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29-385 (4) BP-2024-1137 35 BROOKWOOD DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-385-001 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-2024-1137 PERMISSION IS HEREBY GRANTED TO: Project# roof 2024 Contractor: License: Est.Cost: 11980 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date: 07/08/2025 Use Group: Owner: J WALKER MICHAEL R &KRISTEN Lot Size (sq.ft.) Zoning: WSP applicant: DL WEST ROOFING CONTRACTOR Applicant Address Phone: Insurance: 11 PLYMOUTH AVE AWC4007036390 FLORENCE, MA 01062 ISSUED ON: 09/05/2024 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: 7 2_ Fees Paid: $60.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner a The Commonwealth of Massachusetts :(0): Board of Building Regulations and Standards FCR Massachusetts State Building Code, 780 CMR SEP - 4 M NICIPALITY 2024 USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2611 One- or Two-Family Dwelling DEFT.OF RAIDING INSPECTIONS This Section For Official Use Only ( NOF TKAMNON.MA 01060 //JJ Building Permit Number: �//r CI,.1137 Date Applied: sr ie/ / 9-S•2y Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers SS eAd;c l OC- 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood tone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone'? Municipal 0 On site disposal system 0 Check if yes❑ • SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 'kk k1vr— �(e�c-eac4T'(`e )(�co3 Name(Print) City,State,ZIP ?,S d'bOt* U-t)\ Oc. 4 g$s=z3zk ►a . l k @,tnc6\•<cw. 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 I ier-zEr--Specify: Oft L RAJ Brief Description of Proposed Work': k. e (11. Q Y\.e— cc eke rrt> • 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: I ❑ Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ _ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: Check No. 6 heck Amount: � Cash Amount: 6.Total Project Cost: $ k fl tgf'jb----- 0 Paid in Full rr ,, 0 Outstanding Balance Due: \C kU -!/" SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) t etltat.1 CSn - itb tea- -1 .-�s- 4-314— License Number E i tion Date Name of CSL Holder List CSL Type(see below) \`Ca "k c � Oe . No.and Street Type Description III• b lae'Z__ U Unrestricted(Buildings up to 35,000 Cu.ft.) ( R Restricted l&2 Family Dwelling City/Town,State,MP M Masonry JO Roofing Covering vl Window and Siding SF Solid Fuel Burning Appliances (itr) 13(. dlf.. .A->�� 1 Goa- I Insulation elephone E dd s D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1.qt-61-9- 11 kfroZ. iLa e}4&J Ion HIC Registration Number Expiration Date HIC Com any Name or HIC Rerant Na e % �] ll P LtspA-{n O4Q.p• 4t..6.O-fib'"")C .0 hW I(•(Oa". No and St et Ema�?addrts �•-eelr,. .e PM. 6(a�2_ 6A- .4311 . 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 ti(---__ No .O 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 (4,... ...k er, to act on my behalf,in all matters relative to work authorized by this building permit application. tiAlliQ_ U-ve)1/41 ,-( 41(c alif Zg:. 1 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 contain in this p lication is true and accurate to the best of my knowledge and understanding. ; ,�� //Z rOZY ,', / Pr' ne s o 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 oft NAM(,0� ,. ..: 1,. 4 j •• r '' Massachusetts • �� '" `<-\ 4 f. * - 6 .he r4 at DEPARTMENT OF BUILDING INSPECTIONS a. ' ` t 1 k.;._ . .., Ii '�. ' r` 212 Main Street • Municipal Building vj ? Vi; Northampton, MA 01060 'rsth p'`N� 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 R- -(<v1-' The debris will be transported by: Name of Hauler: U-U �- — ( r. Signature of Applicant: Date: The Commonwealth of Massachusetts J. Department of Industrial Accidents 5 - I Congress Street,Suite 100 at:I � Boston, MA 02114-2017 www.ntass.gov/dia Workers'Compensation Insurance:Afrtdav it: Builders('outractors,'ElectriciansIPlumbers. TO BE FILED WITH THE.PERM)rum;..k l!iota I . Applicant Information Please Print I.eeihly Name(14nsinesslOrraniaationr1ndtvidual): Address: -\ Q 1� ,34. Est- City/State/Zip: RpagiNc,f, > titik& o(bCp2. Phone#: �13�(cflS 3 Are you an employer?Cheek the appropriate hot: Type of project(required): t.r;.I ant a employer with �1._..__errtpluyacs(lull ancl'or part-time).• 7. L..J New construction 2■ 1 am a Tole proprietor or partnership and have no employees vs+orking for me in R- 0 Remodeling any capacity.[No workers'comp.insurance required.] 30 I sin a homeowner doing all work myself.[No workers'comp.insurance required.] 9_ ® Demolition 10❑ Building addition 4.0 I am a homeowrwr and will be hiring;comtracturs to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole l 1.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions SO I sin a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13 Roof repairs These sub-contractors have employees and have workers'comp.insurance.' "` \ GOY t1.0 We are a corporation and its officers have exercised their right of exemption per MU.c. 1 lih�r Q� 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicentt that checks boo g I must also fill out the section below showing their workers'compensation policy information. t tknneowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must subnut a new atlidavit indicating such. :Contractors that cheek 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'sxnrip.lxihc; uurrher_ I am an employer that is providing workers'compensation insurance far toy employees. Below is the policy and job site information. �- Insurance Company Name: 4.. r M t 1�-ca 6� ,ram Policy#or Self-ins.Lic..#: A ..` �U3(o3`?D-zoty Expiration Date: SIVZoZ5— Job Site Address: '35 �t;(y ._A f. City/StatelZip:Flpt6'10.4 I t( . 6(64-2- Attach a copy of the workers'compensation policy 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DR for insurance coverage verification. I do hereby cerf fund r t e pains and penalties of perjury that the infurounion provided oboe,is true and curre'ct. Sinnaatre: D:r.tc. / toy 6 6 Phone#: 03/(per 73/( Official use only. Do not write in this area.to be completed by city or town official ('its or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2. Building Department 3.CityrTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �� 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 (AIC.No,Ed): --- --_ L(A/C,No): ADDRESS: travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAIL# 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: 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 ''ADDL SUBR - - - -- -POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) IMM/DD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY IEACH OCCURRENCE $ CLAIMS-MADE OCCUR 1 DAMAGE TO RENTED ' PREMISES(Ea occurrence) 1$ I__! MED EXP(Any one person) I$ N/A I ---- PERSONAL S AOV INJURY "'$ GEN'L AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE $ POLICY JPER2 LOC I 1.PRODUCTS-COMP/OP AGG $ OTHER. • I $ AUTOMOBILE LIABILITY i i 'COMBINED SINGLE LIMIT i$ (Ea accident) ANY AUTO , I BODILY INJURY(Per person) $ OWNED ____1SCHEDULED i AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE -AUTOS ONLY —_ ;AUTOS ONLY (Per accident) $ 1_, I I$ UMBRELLA LIAB -OCCUR EACH OCCURRENCE $• I _ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION X PER OTH- i ,AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED/ N/A NSA N/A AWC40070363902024A 05/01/2024 05/01/2025 -- - (Mandatory in NH) i E.L.DISEASE-EA EMPLOYEE:$ 100,000 'If yes.describe under 500,000 DESCRIPTION OF OPERATIONS below i EL DISEASE-POLICY LIMIT $ N/A 1 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.gov/Iwd/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.Crowly,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