38B-043 'Q`�°� CERTIFICATE OF LIABILITY INSURANCE 4/11/2` 14
'THIS CERTIFICATE IR>SLWED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIM'S 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
NMRTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(hm)must be endorsed. N 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 Neu of such endorsement(s).
PRODUCE t g2wCT Tierney Teams
Tierney Group PHONE (413)562-7007 FAx (888)271-2226
log I&16 North Elm Street
P O Box 750 $ AFFORDING COVERAGE NAIL•
Westfield MA 01086 INSURER A:Penn America
IauRED msunRoSafety Insurance Company 39454
N R B Exteriors Inc. ImuimcAmeriaan Zurich Ins Co
7 Philip Circle I SURER D Main Specialty Insurance
INSURER E
2Eetx HA 01033 INSURER F;
COVERAGES CERTIFICATE NUMBER:CL13121100171 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.
LTR TYPE OF INSURANCE POLICY NUMBER wolw rm I wpww Mm LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
R COMMERCIAL GENERAL LIABILITY PREMISES fEs $_ 100,000
A CLAIW-MADE Ex1 OCCUR PAV0000154 2/1/2012 2/1/2013 MED EXP(Any one $ 5,000
x $1,000.00 BI Daftet:ible PERSa+nL s AM MLURY $ 1,000,000
X $2,500.00 PD Daftict:ible vo016336 /1/2013 /1/2014 GENERAL AGGREGATE $ 2,000,000
GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000
POLICY MPRO-
,ECT M LOC $
AUTOMOBILE LIABILITY
ANY AUTO BODILY INJURY(Per person) $ _500,000
B ALL 0INNED SCHEDULED 222362 /15/2013 /15/2014
Ix AUTOS x AUTOS BODILY INJURY(Per arrldwt) $ 1 000,000
HIRED AUTOS A DAIAAC>E $ 200 000
$
UMBRELLA LIAa OCCUR EACH OCCURRENCE $
LAB CLAIMS-MADE AGGREGATE $
RETENTION s $
C WORKERS COMPENSAIM SZZUB-5872413-5-13 2/1/2012 2/1/2014 1 STA 9TH
ANY PROPRIETO IP,�YIN -5872413-5-14 /1/2013 /1/2014 �EACH ACCIDENT AO $ 100,000
OFRCI�IBER EXCLUDED? ® NIA
in Nl0 7CM M DIRSCI7,? aRDlt EL DISEASE-EA EM $ 500,000
M yea Oastsiie un kr
DESCRIPTION OF OPERATIONS below THE COMPANY E.L.DISEASE-POLIC $ 100,000
D IP359481 2/1/2012 /1'2013 200,000 Ge wal AffeWe
of CIP159481 2/1/2013 /1/2014 100=each ocasrerm
DESCMnQN OF C4%MIFKMIS I LOCATMM I VEIL INN ati ACOND Iii,AddN1awa!R 5Chm Aw N mate apace Is ntPtled)
siding, ulmdow inata3A&tion, caxpent:ty and roofing
CER I MATE Ha.DER CANCELLATION
pgugli elmi,no@ gaf.coa SHOD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Ii
GAF ACCORDANCE WITH THE POLICY PROVISIONS.
1361 Aps Road
Wayne, NJ 07015 AUTl10R>ZREPFITATLVE
ACS 25(20IMM 0 11IM2010 ACORD CORPORATION. AN rights reserved.
INS025 minmi m Tho Af_AR11 nsrno snel lnnn om nonimfonael tnorke of At'nRn
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 147961
Type: Private Corporation
Expiration: 8/23/2015 Tr# 242322
NRB EXTERIORS INC
NICHOLAS BERNIER
7 PHILIP CIRCLE -
GRANBY, MA 01033
Update Address and return card.Mark reason for change.
SCA 1 t'o 20M-05/11
Address [j Renewal [:] Employment Lost Card
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
k'WjOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: 147961 Type: Office of Consumer Affairs and Business Regulation
Expiration: 8/2312015 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
NRB EXTERIORS INC
NICHOLAS BERNIER
7 PHILIL CIRCLE r
GRANBY,MA 01033 Undersecretary Not valid without signature
Y?
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction SupeniiwrSpecialty
License: CSSL-099565
t 4 §a
NICHOLAS R BERM
7 PBILIP CIRCLE ~�
Granby MA 0103
o"°` Expiration
Commissioner 0512812016
(owner)
W1 N �R N ME ���VE E NTS. � www.nrbexteriors.com
IoNlaater_ ROOFING &SEAMLESS GUTTERS
Windows - Siding- Decks
Residential - Commercial
'r p sal submitted to: 4 Phone# h: fj a, c:
Special requirements
;treet fi
..
