18-027 (2) I
ACORN, CERTIFICATE OF LIABILITY INSURANCE DATE (MIWDDIYYYY) 11 /17/2010
PRODUCER 413.773.3488 FAX 413.773.3489 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Akey Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
348 High St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 669
Green field, MA 01302 INSURERS AFFORDING COVERAGE NAIC #
INSURED Todd Boynton Roofing & Siding INSURER A: Granite State Ins Co. 13102
INSURER a Northl and Insurance Co
83 Silver St INSURER C:
Greenfield, MA 01301 INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POUCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTA I SRC TYPE OF INSURANCE POLICY NUMBER UMBER DA I ODIYYYY) DA (MWDD/YYYY) LIMITS
GENERAL UABLLIrY WS084572 10/25/2010 10/25/2011 EACH OCCURRENCE $ 300,000
X COMMERCIAL GENERAL LIABILITY PR ES Ea occurrence) $ 50,000
CLAIMS MADE I X , OCCUR MED EXP (Any one person) $ 5,000
B PERSONAL & ADV INJURY $ 300,000
GENERAL AGGREGATE $ 600,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 600,000
POLICY rim I I LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
—
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE _ $
OCCUR I I CLAIMS MADE AGGREGATE _ $
$
-1 DEDUCTIBLE _ $
RETENTION $ $
WORICERS COmPENSATIo N WC009943634 10/16/2010 10/16/2011 X ixgawd my-
AND EMPLOYERS' LIABILITY
A AN Y PROPRIETO�XRTNER /EXECUTIVED u E.L. EACH ACCIDENT $ 500,000
(Mandatory in NH) El- DISEASE - EA EMPLOYEE $ 500,000
if yyeess d eea i un der
SPECUIL P ROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
roofing & siding contractor
owner, Todd Boynton, has opted out on being covered under the Workers Comp policy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCR®ED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING POURER WILL ENDEAVOR TO MALL. 10 DAYS WRITTEN
NOTICETO THE CEATIRCATE HOLDER NAMED TO THE LEFT, BUT FALURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
blank Daniel Akey /AKEDA1
ACORD 25 (2009/01) 01988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
October 6 2011
83 Silver St.
Greenfield, MA 01301
tv czar
Complete Asphalt, Slate, and Rubber Roofing Systems and Repairs, Siding,
Replacement Windows, Chimney Pointing and Gutters
Customer:
Mark Lachance Metal roofing
Mark's Motors
222 N. King St.
Nor-thamptonr,- Ma >G1060
Work to be done:
Upper main addition roof only, both sides:
Install 1" x 3" wood purlins over existing roofing.
Install new Fabral Grandrib 3 Galvaized Steel exterior fastener roofing system, and all
appropriate finishing accessories, color to match existing rear overhang metal roof as
closely as possible.
Re -seal and/or re -flash around all protrusions.
Color to be chosen by customer at a later time.
http:/lwww.fabraLcom/res-zrandrib3.asp
?0' tT r'"'7 " e rgs i
Mark – It takes about 4 weeks to get the metal of your choice. Any questions, feel free
to call Todd
Total Cost $ 3,425
(Labor and material)
Deposit required of: $ 1,500 Homeowner: ' — �C�-
___ _ _Balance upon Completion: -- $ - 1,925 _ - - Contractor:
(Sign and return one copy with required deposit)
Top quality materials used — complete insurance co - - . ge
References available. All trash removed by contractor.
Vis' and 1W acce~?ed ‘.
SCHEDULE: Work on this contract is scheduled to begin 11/15/11 and to be substantially completed on
12/15/11
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
MA HIC# 126807, MA Construction Supervisor# CS 079221
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he /she resides or intends to be, a one or two family
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two -year period shall not be considered a
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill).
sonotube holes (before pour). a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
The Commonwealth of Massachusetts
Department o�j Industrial Accidents
- Office of Investigations
_ 600 TT �ashing ton Street
- Boston, MA 02111
w ww. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
'?me ( BusinessiOrganization/Individual ): ltddrtnynton Roofing &Siding —
83 Silver St.
Address: Greenfield, Ma 01301
413 -1/5 -2775
City/S tate/Zip: Phone T:
Are you an employer? Check the appropriate box: Type of project (required): I
1. ❑ I am a employer with
employees (full and/or part- time).*
4. ❑ I am a general contractor and I
have hired the sub contractors 6. ❑ New construction
2. I am a sole proprietor or partner-
ship and have no employees
listed on the attached sheet. 7. ❑ Remodeling
These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
q o workers' com insurance comp. insurance.
�ed. ] comp. 5. ❑ We are a corporation and its 10.0 ElecuicaI repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
r .
myself. [No workers' comp. right of exemption per MGL 12. Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13 Other
employees. [No workers'
I comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
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.
Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. /�
Insurance Company Name: 4.fre f4 —
Policy 4 or Seif -ins. Lic. 4: 090 q��3f� Expiration Date: 17�K
Job Site Address: 'A5 . if ' kr/C.1 ' City /State/Zip:,/'2c' #/ 0 /O )
Attach a copy of the workers' compensation policy declaration page (showing the policy number an expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51.500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIa for insurance coverage verification.
I do hereby cer rift' under the ' and penalties of perjury that the information provided above is rue and correct.
Signature: Date:
Phone C.
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
i i Contact Person: Phone: 1
I '
SECTION a - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: I No Applicable ❑
Name of License Holder :/
License
Todd Boynton Rooting & Siding / - J - T 1
83 Silvor St.
ddress Greenfield, Ma 01301 Expiration Date
413-775-2775
Signatu Telephone
R'eaistered Home Not Applicable ❑
:omoanv Name TOdd Boynton Roofing &Ming Registration Nu ber
83 Silver St d /3
.ddress 413 -775 -2775 • Expiration ate
I Al Telephone
ECTION 10 -1N / KERS' COMPENSATION INSURANCE AFFIDAVIT (lt&G L. C. 152, §,25C(6.1.)
'orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit..
fined Affidavit Attached Yes No ❑
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (I) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building OEcial, on a form acceptable to the BuiIding Official. that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersianed "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
• SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House 7 Addition ED Replacement Windows Alterations) 1 I Roofing 1
Or Doors
_I
I Accessory Bldg. n Demolition u New Signs [CI] Decks Siding [Cj Other
i WcrkDesc iption of Proposed , /Re g', feCro 0 pie 1: of 4 `l
/ �/
Alteration of existing bedroom Yes V No Adding new bedroom Yes `-ivo c/
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil - Sheet
6a. If Ne hou a o r a to existing h c th
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Wocdstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes Nc .
I. Septic Tank City Sewer Private well _ City water Supply
SECTION 7a -OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS A GENT OR CONTRACTOR' APPLIES FOR: SU1LDING PERMIT
1 , 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.
Signature of Owner Date
l � ' 0 , as Owner uthcnzed
Agent hereby declare that the statements and information cn the foregoing application are true and accurate, to the best o my k; owief'•
and belief.
Signed under the pains d penalties of penury.
Print Name
5 //
J of Owner/A --. -
AIPPPP
Section 4. ZONING I All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled • by
Building Deparanent !
.._..._.._ ... __ _r r "ar`
Lot Size , _. .
Frontage ______ __ ___._._. - __._.,... _ ___ . ..._..,_ _ .._.
Setbacks Front
Side L: ... ,,_.._ R L ._.. _. R ,...__._ ___ ______
Rear ._M__ _.__._
Building Height -_..- ___ .__.
Bldg. Square Footage % __..._.__._. ._,. _._.
Open Space Footage - % I
1 ____
.__
_,
& (Lot area minus bldg paved w __
parkin¢)
# of Parking Spaces -- .. -.,--- ,____ -
Fill:
(volume & Location) _._-- -..--- .. —�__ .- — •.— _____ --- -- -- -- ---
A. Has a Special Permit /Variance /Findi g ever been issued for /on the site?
NO 0 DONT KNOW YES Q
y
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex avation, or filling) over 1 acre or is it part of a cmrnrrron plan
that will disturb over 1 acre? YES 0 NO ®®+
IF YES, then - a - Northam - Pion Storm VVateer NianagemerifPeimit from the DPW is required.
•
Department use only
j City of Northampton Status of Permit:
Bu ilding Department Curb Cut'Drrveway_Permit
RECEIVE 212 Main Street Sewer /Septic Availability •
Room 100 later/Welt- Availability
�C ■ 1 Nor thampton, MA 01060 Two Sets of Structural Plans
. n- 413 587 -1240 Fax 413 587 -1272 Plot/Site Plans
IIINxC' :1060-6'!
't - Other Specify
N PLICATION TO CONSTRUCT, ALTER, REPAIR, R OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
‘a) R j`/ ! / Map Lot Unit
/(/( Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 1
2.1 Owner of Record: /
Name ( rintEy / / t) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Tbdf! