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35-093 (6)
BP-2023-0742 6 CAHILLANE TERR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-093-001 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-2023-0742 PERMISSION S HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 2950 DL WEST ROOFING ONTR ACTOR 106007 Const.Class: Exp.Date: 07/08/202 Use Group: Owner: DREW UGEON, ROBERT, APRIL,& Lot Size (sq.ft.) Zoning: WSP Applicant: DL WET ROOFING CONTRACTOR Applicant Address Phone: Insurance: 11 PLYMOUTH AVE AWC4007036390 FLORENCE, MA 01062 ISSUED ON: 06/07/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND RE-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: 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: ( TIT a Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax (413)587-1272 Office of the Building Commiss ner i /I/ /4 The Commonwealth of Massach setts /1/ n Board of Building Regulations and and rds 1 - i 20 F R Massachusetts State Building Code 80t . ' UNI IPALITY NpgT Ullt)/n JSE Building Permit Application To Construct, Repair, Renova eti};...,, : Revi d Mar 2011 One- or Two-Family Dwelling r`' or so/o^4s This Section For Official Use Only ! Building Permit Number: i)'A 3, 140 Date Applied: A eio J ,S /12 6-7 2123 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property d ess: 1.2 Assessors Map&Parcel Numbers CO (�h t to ice 1.1a 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 ❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name nnt) City,State,ZIP ( Cod\l l at t.�k.rC4L L at3)LilS'Z138 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 12kSpecify: VW.° tc — Brief Description of Proposed Work': lQi ci'- A)(1k-t eL e� Inal -(tn 'o `(S(c& �.r s e arA ILI re.5(A.�4 w(� k` `t Cha �r- Q lic, ocA a A e -_ r%Slt S`o`S et " a le Co(:or yv1444-F--41A S S(n.tvcsle SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ '7 ' Sb. I. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee 0 Total Project Cost' (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ 4'..--- � Check No. '1 Check Amount: LP Cash Amount: 6.Total Project Cost: $ 2 5 0 Paid in Full 0 Outstanding Balance Due: / -- SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) wq.L License Number Ex iration Date Name of CSL Holder ` iwc - u- q List CSL Type(see below) 1� No.and Street �`�\ Type Description i' ? - OCO(.� R RstrictdUnrestricted(Buildings up to 35,000 Cu.ft.) lE1214 R Restricted 1&2 Family Dwelling City/Town,State,ZIP Masonry Roofing Covering vt Window and Siding SF Solid Fuel Burning Appliances &WV- .- 731( 04` ` -8.4S Etp_SYMA/CalAlI Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) �. (�-�-•-�' I \ C��,1 err t 32`a- 2b HICC Registration Number E irat n Date HIC Company Name or HIC Registranl Name No,„And Street Email addres 'P.-DMA/4 iMA • °Co 4`Z 613)4 c- -3l I 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 No .0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT // / I,as Owner of the subject property,hereby authorize 0,(_,• 1" obetzif de to act on my behalf, in all matters relative to work authorized by this building permit application. \� Cecsn s Iet.b-,3 Print Owner's Name(Electrol i 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' this app 'cati n is true and accurate to the best of my knowledge and ee/5± Print ner's Auth ized 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 Eedrooms Number of bathrooms Number of Ealf/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" City of Northampton I, „>"v Massachusetts �.. '" DEPARTMENT OF BUILDING INSPECTIONSft 212 Main Street • Municipal Building Jb tea~ Northampton, MA 01060 SSNry \" 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: A (4,in Location of Facility: \16V 1 koza f.,((d 2.3� Ziguilattatist—U- (n h The debris will be transported by: Name of Hauler: D•( � C-,— e (2vb CT(k Signature of Applicant: rk/i/ Date: — 4 **s. The Commonwealth of Massachusetts ET„11=e 1 Department of Industrial Accidents I Congress Street, Suite 100 ,, if a ---'4Al Boston, MA 0114-2017 ''. -12 r 7' ,, www.mass.goWdia It otkers'Compensation Insurance Affid AV it:Buildersi( rintractorsfElectrieituvPlumberi. It>BE FILED WITH THE PERMITTING AUTHORITT. Applicant Information Please Print teitibls Name iLIS.=:ii.Organization Inkto.itluallc.. ii).(..L.1.1—) Address: \it. il ....(ifk4..e>ock4k. City/State/Zip: Roca AL_k rIAA-. octrt:L. Phone -r';: 6(-- ) e_ecis-- R-31 ( / Are you an empkiyer?Cheek thr a p p Top r nue hot: 1 Type of project(required): am a employer with _ --7:._,rnarployees(full itenFor part-timet.* 1 7 0 New construction 20 I am a sole proprietor or pannership and have no employees,working tOr me.in ii /L 0 Remodeling ally capacity Nu workers.'comp.insurance requiredi 9. 0 Demolition •.kcj I am a honk-owner doing all work myself.No woritims*cony'.insurance reatiredi' ]0 0 Building addition 4.E3 l am a lionsnawner and will'be hiring oantradurs to cvntinct all*orlon my property I'.,;I. MAIM that all exmtractors either have workers"corrarrensatimi treurrance or are sole 110 Electrical repairs or additions proprietor.Nor ith no employees. , 1 2.0 Plumbing,repairs or additions SC3 I am a general contractor and I have hued the sub-commetors Listed on the attached street i 30oof repairs Thew aub-contractor.ltas employees and lune workera`etnrip. ursuraricc; 14.00ther Ati.,... P-cpcf- iS.0 We are a ourporation and its otlicas have exereised their right of CAemption per MC&L. ,. 132.§1(4),and*v Lase no errasloyees.[No'workers'comp.insurance required.I. *Any appfnant that chocks box al mew also fill out the section below showing their workers'compensation policy information t Horneownen who%I:Amn this affidavit indicating they arc doing all work and then hoe outside cernimalors must sittinut a new affidavit indicating sila TCoritracsori,Mat check Mr;hos,must tumefied an atiditional sheet show iris the name of the,:as-t-tvictriwtor.,and state whether or no;those entities hoe employee. If the sub-ecmtraetor N lia%.e employtxs7 they mum fros.ide their *titli:els'k...'iNcip iv ite,p,numb,: lam an employer that is providing workers'compensation insurance few my employee& Below is the policy rind job site information. Insurance Company Name: A ,/X • IV\ - Mt,.3.1-C-3CcA (,1(\-S. (SC) - _ Policy#or Self-ins. Lie.#:40C c(coq-oye-3'ID Z0Z7DA- Expiration Date: 5 i ZZ Z1 (9, .__. Job Site Address: te C„Cc\nake.44.1„.e-124-14 .. Crty/StateiZip: .,_(-4.44, iti-lie 00 . Attach a copy of the workers compensation polky declaration page(showing the policy number andiespinition date). Failure to secure coverage as required under MCii.c. 152, §25A is a criminal violation punishable by a fine up to S1.500.00 ardor one-year imprisonment,as well as civil penalties in the form of a STOP!WORK ORDER and a line of up to 5250.00 a ..,..,,e day against the violator. A copy of this statement may be f orwarded to the OB - of Investigations of the DIA for insurance coverage verification. I do hereby c , ,.un#er w 1 ins and penaltieS of perjury that the information prol'illiq oboe.is true and correct. .----y Signature: ' 'e'P - Date: 5- Z 3 Phone#: 1.--5J 6 ,i -43 /7 Official use oak. Do not write in this area,to be completed by city or town official ( it'. or Town: Permit/License fl Issuing Authorit., triage one): I. Board of licalth 2. Building Department 3.City/Town Clerk 4.Ekftrical Inspector 5. Plumbing Inspector t.,.Other I Contact Person: Phone#-: ".... ...... ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 05/19/2023 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 Travis Sias NAME: KSK INSURANCE AGENCY INC (A/c No.Exit (413)527-7859 1{ac,No): E-MAILDE ADDRESS: travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAIC# EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: _ DANIEL WEST INSURER C: D L WEST ROOFING CONTRACTOR INSURER D: 11 PLYMOUTH AVE INSURER E: _ FLORENCE MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: 893862 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 i3Y PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER LIMITS (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILYINJURY(Peraccident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXA OFFICER/MEMBER EXCLUDED?ECUTIVE NIA N/A N/A AWC40070363902023A 05/01/2023 05/01/2024 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I 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.govilwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Daniel West ACCORDANCE WITH THE POLICY PROVISIONS. 11 Plymouth Ave AUTHORIZED REPRESENTATIVE `-Th C f 7� Florence MA 01062 Daniel M.Cro vIey, CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD