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24C-107 (2) 28 FIFTH AVE BP-2020-0973 GIS#: COMMONWEALTH OF MASSACHUSETTS MV.-Block:24C- 107 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-2020-0973 Proiect# JS-2020-001650 Est.Cost: $6300.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Group: DICKY MATOS 105917 Lot Size(sq. ft.): 2744.28 Owner: RADCLIFFE DAVID J toning_URB(100)/ Applicant: DICKY MATOS AT. 28 FIFTH AVE Applicant Address: Phone: Insurance: 3 GLEN ST (413) 530-5335 WC HOLYOKEMA01040 ISSUED ON:2/28/2020 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 Si(;nature: FeeType: Date Paid: Amount: Building 2/28/2020 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only 777 City of Northampton � � '/ , tatus,of Permit: Building Departrgent urb Cut/Driveway Permit 1 212 Main Street / FEB Sewef/Septic Availability Room 100 7 to tetets ell Availability v, a r Northampton, MA 0 of`structural Plans nn� phone 413-587-1240 Fax 99t"'?rT1 ,��� Plot/ ite Piens ti'a PE r Sp ify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLI3(H A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office d 0D �V P/1 �� Map -2 ``/C Lot t 0 !�7 Unit /Iva" aM)(p Q Zone Overlay District Iva" / Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �t<ri c/ 244�� po So t Curr n M i'ng A Zress:_ "1 7 13 4 `]f 7 Telephone Signa ur 2.2 Authorized Agent: Name(P t) Current Mating Address: igna a Telephone 7- SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building a (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 7u 6. Total= (1 +2 +3+4 +5) G) , �} Check Number This Section For Official Use Only - Date Building Permit Number: `" c�IL/' / 7 Issued: Signature: Z-27 -26W Building Commissioner/Inspector of Buildings // Date 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 he filled in by Building Department LotSize e_.. __ _,.. ... __ ... _ __R .___ r._ a.m_ t_ _ __ -Frontage ------- Setbacks ___m__Setbacks Front �..w._._: L_--._j Side L:L—_..._l R:;a 2 L:�l..,.=. R:C Rear L _ Building Height rm--7 Bldg. Square Footage �._.__._ % ------ Open __-Open Space Footage % --------- (Lot --.-----(Lot area minus bldg&paved L—.--! parking) #of Parking Spaces -- Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW ® YES 0 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 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® , Date Issued: � � C. Do any signs exist on the property? YES 0 NO 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading ex avation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES0 04W NO 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 F7Replacement Windows Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [p Siding [p] Other[Cg Brief Description of r posed / Work: lr2e- e rao �nS'.��c�oe e—""VIC Alteration of existing bedroom Yes--Z—No Adding new bedroom Yes ,J<_No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. 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 as Owner of the subject property hereby authorize CL to f, in all matters rel a to work authorized by this building permit application. ,v Signatu of Ow+r Date as Owner/Authorized Agent hereby dre that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. ee Signed under the pains and penalties of perjury. Print ne �z- �-s Signature of Owner/ nt D to SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: t� G Y /yl �t / "� (rots— u License Number Addre --L4Expirati n Date S. -,5-925- Signature Telephone 8. Reaistered Home improvement Contractor Not Applicable ❑ Company Nam 'Registration Number A'cTcTress Expi�ra on Dat Telephone 3j, Jr3 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.......A No...... ❑ //.. City of Northampton i Massachusetts wr :c DEPARTNWT OF BUILDING INSPECTIONS ?� r 212 Main Street • Municipal Building 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 he registered vp Type of Work: e;�Iv v Est. Cost: Address of Work: a2 JP Date of Permit Application:_ 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: c� a bi l� Date Contrac or 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 r , City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONSI ro;` 212 Main Street •Municipal Building 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: (Please print house number and street name) Is to be disposed of at: ae11' et) mgr•-1 o/a (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from. (Company Name and Address) aZ g —e of Per 11 ica or Own ate 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 sy www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aimlicant Information Please Print Leeibly Name (Business/Organization/Individual): /D/r✓�(� � ��' Address: S /� City/State/Zip: Phone#: / �av - S33S Are you an employer?Check the appropriate box: Type Of project(required): 1.E3 I am a employer with_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.❑I am a homeowner doingall work myself 9. ❑Demolition y [No workers'comp.insurance required.]' 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 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:(76� Policy#or Self-ins.Lic.#:�jj /� -?1d 'V 3 Expiration Date: a ! I if Job Site Address: a,F�'�1 s� Igo City/State/Zip: D! Ole Cl Attach a copy of the workers' compensation policy declaration p1die(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 n r th epa sand penal!' oferjury that the information provided above is true and correct. Sian e: Date: Phone#: 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(YYroD/YYYY) I CERTIFICATE OF LIABI-_ITY INSURANCE 02/22/2019 1 nlATE IS ISSUED AS A MATTER OF INFORMATION ONLY AZ CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, E?TEND 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, ImNO_ R—f the certificate holder is an ADDITIONAL INSURED,the pohc les must have ADDITIONAL INSURED p►ovlslons or be endorsed• I If SUBROGATION IS WAIVED, sub ect to the terms and conditions of the T Iicy,)certaln policies may require an endorsement A statement on this certificate does not confer ri hts to the certificate holder in lieu of such Jndorsement(s) PRODUCER O'RA Heethef FIeU _ - - ----1 532-0889 CHI Insurance Agency,Inc. ��'�exile (413)53Fr2685 _ _ LA ct Nal: ( ) 416 Maln Street e�AIL Bury chid en oom -( AD SS;;; rYG — 9 CY•------ - —. INSURERS)AFFORDING COVERAGE _-__ _ NAIC Y 1 HolyokeNsuRED _ 22667 — __ _ _ _ MA 01040 INs,1RER A, ACE AMERICAN INSURANCE CO __ INSJRER B _.__- ------ — --- - -- Dicky Matos dba DMR Roofing INSJRER C. 3 Glen Street INSJRER D; INSURERS- Holyoke 1 Y MA 01040 INSJRER F OVERAGESREVISION NUMBER: CERTIFICATE NUMBER: _ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 3EEN 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 I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 3Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEi N REDUCED BY PAID CLAIMS. —fADDL tJ SUBR POCY EFF T POLICY EXP LIMITS .7R TYPE OF INSURANCE — INSDNIVD POLICY NUMBER IYY/DDIYYYYI (MM/DDM/YY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S — E�A MISESO(Eaocw��nce) S CLAIMS-MADE PR MED EXP(AnY One Person) S -� PERSONAL 8 ADV INJURY S l _ GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY` JECT LOC PRODUCTS-COMPIOP AGG I S i AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ , (Ea accident) - _ ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per acaaent)I S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY ,(Peracaaent) $ $ I UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE1 AGGREGATE $ DEL) RETENTIONS ; ) WORKERS COMPENSATIONP—T R r O L1 AND EMPLOYERS'LIA84 TY Y/N �(X` STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE UB1 K$36443 E.L.EACH ACCIDENT S 100,000 4 OFRCER/MEMBER EXCLUDED? " NIA 03112120191 03112!2020 (Mw atory In NH) E.L.DISEASE-EA FEEMPLOYEH S 100,000 K es,085dtbe under DESCRIPTION OF OPERATIONS belov, E.L.DISEASE-POLICY LIMIT i S 500,000 1 I i ESCRIPTK)N OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,m.ry be attached M more space Is required) 1 ;ertificate Issued as evidence of insurance. i ERTIFICATE HOLDER CAACELLATION T— ,AOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I ,IE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I .OCORDANCE WITH THE POLICY PROVISIONS. AU HORIZED REPRESENTATIVE v � I CORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are rcgistered marks of ACORD -ornrr,onwea##A of Anassacnusarts ' - � .i, Divisian aJ;P'rpPesssorlaE i_ic�n�ure " Boara of Bu!'dinq Reguiations and 5tandatrss Co n�tr�.icrian,Su�eruisor DICKY MATOS 3 GLEN STREET , HOLYOKE MA 01040 Corn,missioner Office of Consumer Affairs and Business Regulation One Ashburton Mace - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Individual DICKY MATOS Registration: 166207 3 GLEN ST. Expiration: 05/06/2020 HOLYOKE,MA 01040 SCA 1 0 20M-05/17 Update Address and Return Card. Office of Con=nw Affairs&Business Reguiedon HOME IMPROVEMENT CONTRACTOR TYPE:indMdual Registration valid for individual use only before the eiratlon date. if found return to: 1 Office of Consumer Affairs and Business Regulation DICKY MATOS One AshAurton Plaoe-Suite 1301 Boston,.AA 02108 DICKY MATOS 3 GLEN ST. HOLYOKE,MA 01040 Undersecretary Mot valid without signature 3 Glen St Holyoke, Ma 01040" 413-530-5335__:= _ CS105917 '� IMA Date ffeb 19,2020 HIC-166207 DE Avg CT- 0639705 P.O. Terms Bill To Davp Radcliffe Ship Via (508)479-4437 Ship Date 28 Fifth Avenue Northampton, MA 01060 quackeye@gmail.com Qty Description Unit Ext 15 NEW ROOF 420.00 6,300.00 Tear off entire roof Inspect plywood (if any damage will be and additional cost of 60.00 per sheet 1/2 inch and 75.00 3/4 plywood. Install ice water barrier 6 ft and valleys Install syntectic underlayment to rest of the roof Install limited lifetime warranty architectural shingles Seal all pipes and vents Install 8"drip edge Remove all trash and debris Install a Tamko Rapid Ridge Vent Building Permit included l l I Total(15) $6,300.00 1 ignature i 0- 1 M1