.� �,
'ity, state, zip code
roposal to furnish and install the following
Re-roof D�Year-off ❑ Gutters p
We shall acquire necessary permits for all work
Complete Roof Preparation
Home's exterior to be protected by tarps and plywood
Shrubs, landscaping,trees to be protected, roofers buggy used
Entire existing roofing materials to be removed to existing decking, including flashing, etc.
Site to be cleaned on a daily basis with roll magnet, debris to be removed at project completion by dumpster
Deteriorated existing decking to be replaced at w sheet of plywood t
Complete CertainTeed Integrity Roof System 1
Install Winterguard ice &water barrier along bottom 3 ft. of all roofs, ❑ 6 ft.
Install Winterguard ice &water barrier around penetrations, in valleys and all critical areas
Install 15#saturated asphalt felt paper to entire decking
Ii "Install Roofers Select Premium underlayment to entire decking
Install DiamondDeck Synthetic underlayment to entire decking
Install 8"perimeter metal flashing to all edges of all roofs, ❑ white ❑ brown
f Install SwiftStart starter shingle to bottom and rake edges of all roofs
I Install CertainTeed shingles to manufacturers specifications, ❑ 6 nails ❑ 4 nails
Install Shingle Vent II PVC ridge vent to all peaks in heated areas
Install Shadow Ridge to all hips and ridges,over ridge vent where applicable
Install new lead counter flashing to chimney
New flashing installed where necessary
Install new pipe flashing to waste vent stacks
Warranty options
We guarantee our labor/workmanship for 20 years
Upgrade CertainTeed 5-Star Sure 5 , 'us SO-year nonprorated coverage,including workmanship
Upgrade CertainTeed 4-S re Start Plus, 50-year nonprorate-& c e
CertainTeed Landmark-col ' 3-tab
M,
CertainTeed Landmark Pro-color
e propose hereby to furnish materials and labor—complete in accordance with above specifications for the sum of.Total Due
CCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are - 1/3 Down Payment$
itisfactory and are hereby accepted You are authorized:to do work as specked. Balance due
ayment will be 113 down at start of job,and balance due upon completion. upon completion
►ate: Signature:
)ate: Estimator: (Print Named � (Sign Name)
�
i a
The Commonwealth of Massachusetts
Department of IndustrialAccidents
f Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): nrb exteriors inc
Address:7 Philip cir
City/State/Zip:granby ,, ma 01033 Phone #:413 563 6354
Are you an employer? Check the appropriate box: Type of project(required):
1.M I am a employer with 5 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working or me in an capacity. employees and have workers'
g Y p ty• 9. E] Building addition.
[No workers' comp. insurance comp. insurance.1
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑E Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#I 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:american zurich
Policy#or Self-ins. Lic. #:6zzub-5b72413-5-14 Expiration Date: 12-1-14
Job Site Address: 10 lasell ave City/State/Zip:florence ma
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 MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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!
9-10-14
Signature: Dat e:
Phone#: 413 5636354
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction�Supervisor: Not Applicable ❑
Name of License Holder:
License Number
n�� c ✓ Uf�1� 1� t4ol
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
�qI1� & k
Company Name R Registration Number
AA
Address Expiration Date
Telephone
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....... N 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 ZonifIR La apd State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors D %
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[C7j
Brief Desc i tion of Proposed I ,
Work: 1'�.i�w..>--L ' 7G f,!:3
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
I, X 0'/" , C as Owner of the subject
property ,
hereby authorize � V/�yl
to act on my behalf, in all matters relative to work authorized by this building permit application.
C , uu-' "l
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under , pains and penalties of perjury.
Print ame
Signature of Owner/ gent Date
r Department use only
`'pity of Northampton status of Permit:
Building Department Curb Cut/Driveway Permit
SEP 152014 212 Main Street Sewer/Septic Availability
ROOM 100 Water/Well Availability
c hampton, MA 01060
Electric, glum Two Sets of Structural Plans
North r i e: 1 687-1240 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
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
O`-'� C t ,�'cc Telephon rT
Signature
2.2 Authorized Agent:
N�16 ,. r
Name(Prin �L Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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
( ) / i Check Number Q
6. Total= 1 +2+3+4+5
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building CommissionerlInspector of Buildings Date
ry,�
10 LASELL AVE BP-2015-0298
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-043 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-2015-0298
Project# JS-2015-000565
Est. Cost: $12800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NRB EXTERIORS INC 99565
Lot Size(sq. ft.): 4007.52 Owner: COTE KEVIN
Zoning. URB(100)/ Applicant: NRB EXTERIORS INC
AT. 10 LASELL AVE
Applicant Address: Phone: Insurance:
7 PHILIP CIRCLE (413) 563-6354 WC
GRANBYMA01033 ISSUED ON.911612014 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & 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 9/16/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner