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22D-114 (4) 50 AVIS CIR BP-2020-1076 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22D 114 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: ROOF BUILDING PERMIT Permit# BP-2020-1076 Proiect# JS-2020-001821 Est.Cost: $9500.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Group: NRB EXTERIORS INC 99565 Lot Size(sq.ft.): 22215.60 Owner: JOHNSON TIMOTHY Zoning: URA(100)/WSP(100)/ Applicant: NRB EXTERIORS INC AT. 50 AVIS CIR Applicant Address: Phone: Insurance: 510 NEW.LUDLOW RD 1 (413) 563-6354 WC SOUTH HADLEYMA01075 ISSUED ON.4/22/2020 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 Signature: Feer e: Date Paid: Amount: Building 4/22/2020 0:00:00 $40.00 Phone 413 587-1240 Fax: 413 587-1272 $12 Main Street, ( ) ( ) Louis Hasbrouck—Building Commissioner r- Department use only City of Northampton ' Status of Permit: Building Department � '`} Curb Cut/Driveway Permit . 212 Main Stree>��0 $ewer/Septic Availability A A Room 100 �a 20 ater/Well Availability Northampton, MA DV60 / Two Sets of Structural Plans ` r phone 413-587-1240 Faz413=881272 Plot/Site Plans ri Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOV,I;E QR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Propertv Address: ��Thiss section to be completed y office t ✓ + ' Map—�=— Lot Unit Zone Overlay District - Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: n I I Iy�� S C7 Avi S C r Name –fi �(�Priint) Current Mailing Address: _ 1 , Telephone J U Signature 2.2 Authorized Agent: ��� tr ✓� o,s ; , iia C;L,/ Name(Print Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permif a ';cant 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) Jy' 5. Fire Protection 6- Total=(1 + 2+3 +4 + 5) 9 L) J; , 8695LChec:k Number 01' This Section For Official Use Only Building Permit Number:­5 .. 0- 10 �� Date �Q Issued: i Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoalicable) New House - Addition Replacement Windows [Alteration(s) Q Tofing Er Or Doors 0 AccessoryBldg. 0 Demolition ED New Signs [p] Decks lQ Siring jp] Other[a Brief Description of Proposed n Work: Q Pin �Xi S tel.--� / /� G�.. �,�i t— -{t> d„'► S(i! C Alteration of existing bedroom Yes No Adding new bedroom Yes No AtSached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.A 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 V S u,-\ as Owner of the subject property hereby authorize W(nn � -QK A--e to act on my behalf, in all matters relative to work authorized by this building permit application. 6 Signature of Owner Date I, t V �}� ✓ L/ t �' C 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 Signgififfe o caner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable ❑ i Name of License Holder: (t J/l i / C License N umber Address C , Expiration Date re Telephone L(I 7 96 9,ReaisterednnHome Improvement Contractor: Not Applicable ❑ Com any Name Registration Number -SA ft) w (�► ` �( / ✓� Address Expiration Date y 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 t Massachusetts WK DEPARTMENT OF BUILDING INSPECTIONS o, z 212 Main Street a Municipal Building T 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 to a property licensed sold waste disposal facility,as-defamed by MGL c 1 a a,S 150A. The debris from construction work being performed at: C i (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: (Company Name and Address Appticarrt 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 www mass.govvi is Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant information Please Print Legibly Name(Business/Organization/Individual): LW b 4 ei yV S n \ Address: S 1p 1N-9. L t j City/State/Zip: a u t_)l 7 1C Phone #: S 4' Are you an employer?Check the appropriate box: F9. pe of project(required): 1. am a employer xith_employees(full and/or part-time).' New construction 2.❑I am a sole proprietor or partnership and frave no employees working for me in any capacity.[No workers'comp.insurance required.] Remodeling 3.�I am a homeowner doing all work myself:[No workers'co insurance r ❑Demolition comp. required.] 4.0 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 11.Q Electrical repairs or additions proprietors with no employees. 5.F11 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. tC'ontractors 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: , 14 Policy#or Self-ins.Lic.#: n ZLo T 0'/ Expiration Date: Job Site Address:__ City/State/Zip: 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 S 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 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of iirvestigations of the DIA for insurance coverage verification. 1-7 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 7e Issuing Phone#• ally Licensed a dA sured 510 New Ludlow Rd. MA Reg#20-2015718 South Hadley,MA 01075 MA Lie#: 147961 MA CSL#:99565 Cell:413-563-6354 413-107-ROOF {7663 Office:413-707-ROOF(7663) SHINGLE *RUBBER Fax:413-467-9749 AShingle ECT NICHOLAS BERNIER Master (Owner) ­ [ RoofPros413.co1111NV RoofPros@comcast.net r �sal sil!t_ted to: Phone# h: , c: 1 ionto "ln'� Special requirements street <�-y --- 'ity,state,zip code G j J e/ C-t et [J `1 ? h roposal to furnish and installlthe following /V1, ] 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 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$50 per sheet of plywood Complete CertainTeed Integrity Roof System — /Install Winterguard ice&water barrier along bottom ❑ 3 ft.of all roofs,Er6/ft. Install Winterguard ice&water barrier around penetrations,in valleys and all critical areas l:CInstall C perimeter metal t is underlayment to entire decking stalertainTeed Synthetic lashing to all edges of all roofs,P<hite ❑brown Install SwiftStart starter shingle to bottom and rake edges of all roofs nstall CertainTeed shingl(s to manufacturers specifications,❑6 nails 91 nails tall CertainTeed PVC ridge vent to all peaks in heated areas Install Shadow Ridge to all hips and ridges,over ridge vent where applicable J f(Install new lead counter flashing to chimney ZJ/ flashing installed where necessary Install new pipe flashing to waste vent stacks � rranty options uarantee our labor/workmanshi for 20 years grade CertainTeed 4-Star a Sta s� �rage Y CertainTeed Landmark-color: n% 3-tab _ ] CertainTeed Landmark Pro-color le propose hereby to furnish materials and labor-complete in accordance with above specifications for the sum of Total Due .CCEPTANCE OF PROPOSAL:"fhe above prices,specifications and conditions are - 1/3 Down Payment$ atisfactory and are hereby accepted.You are authorized to do work as specified. Balance due ayment will be 1/3 down at start of joh,and balance due upon completion. upon completion $ i )ate: Signature: )ate: 1`01 ( _Estimator:(Print Name) � L l f/ (Sign Name) estimates are honored for thirty(30)days from above date ►TTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the possibility of roofing 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. .Finance Charge of 1 Y:%monthly(ANNUAL PERCENTAGE RATE OF 18%)will be added to the unpaid portion of the balance due.I gree to Tray and/or guarantee payment of these charges.In the event of default of payment,I agree to pay reasonable Attorney's fees and mut costs.This agreement does not constitute a release of liability.By my signature below,acknowledges an agreement of the above is ereby:made. ignature: A4C REO CERTIFICATE OF LIABILITY INSURANCEDATE IMM/DD/YYYY) 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(ies)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: Dedse Sawicki AMHERST INSURANCE AGENCY INC — -- -- PHONE FAX (Arc No Ext): (413)253-5555 C. F-IMNo► ADDRIes : dsa_wicki�nathanagencies.com PO BOX INSURER(S)AFFORDING COVERAGE NAIL 0 AMR ERST MA 01004 _ _ INsuRERA: AMERICAN ZURICH INSURANCE COMPANY 40142 -- ---------------- INSURED - - INSURER 8: N R B EXTERIORS INC INSURER C: INSURER D: 7 PHILIP CIRCLE INSURER E: GRANBY MA 01033 INSURER F: COVERAGES _ CERT TE_NUMBE 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. LTR TYPE OF INSURANCEIND WVD POLICY NUMBER MM ICY EFF RD ICY EXP YYYY MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A 101 GLOO8936302 12/23/2019 12/23/2020 PERSONAL a ADV INJURY $ 500,000 GEN'LAGGREGATE LIMITAPPLIES PER. GENERAL AGGREGATE $ 1,000,000 POLICY PRO- JECT F7LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER. Employee Benefits $ AUTOMOBILE LIABILITY COMBINEDSINGL LIMIT $ Ea -dent)_ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per acadent) $ HIRED AUTOS AUTOS NON-OWNED PROPERTY DAMAGE --' AUTOS $ Per accident $ UMBRELLALWB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY JOT YIN N X STATUTE ERH IANYPROPR;ETOFilPARTNER/EXECUTIVE E.L.EACH ACCIDENT is 100,000 A OFFICER/MEMBER EXCLUDED? NIA N/A N/A 6ZZUB9F59768620 02/13/2020 02/13/2021 (Mandatory in NH) Ifes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,000 y DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS 1 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,gov/twd/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 AUTHORIZED REPRESENTATNE South Hadley MA 01075 Daniel M.Cr4y,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 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation } Registration: 147961 NRB EXTERIORS INC n Expiration: 08/22/2021 510 NEW LUDLOW RDg SOUTH HADLEY,MA 01075 Vf , � a Update ate Address and Return Card. SCA 1 rj 20M-05117 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corwration before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 147961 08/22/2021 1000 Washington Street -Suite 710 NRB EXTERIORS INC Boston,MA 02118 NICHOLAS R.BERNIER 510 NEW LUDLOW RDlun� SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature Commonwealth of Massachusetts ® Division of Professional Licensure Board of Building Regulations and eSt aidards Const,UCtion Supervisor Sp Y Expires:05128/2020 CSSL-099565 NICHOLAS R BERNIER 510 NEW LUDLOW RD SOUTH HADLEY MA 01075 Commissioner