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35-053
• BP-2024-0556 956 RYAN RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-053-001 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-2024-0556 PERMISSION IS HEREBY GRANTED TO: Project# roof 2024 Contractor: License: Est.Cost: 9350 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date:07/08/2025 Use Group: Owner: LEAH FORBUSH, WENDY(L/E), CARVER Lot Size(sq.ft.) Zoning: WSP Applicant: DL WEST ROOFING CONTRACTOR Applicant Address Phone: Insurance: 11 PLYMOUTH AVE AWC4007036390 FLORENCE, MA 01062 ISSUED ON: 05/07/2024 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 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: /(77 Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner - • -- ..... / ' .,„ . / i g4 The Commonwealth of Massachus0its 4,, i I. FOR 40) Board of Building Regulations and Stindar s 0 Massachusetts State Building Code,/,80 .6, mumciPALITY ...,, USE Building Permit Application To Construct, Repair,Renolikteknolish a`i Revised Mar 2011 One- or Two-Family Dwelling ' A SP".".. This Section For Official Use Only '-:::70;71;;:,,i: Building Permit Number: 3,-)-4/— 6-5t.4 Date Applied: Zus.) 7Z, //4 5-7-2azy Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers Ric., CA. 1.la 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: Zone: Outside Flood Zone? Public 0 Private 0 — Municipal El On site disposal system El Check if yes0 SECTION 2: PROPERTY OWNERSHIP1 2.1 (=-I of Record: akrt-)•‘....-- 9See &-iC,4• RCK. C Name(Print) City,State,ZIP e35-4- Ai is.c4. (4L ) ,-(ace-4.3-i-c, -Arb,..5i4(A.?,' €fttwx-i.k. Ccvt^ No.and Street Telephone Email Altdress 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 El Demolition 0 Accessory Bldg. 0 Number of Units Other Si-Specify: Brief Description Description of Proposed Work2: 0-(1)tA4.4- (2-czAtbk c_tvvcit 11. {-ec j. et, AD,...e_. clzekveA4 fc.e.te c_Dt-Ils. at -3,::::, 4 of r ckirCeli 4tC.A4-Nrc 4bItkift%(< SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials) 1. Building $ 4' ..---- 1. Building Permit Fee: $ Indicate how fee is determined: V 2.Electrical $ 0 Standard City/Town Application Fee 3.Plumbing $ 0 Total Project Cost'(Item 6)x multiplier 2. Other Fees: $ x 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $A A Suppression) ,--- Check No. [15 'Check Amount: Llo Cash Amount: 6.Total Project Cost: $ 9135°. 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �C i. e n Date te License Number Ex i 'on D Name of CSL Holder List CSL Type(see below) RC_ Ll e buyvA-1A ckPe - No.and Street Type Description �� Unrestricted(Buildings up to 35,000 Cu.ft.) I! [ LQ \'�^vA• C3(C 'Z R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry 4) Roofing Covering Window and Siding SF Solid Fuel Burning Appliances \( � -� �� }-�1� �5 �,,cQ I Insulation Telephone Email arl1ess D Demolition 5.2 Registered� Honme Improvement Contractor(HIC) 1 }$3Z L 04., WSJ iws.Cti i(C Cbltkkrecv K›r HIC Registration Number xpir tion Date HIC Company Name or HIC Registrant Name L l pl�Yvto-u_A cc_02 • (uyu �pp ( 'C0-, No.and Strtet Email4abiress WA O(OC/Z_ 5—` '3 Lt City/Town,Stale,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 ______ to act on my behalf,in all matters relative to work authorized by this building permit application. L� LCcf l)� S 1 S1 `'z`( Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 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. ( - -s- glSitcyzY 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(1-IIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. I42A. 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 #0 YH.A1 za,s, :,,‘s fir' fr ..', •.' i, Massachusetts $- <-, * E p� y DEPARTMENT OF BUILDING INSPECTIONS r�3 *t2q. { "t-,m 212 Main Street • Municipal Building v� ,I, ' ` , ., p4 Northampton, MA 01060 Sfp VO`\6, 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: Ue4-1,1 Ktes(c-11ti:s( V i - 1ar-\ The debris will be transported by: Name of Hauler: (U. C. L-) - ( Atuis 6a-ka--4ckv- Signature of Applicant: i;ii__ ....."-- Date: 5/5/tr,L I .... � The Commonwealth of:Massachusetts " :z Deportment ofladustrial,ircidetrts =j,1= st I ("ongress Street,Suite 100 r��'- ) Boston, MA 02114-2017 )vivw.mass.govldia 11 in kers' ('n,rnpensation Insurance Affidavit: Builders1ContracIorstEtectricians/Plumbers. TO BE FILED WITH 1 HE PERMIT1fIr(:AUTHORITY. Applicant Information n �1- Please Print Lcuibl% Name (13usrncs.s,Urga.rum t tun;Ind1v'dual): O.(. (J-1yC.