29-556 .ay- 1'1 -u11 uts: till. rtem111ara insurance 141JOJ00Vly —,
OP ID: LI
,4 CC)
• C° - CERTIFICATE OF LIABILITY INSURANCE D
05117111
THIS 1
THIS CERTIF CATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CEP,TIF!CA c DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TH S CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENT • ?WE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate hdlder is an ADDITIONAL INSURED, the policy(Ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms an • conditions of the policy, certalmr„Ilicies may require an endorsement. A statement on this certificate does not confer rights to the
certificate ho • er In Lieu of such endorsement(s).
PRODUCER 413 -538 -7862 Linda Landry
Remillard ins ranee Agcy, Inc 413 -538 -7179 P H NE FA
79 Lyman St - � Ae. S>�tt: - 5 38 - 7862 1 (Arc , No): 413 538 - 6010
South Hadley, MA 01075 AADD kes; II ndaiandry@remillardinsurance .com
PRODUCER Remillard Ins. , gcy,, Inc. CUSTOMER IDaK: AJHOM - 1
INSURER(S) AFFORDING COVERAGE NAM S
INSURED A J, Home Improvements Inc INSURER A :Western World Ins,, Co.
60 Washington Ave INSURER a; National Union Fire Ins. Co.
So Hadley, MA 01075 INSURER C ; Safety Insurance Company 39454
INSURER O ;
■
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER;
THIS IS TO CE TIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. N: ',WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE Y BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS A 0 CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IR • E OF INSURANCE ADDLISUBR Ptarc1rFPF _ fs6CfCY E�p
, tNCR vow, POLICY NUAttEER IMnt QDIYYYYI! IAI»YYYY) LIMITS
GENERAL Lt :1Ln Y I EACH OCCURRENCE I a 1,000,00(1
J
A c�)MMER IRI GENERAL LIABILITY NPP1260082 04/22/11 04122/12 EmuS tEa nay
DAMAGE TO RENTED a _ 50,000
CI.AI. £•;BADE L X I OCCUR MED EXP (Any one person) S 6,0001
PERSONAL & ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GEM. AGGRE r ATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG It 1,000,000
1 POLICY I I P ST I 1 LOC S
AUTOMOBILE (ABILITY COMBINED SINGLE LIMIT S
C ANY AUT• 2432426 11/24/10 11/24/11 (Ea accident)
BODILY INJURY (Per pertain) $ 260,000
ALL OWN: 0 AUTOS BODILY INJURY (Per aoctdenl) 3 500,000
X SCHEDU '0 AUTOS
~ PROPERTY DAMAGE S 100,000
. HIRED AU. OS (Peracctdent)
NON-OW O AUTOS S
a
UMBREL LIRE OCCUR EACH OCCURRENCE S
EXCESS B CLAIMS-MADE AGGREGATE S
DEOUCTIB E S
J R6 S _ S .
WORKERS CO •ENSATION j \NgSTATU- tOTN-
AND EMPLOYE ` S' UABiUTY �yyY ///J pppN 1 TORY LAWS I ! ER -
B ANY PROPRIE • R/PARTNERIEXECUTIVE f t N ! A WC003796174 05/11/11 06111/12 E.L. EACH ACCIDENT S 100,000
OFFICER/MEMB R EXCLUDED?
(Mandatory In N E L. DISEASE - EA EMPLOYEE; 5 100,000
Kyss de • or
DESCRIPTION ' P OPERATIONS Delow • E.L. DISEASE - POLICY LIMIT S 600,000
I
: OF OPE - TIONS! LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, Irn more spate Is requltad)
•
DERTIFICATE H DLDER CANCELLATION
ANDYDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
And/ Doren ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
/
01968 -2009 ACORD CORPORATION. All rights reserved.
tCORD 26 (2009 09) The ACORD name and logo are registered marks of ACORD
A & J Home Improvements Inc.
---4!11111116ftft--- 60 Washington Avenue • South Hadley, MA 01075 761'563 „
certified Office I Fax: (413) 467 -1500 • Cell: (413)
Weather stopperHootMq contractor
AJHomelmprovemehts @yahoo.com
HIC Lic # 135399 • GAF -ELK ID # CE17267 • CT Lic # 600705 / CS, SL, RF, WS # 101017
Proposal Submitted To: Phone #'s:
S xo Potte, Home: 7'1 / '? Cell:
Street: � tY �)
(9(C5 e
City, State, Zip Cod
n(Q . h A Nk. 60 Faxs ct.kkive nQ . 7 aS
'House ❑ Garage ❑ Other
Proposal to furnish / end install the following:
R efiklc ; � '�a ,t k�� r tau i `:�
❑ Re -Roof t Tear -off ❑ Gutter
Complete Roof Preparation
5e1 Home exterior to be protected by tarps and plywood
/ Shrubs, landscaping, trees to be protected
/ Roofers buggy shall be used where accessible with permission from owner
J Entire existing roofing material to be removed to existing decking, including flashing, etc.
