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38D-030 (5) 292 SOUTH ST BP-2020-0037 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:38D-030 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-2020-0037 Proiect# JS-2020- Est.Cost: $6210.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ROBERTS ROOFS CO INC 100333 Lot Size(sg.ft.): 10715.76 Owner: CHANDLESS CORINNE Zoning: URB(100)/ Applicant. ROBERTS ROOFS CO INC AT: 292 SOUTH ST Applicant Address: Phone: Insurance: P O BOX 1312 (413)283-4395 Workers Compensation BONDSVILLEMA01009I ISSUED ON.7/12/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP SLATE ROOFING &SHINGLE ROOF WITH ASPHALT ON DRIVEWAY SIDE ONLY POST THIS CARD SO IT IS iVISIBLE FROM THE STREET Inspector of Plumbing Inspecor of Wiring D.P.W. Building Inspector Underground: Servico: Meter: Footings: Rough: Rough House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire DiDartment Fireplace/Chimney: Rough: Oil: Insulation: Final: Smok : Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeTyne: j Date Paid: Amount: Building 7/12/ 019 0:00:00 $40.00 12 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner -----`—"-- Department use only City of Ngrtha►1(�pttEl= tatu of Permit / Building geparftttent'" urb uUDriveway Permit 212 Mai Street ewer eptic Availability Roo 1M JUL � 2018 ater ell Availability ` Northampto , MA101060 T o Se s of Structural Plans phone 413-587-12401 Fax �sP' cT' �Usit Plans PFPT 0 IL rnAn,c er Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION P� �0 7 1.1 Property Address: This section to be completedy office 292 South Street Map Lot 0 Unit Northampton, MA 01060 Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Corinne Chandless 292 South Street Northampton, MA 01060 Name(Print) Current Mailing Address: (413)695-0778 Telephone Signature 2.2 Authorized Agent: Roberts Roofs Co., Inc. PO Box 1312 Bondsville, MA 01009 Name(Print) Current Mailing Address. 413-283-4395 Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee /J H 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 + 3+4+ 5) $6,210.00 Check Number This Section For Official Use Only Building Permit Number: Date / Issued: Signature: Building Commissioner/Inspector of Buildings Date info 62—) robertsroofsinc.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 ® DON'T KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW O YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO Q IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing, grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [O] Other[p] Brief Description of Proposed Work: Remove and replace slate roofing with asphalt shingle roofing on driveway side only �/ Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x 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 Corinne Chandless as Owner of the subject property Roberts Roofs Co., Inc. /Brian Blanchette hereby authorize to act on my b7�lf, in all matters five to work authorized by this building permit application. Signature of Owner Date Roberts Roofs Co., Inc. / Brian Blanchette 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 the pains and penalties of perjury. Brian Blanchette Print Name Sig6alw4 of Owner/AgeTir Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Thomas R Roberts CSSL - 100333 License Number PO Box 1312 Bondsville, MA 01009 7/3/20 Address Expiration Date Signature Telephone 413-283-4395 9. Registered Home Improvement Contractor: Not Applicable ❑ Roberts Roofs Co., Inc. 128264 Company Name Registration Number 400 Franklin Street Belchertown, MA 01007 3/16/21 Addre Expiration Date S �• Up Telephone 283-4395 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....... IM No...... ❑ City of Northampton Massachusetts ,G ;! DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Wit, J C'� 1 Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building'be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work:Roof replacement Est.Cost:$6,210.00 Address of Work:292 south Street Northampton,MA 01060 Date of Permit Application: 76 a/(ck I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied _Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: ,Z,/ Roberts Roofs Co., Inc. 128264 Date Contractor Name HIC Registration No. OR: Notwithstanding the above n tice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature Commonwealth of Massachusetts Division of Professional Licensure y Board of Building Regulations and Standards Construction-Supervisor Specialty CSSL-100333 Expires: 0710312020 THOMAS R ROBERTS,JR PO BOX 1312 ` BONDSVILLE MA 01009 nr Commissioner sib Restricted to Construction Supervisor Specialty CS-SL-RF Roofing Failure to possess State guildin a current edition 9 Code matione for revocat,oh assachusetts For infor Call(617 abo this lic 727-3200 or visitut this license license. Cali I I i Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration I Type Corporation ROBERTS FROnFS CO.INC. Regi5trabon 128264 PO BOX 1312 E.pualion 0311612021 BONUSVILLE,MA 01009 I ' tCA t 4 Iwaerrn Update Address and Return Gard. Oftles of Cortaumer ABaln A Business Reeulatlon HOME IMPROVEMENT CONTRACTOR Regrstrafion valid for Individual use only TYPE:Coroomil n before the eapimillon date. If found return to: S49t8hation Es_ ha Office of Consumer Affairs and Suslnoce Regulatlnn 120264 0311512021000 Weshinglue Street•Suite 710 ROGER 15 HOOFS CO.INC. 8os1nn,1VIA 02118 I f AR08ERTS JR � 400OFRANKLIN LIN ST J(llfnl>�] Vr ✓✓✓���'^�--CCV//"'��� BFLCIlrRTOWN,MA 0100 - Undersecretary Not valid Without signature I City of Northampton Massachusetts << tt � A y. DEPARTMENT OF BUILDING INSPECTIONS ro 212 Main Street •Municipal Building CDS Northampton, MA 01060 Debr ' s Disposal Affidavit In accordance of the provisi ns of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting fron the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: 292 South Street Northampton, MA 01060 (Please print house number a d street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: USA Hauling & Recycling - CT (Company Name and Address) Ci ure of Permit pplicant or Owne If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Roberts Roofs Co., Inc Address: PO Box 1312 City/State/Zip: Bondsville, MA 01009 Phone #: 283-4395 Are you an employer?Check the appropriate box: Type of project(required): 1.f] I am a employer with 2 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12Z] Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. I 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance company Name: Farm Family Casualty Insurance Company Policy#or Self-ins. Lic.#: 2008W6216 Expiration Date: 4/17/20 Job Site Address: 292 South Street City/State/Zip: Northampton, MA 01060 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 andpenalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 28364695 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#: DATE(MM/DD/YYYY) �tc"1 CE TIFICATE OF LIABILITY INSURANCE 04/17/2019 THIS CERTIFICATE IS ISSUED AS A MA ER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS j 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 be endorsed. It 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 Sean Rooney y Sean Patrick Rooney,Sr.dba ��"�No 413-887 8817 (AA/C,No):__877-771-6087 Rooney Insurance Services A DDDO RIFs, sean.rooney@farm-family.com 2341 Boston Rd. INSu S AFFORDING COVERAGE N=# Wilbraham MA 01095 INSURER A: Farm Family Casualty Insurance Company 13803 INSURED INSURER 0: Roberts Roofs Company, Inc. INSURER C: PO Box 1312 INSURER 0: _ Bondsville, MA 01009 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. IR TYPE OF INSURANCE ASDL 3Ut R POLICY NUMBER MM/DDY YY MWDD E7(P LT LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000000 _ CLAIMS-MADE OCCUR PREMISES EaENTED oocufrence $ 1 MED EXP(Any one $ 5,000 A Business Owners Policy 2007X0329 04/17/19 04/17/20 PERSONAL SADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY El ESC F-1 LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY C�OMBiNED SINGLE LIMB s ANY AUTO BODILY INJURY(Per person) i ALL OWNED SCHEDULED BODILY INJURY(Per accident) t AUTOS AUTOS NON OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS S UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY TA LITE ER YIN N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. ACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? ❑ E.L.N/A 2008W6216 04/17/19 04/17/20 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 5()0000 i 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sean Patrick Rooney,Sr. O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD