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13-015 (2)
504 NORTH KING ST BP-2020-0649 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 13 -015 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-2020-0649 Proiect# JS-2020-00110,6 Est.Cost: $10000.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SHUMWAY ROOFING 105743 Lot Size(sq. ft.): 101059.20 Owner: PATEL Zoning. Applicant: SHUMWAY ROOFING AT. 504 NORTH KING ST Applicant Address: Phone: Insurance: 625 EAST PLEASANT ST (413) 549-4658 () AMHERSTMA01002 ISSUED ON.11/20/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:ROOF REPAIR 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: i FeeType: I Date Paid: Amount: i Building 11/210/2019 0:00:00 $100.00 . I 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner .. . CEIVE® NOV 2 0 "� 2019 r erci• Buildin r Permit 1�1a 15,2000 i NORTHAMPTON,MA 01060 Department use only U11Y Ot lNorthampton Status of Permit: . Building Department 212 Main Street Curb CutlDrivewayrPermit Sewer/Septic Availability Room 100 Water/Well AvallabiliN. Northampton,MA 01060 TWO Sets of Structural Pians phone 413-587-1240 Fax 413-587-1272 t?IoflSite.Plaris APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 9.1 Property Address: This section to be completed by office t!! ^Ao(4kil 5Af12e-L Map Lot /S Unit f y;rr r j Zane Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPtAUTHORiZED AGENT 2.1 owner of Record: Name(Print) Current.Mailing Address. .,.._._ _-.._.__.............._........ _._.._..._._._._....,._.. .. __..,... . _.._ ..__......_ _. i Signature I- .._.__.._._._.___. _ To Ieephone 2.2 Authorized Argent- Name(Print) Current Mailing _.._ Signature ... � �..,� ...�...�]"D,a.___....,..... .._1 Telephone SECTION 3-E MATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed.by permit applicant ___.�..... ._....____.__w...__..._... _ 1. Building + ' (a)Building Permit Fee ...._._..___...__..._.__......_..._._i ; n .�.._ _..._.._.-__._ _ _a..._._._...._..... 2. Electrical ; .._...._....._.__.... .._.............._._...__............. � � i (b)Estimated Total Cost of 3. Plumbing _.._v__.......,......._._.__._..... ' Construction from 6 j Building Permit Fee 4. Mechanical(HVAC) _._.,.._.................... ... •}.. ....................... 1 5.Fire Protection ? ..._...,-w _._...__...._.._.._._...J 6. Total=(1 +2+3+4+5) Check Number S a' This Section For Official Use Only Building Permif Number Date a i0 G �Q Issued Signat re: l Build[ Commissionarlinspector of Buildings Date YL- I i Versionl.7 Commercial Building Permit May 15,2000 s SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,800 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wali Signs ❑ Demolition❑ Repairs❑ dditions [:] Accessory Building❑ Exterior Alteration [3 Existing Ground Sign El New Signs 1-1RoofingCi�1 Change of Use❑ Other❑ ...... ---......_.__..._ . Brief Description Enter abrief description here. Of Proposed Work 1 SECTION 5-USE GROUP AND CONSTRUCTION TYPE 'USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly1771A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 18 ❑ B Business ❑ 2A ❑ E Educational ❑ 28 F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ i institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 p R Residential '❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ 8-2 ❑ 58 ❑ UUtility ❑ Specify:?_._._.__...._._.._______,.._.._._,_._......_..___._..._._..._.__._._._._.._.___._._.w_.._�...._..._.._..__..-.__...:_.� €......._... .__ .__..___.__........_._.................._..__ _...._...w_.._....._.._..._.._......_......_......___..___..._._.___. ..v........... ..:_._.._ M Mixed Use ❑ Specify:1 M1 S Special Use ❑ � Specify:i_...,_.._._....._.,._w_..___.._...._..__._ ___,.._—.-.Y.....,..__.w_..__.._�.._.._..._.__...�.___r , COMPLETE THIS SECTION.IF EXISTING BUILDING UNDERGOINC_RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): _._ VV,_ _ _...w Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(so 2"a f 2nd( t...__._...._._........... .._...... __..__ ._._....._ l_,.._..._._.,....._.....................__.._.___..._.._..:.._._...__�... 1 rd 4th Total Area(so ! Total Proposed New Construction(sf) _ Total Height(ft) :"._...._-_�_..-._.w...�._..._..� Total Height ft 7.Water Supply(M.G.L.c.44,§54) 7.1 Flood Zgne Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone .__ _. _ Outside Flood Zone[:] Municipal ❑ On site disposal system❑ Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL.DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE 9.1 Registered Architect: _�.__....,,.,_..___,__._.._.___._..._�.._..._.___v__.a.—.._ .__...._......._.._..._.,_.__..�.......__._.,._........__.__.i Not Applicable ❑ w__,..,_....plic.-..---__...._ _ _ ,_..., ....W...,,..._..... s —1 Name(Registrant): _......................... ..._..._---..__._._._......._._..._,....__. _......,..._,........I _...._....._..__.,.._.,_ -._..,_.._...._.__..__._......_,._...._........ . ....._.. _.....___.-.i Ro istration Number Address t —' Expiration.D a te_ Signature Telephone 9.2 Registered Professional Engin®er(s): Name Area of Responsibility Y , _ ..-._... _.. .......w.- _._.. _.... . ... _.. _.,,_..,._ .. _ Address Registration Number __---_ —. ....._....._..........._,_. .......____..._.._..._.._.....__...__-_-__.. ........... Signature Telephone Expiration Date 3 Name Area of Responsibility Address Re iq,stration Number . Signature Telephone Expiration Date t Name Area of Responsibility Address M y Registration Number 1 Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number _ Signature Telephone Expiration Date 9.3 General Contractor Not Applicable D iCompsName: _...�.__............. __._.._._w_._.,..__._.__._.� Res ns a in barge o Construction I LAddrlelslsTele hone 1 Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(TSO CMR 110,11) Independent Structural Engineering Structural Peer Review Required Yes 0 No .SECTION 11-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject 1 property i _....._,_.._._,._.............._____.......,....�......_.....__.,___ __.._.__._w__._,., . hereby authorize-__.....____. �q��`Pt✓t5-•.�—�7._:'l�N __..._... ._..__._._---_ _._ __—..___..__._�---.._...__��__......__..,.._ ____to act on my behalf,in all matters relative to work authorized by this building permit application. _.. ..._ _.._..__., _........,_.__........._...._.............. Signature bTOwner 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. Si ned ndera din,and,penelties of i Print Nam Signature of Owner/Agent Date SECTION 12'-CONSTRUCTION SERVICES 10.1 Licensed Construction Super Aso Not Applicable ❑ Nameof License Holder:1.............. 4r� ._ .._ .. .......tom_. _.__._._.._........_........_..._..._, _ ..,_..._.-_....._.._.i _�`1.._ ...:............:...............,.._....._.._........ License u ber i L g Address Expiration Date Signat r Telephone SECTION 13-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 0 No, Q ' I I i City of Northampton 212 Main Street, Northampton, MA 01060 Solid.Waste 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. Address of the work: The debris will be transported by: �,C The debris will be received by: Building permit number: Name of Permit Applicant 0 Date J/gnature of Permit Applicant I The Commonwealth.of'Massachusetts Department of Industrial Accidents a I Congress Street,Suite 100 Boston, MA 02114-2017 wrc'w massgav/dia Uorkers'compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant information Please Print Le ibl Name(Business/Otvanizationtindividual): IXIva ✓✓�t'f C"` Address: A2—. City/State/Zip: ( Phone M �+ _ Are you an empinyer?Check the approp ate box: Type of project(required): I,®I am a employer with employees(full andlor part-tine).* 7. []New construction 2.❑1 nm a sole proprietor or partnership;and have no employees working for me in 8. 'Remodeling any capacity.[No workers'coiup.insurance required.] 9. �Demolition 3.E]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 a Building addition 4.❑I am a homeowner and will be hiring connectors to conduct all work oil my property. I will 1 1.Q Electrical repairs Ui additions ensure that•all contractors either have workers'compensation insurance or are sole p proprietors with no employees. 12.[�Plumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13t oof repairs 121resw iocontractors have employees and have workers'comp,insurance.' 14.®Other G. Weare a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'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. tContmctors 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`croup.policy number. I ant an employer that isproviding workers'compensation insurance for nny employees. Below is the polity and job site information. Insurance Company Name: Policy#or Self-ins.Lic.it: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is'true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitlLicense# issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PluEInspector 6.Other Contact Person:. Phone#: r ro. Louis Hasbrouck Building Commissioner City of North6mpton 212 Main Street Northampton, MA 01060 The :Massachusetts Building Code; section 107.1 allows for an exclusion from requirements for construction control in certain situations: In accordance with code section 104.1.0, T request that you grant a modification to waive the requirement for construction control of the project at because the work is of a minor nature,.will not affect structural elements, health, accessibility, life or fire safety, and will be done in accordance with the presdiptive requirements of the code. Thank you for your consideration. Respectl' To:Town of Northampton Page 2 of 2 2019-11-01 21:06:33(GMT) 14138955978 From: Rejean J Remillard Insurance s DATE(MPdil w.yIY Y) PERTIFICATE-- OF LIABILITY 44ra4119 THIS CERTIFICATE IS ISWC-D ASA.MATTER OF INFC3RMATIOR ONLY AN'16}~ FER$NQ gIG.HTS UPC)N TH5 GERT1FtC:4TL tiC}Iml7ER.T6iES CERTIFICATE-DOES kO AFFIRMATIV`ELY OR NEGATIVELY'AMEND,EXTEND OR ALTERTHE'COVERAGE AFFORD.ED BY THE POLICIES, BELOW.. `TEAS CERTIFICATE OF INSURANCE.DQI S NOT CbNS.TITLITE.A CONT`.RACT I3li'TV4EEN*THIS.SI1.ING.INSUCtER(S),.AV.TH.OR124G REPRESENTATIVE OR:PRODUCER,AND THE*CE OTIFICATE HOLDER. IMPORTANT: lf.fhe Gartificats holds!"Is an ADIQfTIOPdiaL INSURiorbTin .S . a7U . e endorsed. tf SUOROGATION IS WAIVED.subject to-the.forms and conditions of the policy,certainpollies may rax;hire an indorsement A statement.on. this certificate doss not confer rlghts;to the certificate ltalder in lieu of such endorserrent(O' PR9pUGE ' idaPnE, Lerida Heal,CSR _ Rejean,JI-Remillard InsArrlbricy,Inc., PHONE,, 443-7�'e-3070 tare,odo): 443-768-0Y9a 1040 Springfield Street Freding;Hilfa,f#i1A04Q p ADDRESSI eanr mi!`2aol.com-, _ .. . 1N16UREF2 5j AFFORDING COVERAGS...,.. .. NAIC i INSURER fc; Main Street Amerlcan AssurancQ __....._..r iN>`.i,V,REEl INSIJRER't3': , ... ,....•..A.... . PeEe,r Iaanavita iib INSUREIt.0:.. ., .,..,.�._-.__..__.ate.._x..._.._.__•,..,�.. L�OnaVlta Electiic j INSURER 13 13 MeadowrbrdO Dri+e — Ea%thalrmpton,MA 01427-1769 INSURER a INSURER F: i. COVERAGE$ GEI7TIFICATE NUMBED REVISION NUMBER: THIS I$ O CERTIFY THA t 1 HE POLICIES OF INSURANCE LISTED BELOWHAVE REEK ISSUED°CGI TINE I J yiJRED NAMCD APOVE FOR.THE PQLIGY PERIOD ' tNDICATFD, NOT"(T I(STANDING ANY REQUIRFWENT',TERM OR COtol�lON.�E ANY us�t�!'TRACT QF2 Cf HEIS L7QCUr�ENi 4VITN C3ESPECT TQ YJHtCh 7IiIS. CERTir't<:ATk t,!AY'.BE!S5i1E0 C1R tAAY PERTAIN,T.fiE(NSUI�ANCE AFF,.4 F'R.Ef,SY TFIE POLIS I(v C7�Sc 'Ii3LL7 NEREfN :S11B IEGT TQ ALL TI-tE TER1N3, E'XuLt1SiL7N AND CCINGI t IONS OF SUCH POLICIES.I_I°�gITS.SI lU�4h MAY tIAVE;I3EE1v R�Cit}E GL7 8 s.I�AA�ry CLA�q INSi3 'LTR TYPE OF INSURANCE v Il°x POS IGY hUMF>F fat(DD YYYY P.1N€tR3!YYYY1.1 X COMMERPML OPNERAL L .Y.IAMIT -�_...w.�. I EACH UCCUR:t ENC.L S 1100I7r000 i tLAi!vIS•IARF ...C)CLl1R I rPRF Rf4C . �SRO.OQQ 1000 A I i14PC756F103I3 04105119 0?(tQ m I TIER o Nor&ADV IN,zURI-- s GF.N L AGGRFGATF.11MITAP.N.15S PER; GENERAL��GrurtEL A _ t=.c�LrcY �gi p, Lnc ,Rut>ucrs••coMt oPace xT^ 2,000,000 .(AU'TQM.L?fiILE LiAt3Il]TY t' .... ----. =..._.....,.,,.�. P.h TPiEL;of dT6 E LIM!7�.. �,_..- ... ... ANY AUTO. ©OVILYINJURY'(Per lsE0011) rns.CIiEDULED AUT05,0KY AUTOS � 6pm y{N:;Uriy fntx acc dents S .. HIRED NON,oWNE-..J ._._........:.....�,._..;,..__' AUTOS ONLY -�AUTOS ONLY . .11MBftcILA LIA$ R `..._.W-��__..._...... fiCCU . eACH OCCURRENCE EXCESS LIARi } 1 ,-•-�—..�_._:,:._._ CLA 44S-MAL'+E' GRl=t ATI✓ 5_ =R) " j_RETENTi0N1$ WORKERS GOAIPENSATipN I .. •+-^.--- �.•- �..-- TEtiIi" AND VAIPLOYCRW t AD L17Y - AN,PROFRIETOR:PARTPIER EXGGUT,VF..Y f N { T;L EACH.ACOMEN S OFF.ICCk,'&4FtiHEREXCLJ. EG? .LJ7 NIAI { -- (Maneaiory in NH) I �F L DI�CA�E-E14 eMPi.Q1 cr � y._...~.•.._._..._.. :.. dascrme,under I `..._ ....•_ C i sGfi PT!ON OF OPERA MoNS L'•!�,w I l<<L :t)-[y41 Ask_FC2LiC;`_et lfdiY I bES R19TiAA[OF U"F F•RAIIDNP!LOCATIONS./YEHIGLES:(ACORd 101,Additlunai Rernari<s Scheduie,may be attached If 'Ore space ir:rrquiret{i , 3 GERTIFICATE.I:OLDER CANCELLATION, SHOULD ANY OFITHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE.EXPIE'.ATtCIrIjATE'TeiEREOF,tdC1TiCE'W1LL:BEf3ELIV1 RED 9N TOWN OF NORTHAMPTON 1 1�VCUl�tiANcl Ys�TFt.7HE.POLICY PROvls[ONs. `2'12 MAINS R T NOI2T(-IAMPT6N,MA. Q4Q5Q AUTHORIZRU izEPRES-Nr I � , 1958;2015 ACORD CORPORATION, All rights res.arved. ACORD 25(2016103) The ACORD name and Iona are registered€narkt ai ACORD I I i i