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18C-136 (8) 68 BLACKBERRY LN BP-2020-0653 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C- 136 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-2020-0653 Proiect# . JS-2020-001110 Est.Cost: $23250.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: U S METAL ROOFING DISTRIBUTORS, INC 031003 Lot Size(sg.ft.): 10846.44 Owner: LIVINGSTON HEATHER zoning: URB(100)/ Applicant: U S METAL ROOFING DISTRIBUTORS, INC AT: 68 BLACKBERRY LN Applicant Address: Phone: Insurance: 740 HIGH ST, SUITE 2 (413) 536-5474 WC HOLYOKEMA01040 ISSUED ON:11/21/2019 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 11/21/2019 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner uepariment use onry City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit j rti- A 212 Main Street Sewer/Septic Availability i l ' �• . t. Room 100 Water/Well Availabiliforty ` Northampton, MA 01060 Two Sets of Structural Plans a=rr phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTE RE I N A ONE OR TWO AMILY DWELLING SECTION 1 -SITE INFORMATION J 9.1/Property Address: 2019 Thi section to be completed by office CD i�f QLJ` be(J y i—. DEPT OFGUIIp Lot Unit J NORTHAPMO h?r0N rnblMr'TIONS V 0 r 4A amPloyL ' M A 01066 Overlay District 1 V ,D Elm St.District CS District SECTION 2 -PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Pg4ri ck Lwi ti alor, der14e31QL berq Lrt MrA a iL Name (P t) Current Mailing Address: &flo - oa- el r Vii —r Telephone S re 2.2 Authorized vAgent: f 7qO Name(Print) Current Mailing rete,r o r1 l ce -.—� W3- 37Y- 74170 03-5,76-2S1-7y Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS 7- 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 4. Mechanical(HVAC) �V 5. Fire Protection 6. Total=(1 +2+3+4+5) s' Check Number This Section For Official Use Only Building Permit Number: f Date Issued: Signature: �I al71 -9 - IV Building Commissioner/inspector of Bulidings Date Ket+k@ usrne+x( RaDfl(rnjDrk EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [a Decks [[M Siding [p] Other[cq Brief Descriptio of Prod /�' J Work: earripfls� ' I q C.Qha]4 AD LLYII�. 2-WSAzd't' t9 !Alm /��• 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 . 1. 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, +Pa-4h-e r L o' as Owner of the subject property /y� ) / hereby authorize U S, !•1e,4 �bb�� is��.� ors 3h�. ` to act Snmy half, in all matters relative to work authorize y this building permit application. a � � s tune of C>H7ier: Date N 211 1 U l I, kt_1A /C to 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. Print Name slenature of Owner/Aoerit Date The Comnwnwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 J° www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information n /; Please Print Le¢ibly Name(Business/Orgmizatio//n/Individual): Ur �}"�s, /' Ay A Nl9 b61r `-4r'S S n G- I � Address: -7q0 94 5Y te/ fY)A City/State/Zip: v f ^4 /Pq0 Phone#: yl�� ,j alp-s��-7 Are}ou an em ployer?Ch theappropriate boa: Type of project(required): 1. I am a employer with t employees(full and/or part-time).' 7. ❑New construction 2.[]I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.� 1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]$ El Demolition 10 ❑Building addition 4.❑I 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.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.[3 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.t n Qf /G�t'Mnr 6.[-]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�bther KOD� /` 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: L� 6i�-- l/► V 46al Policy#or Self-ins.L�ic.#: W C o13 1Slol(097 yD(q Expiration Date: 7 /D(,6t.a O Job Site Address: [03 81 ack b L h e— City/State/Zip: JVJ T YMIJ, 61660 Attach a copy of the workers'compensatioA policy declaration page(showing the policy number and ex: i tra ion 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: P<-'aiA � �! Date: /(f6y l 7, -C)c /q Phone#: '113 —37q— 9N70 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. Citi/To-vvn Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: i_ NottAppplicable ❑ Name of License Holder: Gary (fie.� \r\- C S —C7 2J j C)y 3 License Number a� CurninghaK S-� MA DI1O`7 5/19 ��o�b Address Expiration Date `fl3- 379- 11-7a Signatureg Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ 13`f 74)0 Company Name Registration Number V, S• D / ,96a C) t Address �j Expiration Date r / -1 C' r�� c�� SL1�� o� VO)lbe �Telephone `j13--S3 ,`_59 74 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....... 11 No...... ❑ . e'� (2�2�2�2�?iLf1��/�� Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation Registration: 134740 U.S.METAL ROOFING DISTRIBUTION ,INC. Expiration: 01/18/2020 740 HIGH ST.SUITE 2 HOLYOKE,MA 01040 Update Address and Return Card. 41 0 20Mi-05/17 r/Xr office of consumer Affairs&Business Regulation Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR 9 TYPE:Corporation before the expiration date. It found return to: Reoistration Expiration Office of Consumer Affairs and Business Regulation 134740 01/18/2020 10 Park Plaza-Suite 5170 U.S.METAL ROOFING DISTRIBUTION,INC. Boston,MA 02116 GARY C.REHBEIN 740 HIGH ST.SUITE 2 Com` t valid without signature HOLYOKE.MA 01040 Undersecretary Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-031003 Expires: 05/19i2020 GARY C REHBEIN 24 CUNNINGHAM STREET j SPRINGFIELD MA 01107 ; Commissioner CIL City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 srNW,..��0 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: A00 f a0/Q!r°lr�e�1L Est. Cost: o9 •5z) 00 Address of Work: /ic k berry L r r-�l►� bi1 j►'I } D 1 60 Date of Permit Application: Iy O V j 7i of 01 9 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: NOV III 0.0 U. S. e a Z Pup(in �� b,��s zn� 3 `)7 LID Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton r 'r Massachusetts DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street •Municipal Building -- Mr+- Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from 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: 6? Y t6 h? c 1 .4aerri Lane- (Please print house number and str et name) Is to be disposed of at: Cct,S 6114, U14S le S-i7M Mi/t 51 /hlq- (Please print name and locati of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit Applicant or caner Date 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. �\�� U.S. METAL ROOFING 740 High Street-Suite 2,Holyoke,MA 01040 1-800-232-0399.1.413-536-5474-Fax 1-413-533-8166 o„E Sao:Eo ma600�a 1161;y 4hDo,rAm, www.ustnetaitnoSng.net d�� /o 619 I N Pl,ONE NUMBE>l4 e �ie n n -(o70-d srrEET ,ea IOGCiON P Y GIrY.61xTE NDpV 000E D!t oat6atoes We wilt furnish and install new Engler Standing Seam mechanically locked system,24 gauge as listed below. furnish= is Wwrenaaed mr__LQ_years aid the nanRacerrer warrarfta the finish an uta mebl for 36 yrrars. COLOR: SPECIAL INSTRUCTIONS/COMMENTS r ROOF: 4 Jr'( CI VA pS 'T ri 4-.n 0 rOD if SOFFIT: GLIS12OCP -� S#*dI (/Or Dt �4 T�NtA itee, 4--k-Skold FASCIA: -Jo 'all . 44&4r0 Poe-'44&4r0 b�P.Ller�rre).,, P-A-' rooir PLYWOOD: i n 3ik / Al RIPML40VE: a—ST-lf y near' ern ' OTHER: * D P ..A _-� hD.a/ r- re .r t C/rr a f�gXyr�ly: ai OUSE: _ l et cL 19 6 6 p,0O ��':we rcp�c�9r.A�fts Q�t d6flS . PORCH: ""� ADDITION: _ GARAGE: GUTTERS: DOWNSPOUTS :..._ _. _..._. REPAIR Contractor will begin work on or about Ney ka�y�(date).Barring delay caused by circumstances beyond Contractor's control,the work win be completed by DMC. 14(date. All roofing panels are custom fabricated on-site with state-of-the-art rolfforming equipment, `As with any roliform steel panels,a certain amount of waviness or o4 canning may become evident at certain times of the day when sunlight hits them.This is standard In the Industry and does not affect the