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29-560 (6)
46 BIRCH HILL RD BP-2021-1207 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-560 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-2021-1207 Project# JS-2021-002019 Est.Cost: $28800.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ROBERTS ROOFS CO INC 100333 Lot Size(sq.ft.): 142005.60 Owner: MYLES JACOBSON Zoning: Applicant: ROBERTS ROOFS CO INC AT: 46 BIRCH HILL RD Applicant Address: Phone: Insurance: P 0 BOX 1312 (413)283-4395 Workers Compensation BONDSVILLEMA01009 ISSUED ON:4/21/2021 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. Q ) i >4 . Certificate of Occupancy Signature: ' FeeType: Date Paid: Amount: Building 4/21/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner DocuSign Envelope ID:41703503-B626-4BAA BD34 360FF67F91FD / . 14-1/47C&-''- The Commonwealth of Massachusetts /` 4PA / 11 t Board of Building Regulations and Standards..._ 2 �Q2 FCO I I Y . a Massachusetts State Building Code, 780 CM ^ `c;i Building Permit Application To Construct, Repair,Renovate Of De>it h a,-. 4•vise Mar 2011 One-or Two-Family Dwelling ``� o'NS This Section For Official Use Only .f Building P it Number:um� Q p�a/''t..0'7 Date Applied: c:w�.. xo /1:4-Z y-Z1-2 7- Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 46 Birch Hill Road Florence,MA 01062 600 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Myles Jacobson Florence,MA 01062 Name(Print) City,State,ZIP 46 Birch Hill Rd 531-2175 mylesdj@gmail.com No.and Street Telephone Ismail Address SECTION 3:DESCRIPTION OF PROPOSED WORK2 (check all that apply) New Construction 0 Existing Building IV Owner-Occupied li Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: Remove&replace existing shingle roofing with new lifetime architectural shingle roofing complete with all associated flashing details. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All F it `/' Check No.J l Check Amount: _ t Cash Amount: 6.Total Project Cost: $28,800.00 0 Paid in Full ❑Outstanding Balance Due: DocuSign Envelope ID:41703503-B626-4BAA-BD34-360FF67F91FD SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 100333 7/3/22 Thomas R Roberts,Jr License Number Expiration Date • Name of CSL Holder List CSL Type(see below) RC 400 Franklin Street No.and Street Type Description Belchertown,MA 01007 U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/Town.State,ZIP M Masonry ✓S � 2, v�-�' b RC Roofing Covering -S1id� WS Window and Siding SF Solid Fuel Burning Appliances 413-283-4395 info@robertsroofsinc.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 128264 :3/16/23 Roberts Roofs Co.,Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name PO Box 1312 info@robertsroofsinc.com No.and Street Email address Bondsville,MA 01009 413-283-4395 City/Town,State,ZIP Telephone SECTION 6: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 'V No . ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize Roberts Roofs Co.,Inc. g��g:o}tb.�eha11;in all matters relative to work authorized by this building permit application. C ,,�5 jt45 4/20/2021 Print`owner s'iv`'' ifte(Electronic Signature) Date SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. y/-/-1 P: t O er's or A o ' ed Agent's Name(Ellectronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 128264 ROBERTS ROOFS CO. INC. Expiration: 03/16/2023 PO BOX 1312 BONDSVILLE, MA 01009 Update Address and Return Card. SCA 1 0 20MM-05/17 Yiyiu,,,,m/vw7//if. /474.i,,ri/ii-a//' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 128264 03/16/2023 1000 Washington Street -Suite 710 ROBERTS ROOFS CO. INC. Boston,MA 02118 THOMAS R.ROBERTS JR 1 AiatL,It 400 FRANKLIN ST BELCHERTOWN,MA 01007 Undersecretary Not valid without signature Division of Professional Licensure Board of Building Regulations and Standards Constructi , 'v*l& ` jr Specialty /i CSSL-100333 = xpires: 07/03/2022 THOMAS R ROBERTS, JR 400 FRANKLIN STREET 7,1 BELCHERTOWN MA 01007 , t , - 1 , oilerp Commissioner ,d bjEvn a.c‘L v.. Construction Supervisor Specialty Restricted to: CSSL-RF - Roofing Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call (617) 727-3200 or visit www.rnass.gov/dpl DocuSign Envelope ID:41703503-B626-4BAA-BD34-360FF67F91FD City of Northampton .410344 --1. Massachusetts „� DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building ii_ Northampton, MA 01060 Js't-,y. 3.,l\\�.CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: Waste Management, Wilbraham MA The debris will be transported by: Name of Hauler: USA Hauling & Recycling Signature of Applicant j Date: 4b0-10.1 7 DocuSign Envelope ID:41703503-B626-4BAA-BD34-360FF67F91FD The Commonwealth of Massachusetts Department of Industrial Accidents 1-_ D / Congress Street,Suite 100 _ =tz : Boston. MA 02114-2017 e r wiv c.ntuss.goi'/dia _ 11ulkers' Compensation Insurance Af ida'it: Builders/Contractors/Electricians/Plumbers. fll HI. I I1.1:11 NS 1 1 t1 I III. PEKJlI 11ING At'TlIORITI'. Applicant Information Please Print Leaihls Name IBusincss Organisation lndis idual►: Roberts Roofs Co.,Inc. Address: PO Box 1312 City:'State.'Zip: Bondsville,MA 01009 Phone#: 413-283-4395 .ire.Cis an rniptoyrr:'('beck the appropriate boa: Type of project(required): 1 1 am a employer with 3 employees(full and or pan-tine I.r 7. 0 New construction U lam asub:proprietor or purtncrship and hose no employers working fur me in 8. O Remodeling any capacity.(Nu v.urkers'comp.insurance required_) 9. 0 Demolition t fJ I am a hunxvwn.i doing all wurk myself.[No workeas.curr{+_insurance required.]• 4.0 la a hurnoue net and w ill be hiring contractors to conduct all'Aink on my.property- I w ill 10 0 Building addition m ensure that all cwntractun either hase workers'compensation'insurance or an sole 11.a Electrical repairs or additions proprietors w ith nu employed. 12E1 Plumbing repairs or additions 50 I am a uencral cunuactur and I has e hired the sub-contractors listed on the attached'hect- These ub-euntraeturs Inge employed and his c workers'comp.insuruee. 13. Root repairs h.a We an:a corporation and its officer.base exercised lbwright of exemption per h1C,L c. 14.0 Odle! 152 i 1t41.and we hose nu employees.[Nu wurlers'rump.insor once rcyuued.) 'Any applicant that checks box al mint also fill out the section belosi stowing their workers'compensation policy mfonnatwn. ' liorncuss en,who submit this Alain it uulicating they an doing all work and then hire outside contractors must subnut a nos affidas it indicating such. C untractors that check this box must attaeled an additional sheet shins ing the name of the sub-contractors and state whaler or nut those aaitities hose e-tnployce, It the sub-contractor.base employees.ilea must preside their ssurkers'clamp.policy number. I am an employer that is pro►'idini rtorAers'compensation insurance for my employees. Below is the polity and job site information. Insurance Company vane: Farm Family Casualty Insurance Co. Policy#or Self-ins. Lie.#: 2008W6216 Expiration Date:_ 4/17/22 Job Site Address 46 Birch Hill Rd city;sate.Lip:_Florence, MA 01062 Attach a cope of the workers'compensation police 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 S1,500_00 andVor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cos crape verification. I do hereby certify under the pains uud penalties of perjury that the information provided above is true and correct. Sienature / — - I)atc Vd-Iii—i Phone�: 2 - 95 Official use only. Do not write in this area,to he completed by city or town official ('its or I(Mr a: Permit/l.icense# Issuing.Nutherit} (circle one): I. lloirtl of IIcalth 2. Building Department 3.t its I oss a Clerk 4. Electrical Inspector 5. l'Iuntbiii Inspector 6. Other ('nntact Person: Phone#: AcoRO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 04/16/2021 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 Sean Rooney y Sean Patrick Rooney,Sr.dba A; No Extic 413-887-8817 I FA NA: 877-771-6087 Rooneynsurance Services E-MAILSean.roone farm-famil .com y ADDRESs: yi y 2341 Boston Rd. INSURER(S)AFFORDING COVERAGE NAIC# Wilbraham MA 01095 INSURER A: Farm Family Casualty Insurance Company 13803 INSURED INSURER B: _ ROBERT'S ROOFS INC INSURER C: 3090 PALMER RD. INSURER : BONDSVILLE, MA, 01009 - INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL� LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO R CLAIMS-MADE /\l OCCUR PREMISES(Ea EcT uEDence) $ A X BOP X X 2007X0329 04/17/21 04/17/22 MEDEXP(Anyoneperson) $5,000 PERSONAL BADVINJURY $1,000,000 GENT.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY ECT r)LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) X ANY AUTO BODILY INJURY(Per person) $ 250 000 A ALL OWNED SCHEDULED X 2001 C4685 04/24/21 04/24/22 BODILY INJURY(Peraoadent) $ 500,000 AUTOS AUTOS HIRED AUTOSN AUTOOWNED S (PRerraccidentDAMAGE $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION X PER STATUTE OTH- ER i AND EMPLOYERS'LIABILITY Y/N A iANYPROPRIETOR/PARTNER/EXECUT1VE 2008W6216 04/17/21 04/17/22 E.L EACH ACCIDENT $ I00r000 I(Mandatory in NHR EXCLUDED? NIA X E.L.DISEASE-EA EMPLOYEE $ 1 00,000 (Df yes, be under ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sean Patrick Rooney,Sr. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD