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44-047 (2)
BP-2023-1482 22 FAIRWAY DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 44-047-001 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-2023-1482 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est.Cost: 13875 DANIEL WEST 106007 Const.Class: Exp.Date: 07/08/2025 Use Group: Owner: BRANNIGAN LAUREN KATE Lot Size (sq.ft.) Zoning: WSP Applicant: DANIEL WEST Applicant Address Phone: Insurance: 11 PLYMOUTH AVE (413)695-7311 FLORENCE, MA 01062 ISSUED ON: 10/23/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF 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 Dries% 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: Cgi n • }�CUI Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner j : The Commonwealth of Massachusetts Board of Building Regulations and Stand.. ds O , 1i. W Massachusetts State Building Code, 780 .MR44, e90 MUNI •E LIT Building Permit Application To Construct,Repair, Renovate Ct's ',' i i a ?O vise Mar 011 One- or Two-Family Dwelling 44 'To�i,,.c This Section For Official Use Only �5,, oy� Building Permit Number: 6 fr'-2'3 _!N ef.)- Date Applied: / a /� j 2 z 3 �vt,� Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Addresss:, 1.2 Assessors Map& Parcel Numbers 2--lr•4kr-uxil l7r- 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 0 On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Lew raw. 4 icK sov\ '64C c-e. i IMA• OlP47._ Name(Print) City, State,ZIP 2_2 �r-t I Or. CUB Z18- d(tZ (qure..v�K txmv c .Cc t 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 Specify: \, f Brief Description of Proposed Work': iemwvC ,Qy_ As pko,1,4- t(bo.-c c J,& s ,(A SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 13 e 1. Building Permit Fee: $ Indicate how fee is determined: i 0 Standard City/Town Application Fee 2. Electrical $ 0 Total Project Cost' (Item 6)x multiplier x 3. Plumbing $ _ 2. Other Fees: $ _ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ — Suppression) Total All Fe'ets: Ji Check Not 13 Check Amount: "[° Cash Amount: 6.Total Project Cost: $ 1'?,/ 5 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) _ (64 7ssZ�5— License Number Exp rati n Date Name of CSL Holder \,' Q �Q List CSL Type(see below) ��. No.and Street ` Type Description ( b4Z Unrestricted(Buildings up to 35,000 Cu.ft.) �"l_ u^� R Restricted 1&2 Family Dwelling City/Town,State,ZIP Masonry 4OPRoofing Covering `� S Window and Siding 4 (Ar- C( 0/t'.` SF Solid Fuel Burning Appliances V"" (v�� . (c A I Insulation Telephone Email aZhotress D Demolition 5.2 Registered Home Improvement Contractor(HIC) �.(..• • lie R0c) C d-trc edc=.r— R-83 Z9-- zazq HIC Registration Number xpiration Date HIC C`ol p Name or HIC Registran ame No. Street 6,3kgs'_1-3 l( Email ad s City/Town,State, IP 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 . ❑ 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 t. ouy.le3\ to act on my behalf,in all matters relative to work authorized by this building permit application. (Apre," (-ZGkSovv Print Owner's Name(Electronic Signature) bate 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 contain this tc ion is true and accurate to the best of my knowledge and understanding. bz/(4 Vec23 Print ner's or Aut orized Agent's Name(Electronic Signature) Date NOTES: I. 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" City of Northampton THAM f'. ocy �� s.., S 4,...., " .' Massachusetts �'<<> ti * � G �" t ;, DEPARTMENT OF BUILDING INSPECTIONS �, ty w ¢ �. 212 Main Street • Municipal Building • ^a" `-,,, Northampton, MA 01060 4,,, 14/ 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: VectH R9d The debris will be transported by: Name of Hauler: .L, CI-NGlA S Signature of Applicant: Date: is/<<iz`-c3 The Commonwealth of Massachusetts Department of Industrial Accidents 13 li-...i r, i Congress Street,Suite 100 Boston. MA 02114-2017 •• •:-74,' WWW.mass.govidia Workers't'cimpensation Insurance Affidas it:Builders/ContractorstElectricians/Plumbers. TO BE FILED WITH THE PERMFITESit;AUTHORIII. Applicant information Please Print Leeiht% Name(ausincssoorganizatioronai,,,iauah: !