(- (Ze 4�cs (6vulta(ltnc Address:__l��yti L 1Q__ City/State/Zip: �t.. , • 6042 Phone#: 6Wb) 4,g5= 31( re wd an employer?Cheek the appropriate box: Type of project(required): i' am a employ*.with Z.employees(htt1I andior pare-tirnet.• 7. o New construction 20 I am a Toole proprietor or partnership and have no employes working for me in 8. Q Remodeling any capacity.[No workers comp.msurane'e required.) kO l am iu m a eownea doing all work myself.[No workers'comp.insurance required.]' 9. El I)entolition 4.0 I am a homeowner and will be hiring contractor}to conduct all work on my prs perty. I wit. I El Building addition ensue:that all contractor:either have workers :nsxtiaut assurance or an sole II. Eleuncal repairs or additions proprietors with no employees_ 12.0 Plumbing repairs or additions sin I am a general contractor and I have hired thesub-contractors Listed un the attached sheets_ These sub-contractor:haw employee's and Muse winters'mono.insurane .A 1 pOt'repa�ir'sl,1 ed 6.o We are a corporation and its officers have exec iced their right of exemption per MGt.c l ter 152,§1(d),and we have no employees.[No woriers'comp.insurance required.] "Any applicant that clucks boa al must also till out the section below show ing theirwurtkcrra'compensation policy infonnattorr. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. %Contractors that check this box must arts bed an additional sheet showing the name of die sub-aontr-actors and state w holier or not those entities have employees.. If the sub-contractors base employees.they must preside their workers'comp.policy number. I am an employer that is providing n'orAers'compensation insurance for nit e nplorrrs. Below is the policy and job site ire Jorrnntiotl. Insurance Company'slatne: A,1, K. (14,k( Gi,„`� . - Policy#or Self-ins.Lie.#: aW Lqtr=a-a3Co3 Q61.0Z-1 f4-- Expiration Date: Si i I ' Z-.S— Job Site Address: 1t e d4 41/1 CitytStatefZip: *s4v v, j . b(tsceZ Attach a copy of the workers'dimpensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MCIL c. 152,§25A is a criminal violation punishable by a tine up to SI,500.U0 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator. A copy of this statement may be forwarded to the Office or Investigations of the DIA for insurance coverage verification. I do hereby cert under ii ' this and penalties of perjury that the information provided above is true and correct. Signature: Date.: Ssr`.3z ( Phone : i 3) 6q S- 1-3(c Official use wilt. Do not write in this area.to be completed by city or town of iciaL City or Tie.n: PernritiLicense# Issuing Authoritt (circle one): I. Board of health 2. Building Department 3.CitylTown Clerk 4.Electrical Inspector 5. Plumbing Inspector i.Other ('outset Person: Phone#: AC�® DATE(MM/DDIYYYY) `� CERTIFICATE OF LIABILITY INSURANCE 04/03/2024 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 PHONE 413 527-7859 FAX {A/G,No,Ext): � (A/C.No)____-- ADDRESS: E-MAIL travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE - NAIC B EASTHAMPTON MA 01027 INSURER A: 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: 993514 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 IADDL SUER POLICY EFF POLICY EXP LIMITS LTR 1NSD WVD POLICY NUMBER (MMlDD/YYYYI (MMIDD/YYYY) COMMERCIAL GENERAL LIABILITY 1 1EACH OCCURRENCE $ `DAMAGETO RENTED ' f PREMISES(Ea occurrence) S -_J CLAIMS-MADE OCCUR MED EXP(Any one person) S 1 _I N/A PERSONAL tL ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE S I POLICY[ ,jE ; LOC PRODUCTS-COMP/OP AGG ;S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ .(Ea accident) ANY AUTO 1 BODILY INJURY(Per person) $ OWNED SCHEDULED I N/A 1 BODILY INJURY(Per accident) $ I AUTOS ONLY . AUTOS I HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY ;AUTOS ONLY ;_(Per accident) S UMBRELLA LIAB OCCUR i EACH OCCURRENCE S ' EXCESS LIAR CLAIMS-MADE N/A I'AGGREGATE $ ,DED RETENTIONS $ •WORKERS COMPENSATION PER 1 OTH- AND EMPLOYERS'LIABILITY X I STATUTE •ER i ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N I E.L.EACH ACCIDENT $ 100,000 A 'OFFICER/MEMBEREXCLUDED? N/A N/A N/A AWC40070363902024A 05/01/2024 05/01/2025 - - - -- ------ - --- - - (Mandatory in NH) % E.L.DISEASE-EA EMPLOYEE S 100.000 .If yes,describe under I DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT S 500,000 I ' 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- compensationfinvestigations/. 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.Crowley,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