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22D-114
Department use only City of Northampton` Status Status of Permit: Building Department �, Curb Cut/Driveway Permit 212 Main StreepR Viewer/Septic Availability f /► Room 100Water/Well Availability Northampton, MAOV60 c�Q�Q / Two Bets of Structural Plans .�• phone 413-587-1240 Fax 41 3=88-7,71Z72 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVAT€.OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed y office v ✓ { Mapes` Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1: 1 •Aj SC AVIS C � r Name(Print) Current Mailing d r�s:S I/ Telephone U Signature 2.2 Authorized Agent: r K 1 Name(Print Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 8695 (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) ►T 5. Fire Protection 6. Total = 0 +2+3+4 + 5)--T— 2+3+4 + 5) U • (;Ci 8695 1 Check Number 4 /� /y This Section For Official Use Only Building Permit Number: .. ih- / 70 Date V Issued: Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Er Or Doors M Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[U Brief Description of Proposed Work: �•t'w;�.� i'?vSf7e--, //`�/� G. . 31 4 ti1 Sne c 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 /-A n u� as Owner of the subject property nn hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I' YZ �/` `/�� '� ` 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 SigrxtWe o wner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable ❑ t Name of License Holder:--. ! �l 1.t J/I I {/ ML C License umber hod Address — C , Expiration Date re Telephone - ( q7 9,Reailstered Home Improvement Contractor: Not Applicable ❑ IQ lA V2 Com any Name I Registration Number n Address V Expiration Dat — �ij �(M lkm 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 building2ermit. Signed Affidavit Attached Yes....... No...... ❑ --_� City of Northampton Massachusetts 2 �. DEPARTMENT OF BUILDING INSPECTIONS �, z 212 Hain street •Municipal Building a Northampton, MA 01060 s a _...�. 'r 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 MC-Lc 1 11,S 150A. The debris fromconstructionwork being performed at: (Please print house number and 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: C� I w� (Company Name and Address C �Appftant or Owner 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. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 >'vww.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant.information � /�/� Please Print Let?ibly Name (Business/Organization/Individual): b'y U j� l2xj ups C Address: S 10 VN �--t�l�.,� /y 'v City/State/Zip:,�-,, a CA 7 �� Phone#: S Are you an employer?Check the appropriate box: �,� Type of project(required): 1.1�`a"'a employer w7th_employees(full and/or part-time).* � 2.2.F11 am a sole proprietor or partnership and have no employees working for me in 7. New construction any capacity.[No workers'comp.insurance required.] g• Remodeling 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property.ro I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 5.[]1 am a general contractor and T have hired the sub-contractors Listed on the attached sheet. 12.Q Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.I 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-contrauors and state whether or trot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: n-12-'A Expiration Date: Job Site Address:_ �U (it; S t V City/State/Zip:.(��D��,,..,R, 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 er a pains and penalties of perjury that the information provided above is true and correct Signature: Date: — Phone#: Z 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#: ully Licensed awn!, ;cured u a 0"` `bc a 510 New Ludlow Rd. MA Reg#20-2015718 South Hadley,MA 01075 MA Lic#: 147961 MA CSL#:99565 Cell:413-563-6354 413-707-ROOF (7663) Office:413-707-ROOF(7663) Fax:413467-9749 SHINGLE *RUBBER SELECT NICHOLAS BERNIER ShingleMaster L (Owner) Cerra Teed RoofProsMaom RoofPros@comcast.net sat srtitted to: Phone# h: c� 7 rev c: a k ln.ta h Special requirements street ;ity,state,zip cgde - roposal to furnish and install the following /A t� ] Re-roof ear-off ❑ Gutters ] We shall acquire necessary permits for all work Complete Roof Preparation Home's exterior to be protected by tarps and plywood q' bs,landscaping,trees to be