(_,..(,)... ...A kez.:=4P-LS Address: ..,_\, Q ,vtiLA,--tx 043JL- City/State/Zip: 6.(oc -Z, Phone#: „6_!.3_) ee,c'S--'43 (( / ti,L Ilte appropriate Nis: Type of project(required): entployto Ann t employees(full and'or part-timel.° 7_ 0 New construction ,111 a auk proprietor or partnership and have no employee.working for roe in 8. 0 Remodeling voracity INu workers'comp.insurance minimal 9. D Demolition ama tO I am a l :sonnet doing all work mysell.INo workt.75:VOW imutunoe rs-quared y I op aiuikling addition 40 I am a liontwastrier and Will be hiring contractors to conduct all work on my prriperty. I will ensure that all contras-Aft either have workers-compensation insurance or me sole i la Electrical repairs or additions proprietora with no employees. i ID Plumbing repairs or additions Nj I am a general contractor and I have hired the sub-eintitractors listed on the attached sited_ 13{5Roof repairs These sub-contractors hive employee%and have workers'comp.itisurvnee.: ..se (Zdsc>4 6.0 We are a i..-ein$414"21iLltA and its officers have exercised their right of exemption per NMI c. 14.r;10ther V\.0, ...) 152,§l44j,and we have no employees.(No ixra comp.insurance required.] Any apptioutt that checks box ti I must also till out the section treloss show in g then workers'compensation policy information t Homeowners who submit this affidavit indicatine they art doing all work and then hire outside contractors must submit a new affidavit indicating such. %Contractors that check this bat*must attached an additional sheer show ing the name of the suls-cmitractors and state whether or not Muse entities have employee. it the sub-toisiractors[LIN,'empitlyititi.they must pi to.ole tiler ,torl,cr,'omnp.policy number lam an employer that is providing workers'compensation insurance jot my employees. Below is the policy and job site information. Insurance Company Name: ki, (Lk ttitl3i(Xvik 1,-1/-9 • 63 - _ Policy#or Self-ins. Lie.#: 116-'6 cte'c'-7t> 3*,Z0Z3/1,- Expiration Date: SI i 1-t-f- 2 4 Job Site Address: .1.-1.— Cr-<-iLetr ( r)r; City/State/Zip: (paxi.‘ - 6(Ocz_Attach a copy of the workers'compensation policy declaration page(showing the policy number an expiration date). Failure to secure coverage as required under MGL c. 152. *25A is a criminal violation punishable by a tine up to SI.500,00 ataror 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 die violator.A copy of du, ,.. Iteinerit may be forwarded to the Office of Investigations of the DIA for insurance co%erage ye ri fiCation. I do hereby cer ,und r rJIel tins and penalties of perjury that the inlitrmation provided above ...s true and correct Signature: ,,e, fr"'"--- Date: Phone#. Official use only. Do not write in this area.to be completed kv city or town oflicial. ('it y or Toss ii: Permit/License 4 ... Issuing Authorit, (circle one): I. Hoard of Health 2, Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6,Other ("(intact Person: Phone#: • ACORE, 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 NAME: Travis Sias PHONE KSK INSURANCE AGENCY INC tA/C No,W: (413)527-7859 •( No); E-MAIL ADDRESS: travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAICa EASTHAMPTON MA 01027 INSURER A; AIM MUTUAL INS CO 33758 INSURED INSURER B DANIEL WEST INSURERC: 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 BY PAID CLAIMS. INSR INSDADDL SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE (MMIDD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED 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 AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION PER H- X STATUTE ER I AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? NIA N/A N/A AWC40070363902023A 05/01/2023 05/01/2024 - — (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/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 Florence MA 01062 Daniel M.Crovley,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