Site to be cleaned everyday with roll magnet debris removed at project completion (included in price)
4 Deteriorated existing decking replaced at $2.50 per sq. ft. DZ. NOip'v16'w.- Ovotol
hite Brown 8 inch metal drip edge installed at eaves and rakes ❑ White /Brown 5 inch for re -roof only
/ New flashing will be installed where necessar / install lead to chimn
Install new pipe boot flashing
CiWe shall acquire all appropriate permits etc. for all roofing work
Complete Roof System
We propose hereby tQ urnish materials and labor - complete in accordance with above specifications for
the sum of: ';(1')(-)) `j `f
Total Sale Price $ 100,06 Down Payment $ atb0. 00 Upon Completion $
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory anc
are hereby accepted. You are authorized to do work as specified. Payment will be 1/3 down upon
signing, and balance due upon completion. Unpaid balances shall accrue with interest at 18% per
annum. Purchaser(s) will pay for all costs, expenses and reasonable attorney's fees incurred by
A & J Home Improvements, Inc. t. ecover any su s due under this contract.
Date: /01/0 MN/Signature: A1!7 L , Phone # 4/3, ; .1 003(
Date: 10 j Estimator's Signature:
ATTENTION HOMEOWNERS: Please cover all personal belongings in the attic, garage or storage
• . _ _ _.._!I!�_. _t .__s:�,. rlwh64C. „r .I,ucf , -nminn thrniinh cracks of the wood. A & J
L\ The Commonwealth of Massachusetts
( Department of Industrial Accidents
j�; Once of Investigations
o
1: ��1 600 Washington Street
I_
.j Boston, MA 02111
_ `' www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Annlieant Information Please Print Lenibly
Name (Business/Organization/Individual): : ,.. , v m e i nl
Address: ; 0 W( tsh ∎✓tc *,0, !`1 veik
City /State /Zip :_ {..�<,. it lett , 1 �► ' Phone /#: _ _______
/I 3 4 /6 ) IS G ()
Areyou an employer? Check !Ile appropriate box: Type of project (required):
1. ar I am a employer with _ ___ 4. ❑ I am a general contractor and I 6. Q New construction
employees (Rill and /or part - time).* have hired the sub - contractors
2.L1 I am a sole proprietor or partner- listed on the attached sheet. 7 • Q Remodeling
ship and have no employees These sub - contractors have S, Q Demolition
working for me in any capacity. workers' comp. insurance. 9, Q Building addition
[No workers' comp, insurance 5. [11 We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 1 l .❑ Plumbing repairs or additions
myself. [No workers' comp, c. 152, § 1(4), and we have no 12.('i�Roof repairs
insurance required.] '' employees. [No workers' 1.3.0 Other
comp. insurance required, - -- _
`Any applicant that checks box i! i must also till out the section below showing their ssotkers' compensation policy information.
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 their workers' comp. policy information.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. (,\ T.
Insurance Company Name :___.)l.x , 1 t . t . i l r 0,, .AQ_ :�-+ r'. _ _
Policy # or Self-ins. Lic. #: l -.s, C� U0, `) j ` (;� _ i __ — Expiration Date : '`a l± _ _ t �,t� 1 �
Job Site tldciress: _ 6
& S B ` (r
Ra City /State /lip :____F 10t144. !
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of,MOL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
l do hereby c•ert f ' under th_q_pn, and penalties of perjury that the information provided above is true and correct
'jig i t ire � . " .� ^"ti �_ Date: ` 'S ' A —
r
?hone # #: /. _ c 1 � (k 1 l i-•C? _ -- -- _
t
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: _ _,_____ __ _,_.-__ - Permit/License 0 ._
issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ____ _
Contact Person: Phone #:
arrraw•ww■
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 10101.7
P License Number
nt — C1 0 13
Address Expiration Date
Ratqk Aftivn1 MA--
Si Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
n 3 4D•Q I mpkoRimAL 2 y539 c t
Company Name Registration Number
Gf7 t:eXilSk1t1 1 �4 14 IO S 1'c�Ot 1
Address U Expiration Date
Telephone %t /5
SECTION 10- 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 1 No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own 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 homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ligi
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [D]
Brief Description of Proposed
Work: strip and shingle roof
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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.
S ignature of Owner Date
I t l t - tb"\R Ti4 „4 -fr , as Owne uthonzed
Ageni hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my edge
"Oa-belief.
Signed under the pains and enalties of perjury.
,....
Print Name
Signature of • ner /Agent Date
4
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO V
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
RECE • Department use only
City of Northampton Status of Permit:
3 2011 Building Department Curb Cut/Driveway Permit
DEC I 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
ptON .o1060 t rthampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
C C0-4Th Map Lot Unit
ijU� Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Stacia Potter 685 Ryan Road Florence MA
Name (Print) Current Mailing Address:
413 727 8636
Telephone
Signature
2.2 Authorized Agent:
0 3" 4T . , , .. - Leo test,,, i, A — \ 0d tI.I'
Name (Print) • Current Mailing Address:
It /
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 7,950 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 7,950 Check Number 011/9 7 443 5_
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
605 RYAN RD BP- 2012 -0573
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 556 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0573
Project # JS- 2012- 000971
Est. Cost: $7950.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: A & J HOME IMPROVEMENT INC 101017
Lot Size(sq. ft.): 20037.60 Owner: POTTER STACIA
Zoning: URA(100) //WSP II Applicant: A & J HOME IMPROVEMENT INC
AT: 605 RYAN RD
Applicant Address: Phone: Insurance:
60 WASHINGTON AVE (413) 323 -7847 WC
SOUTH HADLEYMA01075 ISSUED ON:12/13/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 12/13/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner