLiDbe ncortd: r10 r fT on 1 f F O I o u n Name(Print) City,State,ZIP acc cAyAoco Ave au 5-1i-9O4 lOcKoroberi-Qcur�a.tl . corms No.and Street Telephone Email Addres SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition ❑ Accessory Bldg. ❑ Number of Units Other,Specify:[hLrn(1- -)( (P{)Gt,�Y'S Brief Description of Proposed Work': `1 f-elLnt, C�nlvnak1 c * SS ,Si-eel l`ram P SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ (` 1 J Lic co 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ 0 Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) 0 Total All Fees: $ (� Check No.1$� Check Amott:(I6 Cash Amount: 6. Total Project Cost: $C{qLJ(.i CO ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) I D 5 J O--1 r (4 a L' 3C,tr1eS LIDCL`,l ��C License Number Expiration )ate Name of CSL Holder Cv' L—t �T�� 54- List CSL Type(see below) No.and Street Type Description SOu-\n �' 3`7n�� OtO��� U Unrestricted(Buildings up to 35,000 Cu.ft.) v � I Inv )J (� Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry 3l.rYNDtre Sc u"v y 2(Ill(-LS RC Roofing Covering WS Window and Siding r (or-, �1 Solid Fuel Burning Appliances C�--I,13�30)— �-! CoI Insulation Telephone Email address D Demolition 5..22'Registered Home Improvement Contractor(HIC) 1 CS dq 1L G1 -� r we c7li ,. l \L.�ntt U L(I HIIC Registration` Number Ex atio ) Date ` H Name or HIC R strant me o f y r r Cc sctvr-int-rtre� herint v- 2Jr✓«s, NStreet UrAre ^ _ ©kl 1, e;,3u_-7n the Email address / COYy1 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 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 �l' -e C r l L �r V tc J to act on my behalf,in all matters relative to work authorized by this building permit application. r-obeck L,ccA,k of it Print Owner's Name(Electronic Signature) 1,sa ate 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. Os Cale Iy 11 a3 Print Owner's or Authorized Agent's Name( leonic 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 o t Kl�rH f. SAS A Massachusetts qts r.; Irr .c y, ;� ! DEPARTMENT OF BUILDING INSPECTIONS y •.1 212 Main Street • Municipal Building ud•. :�a Northampton, MA 01060 �S17y•. ��� 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: CCL_C\,\_CL asLA - Card hrfAire--1 The debris will be transported by: Name of Hauler: t-1\.treS[ - CA141'11191 CZYVI CIZ-S Signature of Applicant: Date: LO 4l id3 The Commonwealth of Massachusetts la. _ Department of Industrial Accidents , II-...p 23 _.mow 51 1 Congress Street,Suite 100 !ji— t' Boston,MA 02114-2017 `.';,.�=stu wwwwmass.gov/dta II utters'(:o.pensadon Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AIlI'HOI(ITti'. Annlicant Information I,� Please Print Leeibly me Na (RusittessiOrganization'lndividual): rl''e co 1 C Y l l y,'1„�_�/ 5 ex (f t &Q..S Address: a 17 Pei.rn r / City/State/Zip: L 1'e 1 M P O 10ScA Phone#: 0-I 13) -fin 9 CD Are ye.an etariryet?Ckeek the appropriate box: Type.f project(required): 1 I am a employer with__-1 employees(lull and or part-tune).." g7. New construction 2I am a sole propriety or partnership and hale no employees working forme m 8. 0 Remodeling any capacity.[No workers`comp.insurance na(wrcal.l 3CI I am a hunuwncr doingall work myself_[No ssuricrs'c insurance 9. ❑Demolition rc 4.0 I am a homeowner and will be hieing contractors to conduct all work on my property. I will 10 Q Building addition ensue that all cortrae[ors either have wwkcts'compensation iaehnance or arc salt I I..Electrical repairs or additions tun with no c�toployenc_ pfPp`h 12.0 Plumbing repairs or additions 5.10 I am a general contractor and I have hind the subti,�ntracton listed on the attached sheet_ 13❑Roof These subti"raura,turs hasc employees and has or e workers'comp.utsurancc_• repairs nt 6.0 We are aoerpraatiun and its officers hose esereised their right of csevuptim per!SK IL c.. 14. O Cf�`��/ ' 15231(4),and we have no employees.[Nu wrrkc •comp_insurance nyuircd_f A 1 J 'Any appbei t tint ducks box al snort also fill rut the section below showing their workers'comp eowiliea polity nhfortneintn. f Iloareawaes who auMnit this affidavit indicating trey are doing all work and dim hire outside euumme ors astir outwit a new affidavit indicating such :Contractors that check this hoz moo attached an additional sheet showing tic nano oldie sub-cuma[lorsand stale whether lit nut those amities have employees_ If the sub-contractors hose employees.they must proside their worker;comp_policy number. I am on employer that is providing workers'compensation insurance for my eatployees. Below is the policy and job site information. insurance Company Name: "e(/etQ S /' _ Pokey#or Self=ins.Lic.#:7PJ U f3& O 3 3 5�'� Expiration Date: 511 Q./a q lob Site Address: C thtt©W V?VC, City/State/Zip: rbr fryi rnp-{on, f ifiR Attach a copy of the workers'compensation policy declaratieti page(showing the policy number and expi date).CI D WO Failure to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 the pains and penalties of perjuty that the information provided above is true and correct. i Signature: Date: t b) i I 1 02 3 Phone#: (q13)`Z 3L0_ C ` `I CD Official use only. Do not wile in this urea,to be completed by city or town official I ('its or Tows: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.(7ity/1'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: di Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Constructirle p rrifsqr Specialty •f CSSL-105507 f pires:01/19/2024 JAMES J WALLING 40 HIGH STREET P.O. BOX 40 SOUTH BARR6 MA 01074 tr)fJ,t`da-'- • Commissioner ;�a..C,,,;: V ant Via THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home improvement Contractor Registration • Type: Corporation FIRESAFE CHIMNEY SERVICES Registration: 182449 277 PALMER RD UNIT 2D -t Expiration: 06125/2025 WARE,MA 01082 <ac,. :cam 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 JAMES WALLING JR .7 277 PALMER RD WARE,MA 01082 Undersecretary of wJtit signature ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 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 NAME: Jessica Pierce BRABO INSURANCE (ac°.No.Ext): (508)830-3800 Fax L ADDRESS: jpierce@braboinsurance.com 65 Cordage Park Circle INSURER(S)AFFORDING COVERAGE NAIC C 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. IUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD ADDL SWVD POLICY NUMBER (MM/DDIYYYY) (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET 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) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PEX PERTUTE OTH AND EMPLOYERS'LIABILITY A OFFER CER/MEMBEREXCLUDED?ECUTIVE NIA N/A N/A 7PJUBOG03354623 05/12/2023 05/12/2024 E.L.EACH ACCIDENT $ 1,000,000 (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.Crowlby,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 ACORO (MM/D DATE DNYYY) 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 65 Cordage Park Circle PHONE ra Lo,Ext): (508)830-3800 FAX No):(508)746-1540 Plymouth,MA 02360 E-MAILADDRESS: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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DDNYYYI (MM/DD/YYYY] A X COMMERCIAL GENERAL LIABILITY _EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR WS551038 7/15/2023 7/15/2024 DAMAGE TO RENTEDaoccurrence) $ 100,000 PREMISES(E 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 JECT PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY accident) AUTOS ONLY _ AUTOS ONLY UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR 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/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/LOCATIONS I 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 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