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BP-2024-0604 666 KENNEDY RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 04-011-001 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-2024-0604 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2024 Contractor: License: Est.Cost: 4600 MMC SPECIALTY ROOFING INC 76497 Const.Class: Exp.Date:06/07/2025 Use Group: Owner: KALINA ROESSLER JO R&NORA Lot Size (sq.ft.) Zoning: WSP Applicant: MMC SPECIALTY ROOFING INC Applicant Address Phone: Insurance: 176 PINEVALE ST (413)642-3842 AWC4007030594 INDIAN ORCHARD, MA 01151 ISSUED ON: 05/16/2024 TO PERFORM THE FOL L O WING 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: ii/.72_ Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner —C.-15)t-- _-- -ilk, 1, L . it. The Commonwealth of Massachusetts 1 (� 202Q H Board of Building Regulations and Standards t a� FOR k �_ Massachusetts State Building Code, 7$0 CMR M cL N1CIPALITY � ,�r,1N�?:� i� USE Building Permit Application To Construct,Repair, Renovai—dOr tifsh t3"^S'I sed Mar 2011 One-or Two-Family Dwelling +, This Section For Official Use Only Building Permit Number: /bI&I2(/1 0 01 Date Applied: eel,i t—) es 1/7 5-I6.ZozY Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 P_ roperty Address: 1.2 Assessors Map& Parcel Numbers 6�do ke^neS Rcd , Leeds,PIA 1.1a Is this an accepted sZteet?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: A/ors VcRt 1~vl0. ,_ _U 5 M�41 oiOs3 Name(Print) City,State,ZIP o6 Kc vunect Road( No c-o-P No.and Street Telephone mail ddress SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.," Number of Units Other 0 Specify: Brief Description of Proposed Work2: TCe.,.— OA ' i• Sin3w)Ps 41. . . rep 1(.- t.,):NA.. 1G(-J 3[) Qa- 0.CZ1-�Ar. \ st— .-. 1c5 On -is---� 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 Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees;l$rt 6 Check No.0 1' v Check Amount: 6.Total Project Cost: $ 41 boo 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) e\t4}C� 4- License Number Expiration Date Name of CSL bolder List CSL Type(see below) No.and Street Type Description ((�� Qr ^,�lG. � l't 1 1, \� Unrestricted(Buildings up to 35,000 cu.ft.) ," R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry ;41-`J- C tel(5t r�vl,t I ,(/� Ot O(O RC Roofing Covering WS Window and Siding 1 SF Solid Fuel Burning Appliances -cgg3 S49Ut7$ l`,t-C1►'1 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement fContractor(HIC) 1-7 S g30 0/25 MM c_ 5' 'C z�� HIC Registration Number Expon Date HIC Company Nettie or HIC RR istrant Name—) l 162 P i v+e__v�l e re4* Nv< 10 17S /►^ No.and Street Email address ;an 0c0.1"0 /01A1p1lS1 1413 -6N2-38412_ 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 Ja' 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 MAC_ 5ct c c t 4 R.or E�✓tq to act on my behalf,in all matters relative to work authorized by this building perft4 application. J 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. Mct++hP_.,v t")t✓c-S\2 1 Zy 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" City of Northampton ' Massachusetts ti (�,� DEPARTMENT OF BUILDING INSPECTIONS y` j•° 212 Main Street • Municipal Building J`. ksj Northampton, MA 01060 "'•.• D% 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: W Ab�\r‘.c /0,, The debris will be transported by: Name of Hauler: A e_c;Go,v wcxk Signature of Applicant: Date: 5 ( ZLt The Commonwealth of Massachusetts I: — —!'l. Department of Industrial Accidents 'sii,_ ' 1 Congress Street,Suite 100 er f if= Boston,MA 02114-2017 %...� � www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ^^ Please Print Legibly /Name (Business/Organization/Individual): v 1 e— 5 1 CS.-\,,c t `D }C i✓l Address: \`76 P}�e - \e City/State/Zip: c5601/4t.I prcl-,.� ) M.A 1OR iPhone#: 4(3 -- 64(2_ _ 3 SYZ Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with ) Z employees(full and/or part-time).* 7. 0 New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 l Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.®kOOf repairs These sub-contractors have employees and have workers'comp.insurance? 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. A 1 ii A Insurance Company Name: A , /.4t,+t \ '�1 ,uc-G,vt< Policy#or Self-ins.Lic.#: AWC — L{n(�''�i f—'7Q c 54`-(.2 .4 c2lExpiration Date: 6/77�`/ Job Site Address: 6 66 I --ln✓ec- I'�Q City/State/Zip: �.E�LC9S)) Oi.O 3 Attach a copy of the workers'compensatiojolicy 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verific I do hereby rtify uad he pains and penalties of perjury that the information provided above is tru and correct. Signature: `\ _— Date: 5/ 5 2-L( � Phone#: 4( — 6c(2— g4-{2 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Constot ervisor CS-076497 z �ires:06/07/2025 t .� CLIFTON FROST 89 MARSH HILL RR BRIMFIELD 9'101D ab IL b�r�I JV t Commissioner �., (`ti„ls4 ' - „ ..'...IN MMCSPEC-01 NICOLES .4TE(ININDONYTYI `c�oRo CERTIFICATE OF LIABILITY INSURANCE °”6/7/2023 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 POUCIES 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 84SURED 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 f such endorsement(s). PRODUCER coNTAONCT Nicole Sarafin Phillips Insurance Agency,Inc. PHONE 413 594-5984 FAX 97 Center Street (A/C,No,Ext):(413) I lac,No):(413)5924499 ' Chicopee,MA 01013 ,wnoi&M.nicola@phillipsinsurance.com INSURERIS)AFFORDRIQ COVERAGE NAICI _- — INSURER A:The Cincinnati Insurance Companies INSURED INSURERa:Arbella Protection Insurance Company MMC Specialty Roofing Inc ersueeRc:National Union Fire Ins Co. 19445 50 Valley View Drive INSURER D:A.LM.Mutual Insurance Company 33758 Westfield,MA 01085 INSURER E:Liberty Mutual Insurance Co 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. TYPE OP RIa1IRAlICE MD�yya BUBR/ _POLICY NUMBER �OUCY OFF r01.ICY O(r ... �UNITS .--__ X GO UAELI IAL GENERAL TY L EACH OCCURRENCE $ 1'000'000 CLAIMS-MADE [x I OCCUR CSU0147019 8/7/2023 6/7/2024 L s'. S l $ 30%000 I MED D(P y am $ 5,000 — LAn _ PERSONAL a ADv INJURY $ 1,000,000 ._ AAOR --- O�MIT APPLIES PM -GENERAL AGGREGATE $ 2,000,000 )7 POUCY X .p�T f ,LOC PRODUCTS-COMPIOPAGO $ 2,000,000 OTHER: $ B AUTOMOBILE umsuTY m SINGLEn:mew LET $ 1,000,0t10 my AUTO �H 1020117984 8/7/2023 6/7/2024 gamy Kam o'er Dasonl $ AUTOS ONLY A�UgTyOSSyUy�� - BODILYE INJURY(Per oedema _ __'AUTOS ONLY _ AUTOS Ora.Y f«'` OE $ $ C X UMBRELLA L _,X_,X OCCUR --- EACH OCCURR ENCE $ 5,000,000 AS excess use aLAars.MADE TBD 617/2023 617/202.4 AGGREGATE 1 5,000,000 DED 1 I REIETTr1qrormtlONi D 21)EYPLOM LIM�frr — j xJ PEA I i ANYMEMPIPPRIEMPAENRIEU XECUTIVE I"I NIA AWG100-7o3os9<1-2o23A B17I2023 6/712024 EL.EACH ACCIDENT $ 1,000,000 yiaan 1.L.DISEASE-EA EMPLOYEE $ 1.000,000 DESCRI OoN DI IO N OF OPERATNS below E L.DISEASE-POLICY LENT $ 1,000,000 E Worker's Compensatio 'WCS33$821N4R-013 1/24/2023 1124/2021 State of CT 1,000,000 i DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES IACORD 101,AddIllond Remarks&EN**may to aeadIsd Imes @Pam is,sq,dnd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLN:Y PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD