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29-544 (5) BP-2022-0546 41 INDIAN HILL COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-544-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0546 PERMISSIONIS HEREBY GRANTED TO: Project# ROOF Contractor: License: Est. Cost: 18000 RHINO BACK ROOFING LLC 106183 Const.Class: Exp.Date:05/26/2023 Use Group: Owner: GROSSO MICHAEL G&JULY SIEBECKER Lot Size (sq.ft.) Zoning: FFR/WSP Applicant: RHINO BACK ROOFING LLC Applicant Address Phone: Insurance: 532 HOPMEADOW ST STE 4 860-438-6158 6S62UB-2E33572 SIMSBURY, CT 06070 ISSUED ON:05/19/2022 TO PERFORM THE FOLLOWING WORK: STRIP AND RESHINGLE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I . CI7 . II Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner , LEIS i) t, he mmonwealth of Massachusetts IlUt Bo d of uilding Regulations and Standards FOR MAY 8 202 as ach efts:State Building Code, 780 CMR MUNICIPALITY USE - .B Permit A plicakion'To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 r C'`run r y,r I^isPFcrioNs One-or Two-Family Dwelling ------------- - ` This Section For Official Use Only Buildin Permit Number: j,P-eZ ..-b cif, Date Applied: co),...) Z5 / 5-1q.26ZZ Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 't1 1f\c .,c&r tsn\\ a47 6-yy 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: ,Mk . Cyrdsso ir).rev\ce ( \Pc b1U(0 — Name(Print) City,State,ZIP `*\ t,nci.t a r. i \k\ L1 l 3- 5u 3-B'Z l 1 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other V Specify: —r-O st. ittl Brief Description of Proposed Work':'(1r-Ove k re-0 a CC e(i St1`(l SV\l f\g 1e S v\ca,J a>-�\10Al 0rCAAi-k-ee} ru Mt 1n 1es -Cve la ►v Cnde. OLAAct coon ut c)v re kr C,QNY\ t-e not cl Orl S 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: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fee: $ Check No. O'lGSCheck Amount: 44 Cash Amount: 6.Total Project Cost: $ \gt OOO 0 Paid in Full 0 Outstanding Balance Due: r ` SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) `oLD OZ 0c)-3 'MO fN License Number Expi ation Date Name of CSL Holdet `q List CSL Type(see below) f� No.and Street Y Type Description \ _ ti 6 5- Unrestricted(Buildings up to 35,000 cu.II.) City/Town,State,ZIP R, Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering O� �`1_ WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address _ D Demolition 5.2 Registered Home ImTprrove t Contractor(HIC) t(t ii O q 12°23 1 \\\'\\(\O C — t�U� HIC Registration Number Expiration Date HIC 7— Name or HIC R t� • �" N d Stre C iL McmSScko, f v`1dl U C1L U— "L 3C(' mailE address 1-vti�•yl 'cci yl City/Town,Stat P Telephone one 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 No...........l7 SECTION 7a:OWNE AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Ir-k\A 6 n o G 7)� to act on my behalf,in all matters relative to work authorized by this building permit applic, . Q\ e Gs.s-o Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' 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. OiNeli a. ,) s LoI2Z- Print Owner's or Authorized Agent's Name(Electronic 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" 1Lk S 1 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 0 2 114-201 7 ii #it.mass.gov/dia VI4.ikers'('ompensatiun Insurance it:Builklers ContratturviEleetriciansiPlunthers. 10 BE FILED I+,I I II'I III.I'E[t'II riIN(:AIIITNORIi t. Applicant Information(l3 + Please Print Ixeihl Name uaincsstorgunlzatiundindividual): R v\ '�7v�G� V-0J�,rl q L LC_ Address: S�� irv\�:& � SA- • J City/State/Zip:S,,(•(\Skovn C - ()19 01 d Phone#: 3"1.17 0--` 1. 3zs-%2 f S Are yea an employ t r'.'t hick the appropriate hot: Type of project(repaired): 1.0 1 ant a..ngolarncr with eatrpdnyres(fill and,'ut part-time t.' 7. ©New construction 271 I am a sack proprietor ur pcnineasiup and have nu-employees wurkntr fur me in s. a Remodeling atn•capacity..Diu wurkcr,'cuinp.Insurance require d.) 30 l ant a Isnneowaea doing;all work myself.lNu workers'comp..inaurrrtec re+tpuired_ " 9. ❑ Demolition Building addition 4.0 i am a Ihtnrosaowrr-r and will be Inning ntmtr.wiurstu conduct all wink on my prpropertyI will 111 a e7uur;iitat all etioranwtues rich,r lukc workers'eorripertuix+n uwtinern:a are sole 1 l CI Electrical repairs or additions pntpnctors with nu crnpluyecs.. 12.0 Plumbing repairs or additions : TI I ant in. -tal contractor and I have hired the orb-contractors listed on the annelh ni sheet. 7—'These sab-contractors bate employees and hese vomiters'c anp.insurance. 13�RtlUfrCpair! 6.0 N'c an a corporation and its offset-vs have cu.-wised their right of car:minittrt per RMCit.c. 14. Other l x T;1i 41.and we ILVOIC nu eatpIuyecs.[flu wooers'eurnp.insurnnee rorautred.l *Any applicant that chocks bus ri imni also fell out the section brluw shuts ins their winters'compensation policy information_ t Iturtierow ncrs w hu submit this affsLtit ache:tine they are doing all wurk and then flat:mashie cuniracturs musi submit a new aifida%it indie-atinp such. :Contractors that cheek this bus must attached an addaLiunal shout sbuwing the inane ache subscontir eturs and state:whetter ur nut those entities lase employees.. If the sub-cientr.acturs have argrlu%ces.they must pmsidctheir workers"annp.pulley nrnnber- 1 am an employer that it providing workers'compensation insurance for my employees. Below is the policy and job site information.(n,uranee C'onipany Name: Sg oA,\a c(wed Policy 4 or Self-its. Lic.#: Expiration Date: Job Site Address:'\ \v'cLor.\ City/State,+zip: Ace 01 Olo-y ►ttach a copy of the workers'coinpeusation policy declaration page(showing,the polio} number and expiration date). E=aiicvre to secure coverage as required under MGL c. 152,*25A is a criminal violation punishable by a line up to 41.50(1X1 and or one-year imprisonmoit.as well as civil penalties in the form ofa STOP WORK ORDER and a line of up,to S250.(KI a day against the violator.A copy of this statement tnay be forwarded to the Office of lnvestistatinns of the D[t'1 for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the in fr rmatiuu provided nbi've is tare and correct. Sisdnature:M P` C� J�—� Date � l O l Phone#: g'L' o q)S—U) I S-CkP Official use only. Do not write in this area,to be completed by city or town ofciat ('it♦ ur Town: Permit'License Ai Issuing Authority (circle ono: I. Board of health 2.Building Department 3.(•it ,:fur►n('Perk 4.Electrical Inspector 5. Plumbing Inspector b.Other Contact Person: Phone#: City of Northampton ? � Massachusetts 4,, �. s;�e, A. 4 DEPARTMENT OF BUILDING INSPECTIONS 9 '. 212 Main Street • Municipal Building Jh CD tif— Northampton, MA 01060 s sil' 3,,�(\`� 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: Vet5\— v 61 , CA-- The debris will be transported by: Name of Hauler: Signature of Applicant: �� ,l7Y,�LI_ ��`'� Date: 01 b frZ A��® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/21/2021 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 have ADDITIONAL INSURED provisions or 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 Gregory Lano NAME: May,Bonee&Walsh,Inc.DBA Insurance Provider Group PHO No,Est): 684-2721 FAX No): (860)684-6582 (AIPO BOX 127 E-MAIL greg@ provider rou insurance com ADDRESS: g p' 52 Main Street INSURER(S)AFFORDING COVERAGE NAIC# Stafford Springs CT 06076 INSURERA: Cincinnati Specialty Underwriters 13037 • INSURED INSURER B: Arbella Insurance 41360 Rhino Back Roofing LLC INSURER C: Ace American Insurance co 22667 532 Hopmeadow St Suite 4 INSURER D: INSURER E: Simsbury CT 06070 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2172105773 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 ADDCSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE REN CLAIMS-MADE I— OCCUR PREMISESO(Ea occuErrence)D $ 100,000 — MED EXP(Any one person) $ 5,000 A CSU0117828 07/15/2021 07/15/2022 PERSONAL&ADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 HPOLICY n PROT- n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JEC OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED 1020108466 07/15/2021 07/15/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY 1Per accident) $ X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 — A EXCESSLIAB CLAIMS-MADE CSU0163811 07/15/2021 07/15/2022 AGGREGATE $ 1,000,000 DED RETENTION $ $ WORKERS COMPENSATION X STAR TUTE EORH AND EMPLOYERS'LIABILITY Y/N 500000 O ANY PROPRIETOR/PARTNER/EXECUTIVE n NIA 6S62UB-2E33572-5-21 07/15/2021 07/15/2022 E.L.EACH ACCIDENT $ , OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Evidence of coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE l ...4444a ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD lil Gomm r.fiwtaith L`i MasAaChusetts l`:iy zi n d' Ot:upali©rrnJ Lico nstrrr P ciat Li 04 d hilding Re, LFidtians aw Sia r�r�+ C "l lr` r:itig ' up t4I1t9 1 Specialty 1;ssI - 1 "r513 3 4 'Spirit; O5I26,2o23 T1d.10THY A *�--t rH 19 KNOLLwi zGD DRIVE tr. A NEW I`IA TFgD ti'''_T Off Bf le Ake Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC RHINO-BACK ROOFING, LLC Registration: 196409 532 HOPMEADOW ST Expiration: 08/11/2023 SUITE 4 SIMSBURY, CT 06070 Update Address and Return Card. Office of Consumer Affairs& Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 196409 08/11/2023 1000 Washington Street -Suite 710 RHINO-BACK ROOFING, LLC Boston, MA 02118 MICHAEL TROUERN-TREND 532 HOPMEADOW ST GG.(/aGr'oy� SUITE 4 Undersecretary Not valid without signature SIMSBURY, CT 06070