integrity of the metal.This shall not be construed as a product defect and shall not be cause for rejection. Contractor does not perform or assume any responsibility for any painting,staining or wood or wall this"on interior or exterior. The contractor does further agree with the owner that(a)he will begin work within a reasonable time after the execution thereof.and will prosecute it diligently ant with due care,and in a good and workmanlike manner,(b)in doing the work,he will comply with all statutes, rules,regulations and ordinances applicable thereto: Contractor to procure ah permits required by law.Contractor shall provide public liability insurances. Owner warrants that he is the owner of the property on which the work is to be performed or that he Is otherwise authorized on behalf of the owners to enter into this agreement. We Propose hereby to furnish material and labor.complete in accordance with above specifications for the sum of: TilryuLl Mirre- 1 hOV 34hTwo-' oro-'kt, et &A dollars($ a3 Q 50 Payment to be Ade as follows: M I�'� awe.a�a�m waya�.a Mmtmn 30 X is 4 ""n sighing ConuaG: aja' J s—e ROOFING DISTRIBtYfORS.INC. a fl %is �f upon den on lob; 1�' ; l• 740 High Street,Sage 2.Ho"M,MA 01040 cnnr 0 Q �Op 1-900-232-0398 X Is3 _L..!!Wan 112 loo v.Vewni agserw,r:o o13i S�' MAa 134740 CTR 602546 _[1Z t(S 1 snas be—de notthwtth upon contpkaborn a swmw work under this contract 6aZ44� Nonce'N.,We~' for twine unproNmenl coneedat9 work sW re".a dorm para */.area 6Qwem (aWirxat doi-0 d mvm then are-aed of the tote!cased pd.a me mea poslamount a Y / // V !�U p deu lir pamen yts orf h Ire can'ladw Rust make.w lid—,m oNar erWw dhw,aee /r,4X� ,�, /11 ,it Iia-3/T—&70 eme,dwwy ol,pedal oder metalete end mulwom Tobe erpeee ft ouw Acceptance of Proposal l have read is document and accept the prices,specifications and conditions stated. I understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified.Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time prior to midnight o fthe third business day after the date of this trans tion.C neellatlon must done In writing.See accompanying cancellation. NOT 51 THIS CONTRACT IF THERE ARE ANY BLANK SPACES r Ur Sgneture Oata Aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYY1) llkk� 08/08/2019 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 polioy(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 Brenda Klaus NAME: Webber 8 Grinnell PHONE (413)586-0111 FAX (413)586 6481 C o AIC No 8 North King Street E-MAIL bklaus@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 Northampton MA 01060 INSURERA: Continental Westem/Acadia 10804 INSURED INSURERS: Union Ins/Acadia 25844 U.S.Metal Roofing Distributors,Inc. INSURER C: WCAR-Liberty Mutual Attn:Keith Rehbein INSURER D: 740 High Street INSURER E: Holyoke MA 01040 INSURER F COVERAGES CERTIFICATE NUMBER: Exp 07/20 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE iNsD wyo POLICY NUMBER MWDD MWDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAM 300,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 10,000 A CPA531260112 07/26/2019 07/26/2020 PERSONAL RADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ®JE �COT LOC PRODUCTS-COMP/OPAGG $ 2.000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED MAA531260212 07/26/2019 07/26/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS XHIRED 1-11 NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /l AUTOS ONLY tPer accident Uninsured Motorist $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ • EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE � E.L.EACH ACCIDENT E 500,000 C oFFICERIMEMBCERIMEMBERExcLUDED? NIA WC231S616974019 07/26/2019 07/26/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Keith Rehbein is Excluded from Workers'Compensation Coverage, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance 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