protected,roofers buggy used Sntire existing roofing materials to be removed to existing decking,including flashing,etc. ite 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$50 per sheet of plywood Complete CertainTeed Integrity Roof System �� /Install Winterguard ice&water barrier along bottom ❑ 3 ft.of all roofs,IS6 ft. Install Winterguard ice&water barrier around penetrations,in valleys and all critical areas stall CertainTeed Synthetic underlayment to entire decking Install 8"perimeter metal flashing to all edges of all roofs, bite ❑brown Install SwiftStart starter shingle to bottom and rake edges of all roofs nstall CertainTeed shingles to manufacturers specifications,❑6 nails 8/4nails tall CertainTeed PVC ridge vent to all peaks in heated areas Install Shadow Ridge to all hips and ridges,over ridge vent where applicable I IrInstall new lead counter flashing to chimney 4-*' New flashing installed where necessary Install new pipe flashing to waste vent stacks Warranty options uarantee our labor/workmanshi for 20 years grade CertainTeed 4-Star Sta usMT=: erage Y CertainTeed Landmark-color: 3-tab ] CertainTeed Landmark Pro-color le propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of:Total Due $1.5 30 I_X� ,CCEPTANCE OF PROPOSAL:The above prices,specificat.°ons and conditions are - 1/3 Down Payment's atisfactory and are hereby accepted.You are authorized to do stork as specified. Balance due ayment will be 1/3 down at start of job,and balance due upon completion. upon completion )ate: Signature: )ate: (0!f 3 _Estimator:(Print Name) Ah f Al V (Sign Name) .sti.mates are honored for thirty(30)days from above date kTTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the possibility of rooting debris or dust in through cracks of the wood.NRB Exteriors Inc.will not be responsible for ebris or dust in the attic or storage areas. t Finance Charge of 1 'i:%monthly(ANNUAL PERCENTAGE RATE OF 18%)will be added to the unpaid portion of the balance due.I gree to pay and/or guarantee payment of these charges.In the event of default of payment,I agree to pay reasonable Attorney's fees and ourt costs.This agreement does not constitute.a release of liability.By my signature below,acknowledges an agreement of the above is ereby made. ignature: .eco o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) L...� NCE 03/13/2020 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 policy(les) must 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 NAME: Denise Sawicki AMHERST INSURANCE AGENCY INC PHONE (413)253-5555 AAX /C,No): ADDRESS:PO BOX 48 S : dsa_wicki@nathanagencies.com - INSURER(S)AFFORDING COVERAGE NAIL 0 AMHERST _ — MA 01004 _ INSURER A: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED - _—-- INSURERS: N R B EXTERIORS INC INSURER C: INSURER D: 7 PHILIP CIRCLE INSURERE: GRANBY MA 01033 INSURER F; OVERAGES CERT TF NUMBER' 1 _ REV NUMB R: 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. ADUCISUEIR POLICY EFF_—POCICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 CLAIMS-MADE I OCCUR PREMISES Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 p 101 GL008936302 12/23/2019 12/23/2020 PERSONAL s ADV INJURY $ 500,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 JECT F LOC 1,000,000 POLICY PRO- PRODUCTS-COMP/OPAGG I$ LI-0THER; Employee Benefits $ AUTOMOBILE LIABILITY EaMBINED SINGLE LIMIT $ accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED _ AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS MON-OWNED PROPERTY DAMAGE - --_---- AUTOS Per accitlent $ $ _ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIA- CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ —" WORKERS COMPENSATION v AND EMPLOYERS'LIABILITY Y/N X STATUTE ERH ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100 OW A OFFICER/MEMBEREXCLUDED? NIA NIA NIA 6ZZUB9F59768620 02/13/2020 02/13/2021 (Mandatory in NHi H yas,describe under E.L.DISEASE-EA EMPLOYEE�$ 100:000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 500,000 N/A i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass-9ov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Roof Pros ACCORDANCE WITH THE POLICY PROVISIONS. 510 New Ludlow Road AUTTHHOR17ED REPRESENTATIVE South Hadley MA 01075 '" Daniel M.Cr I y,CPCU,Vice President–Residual Market–WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD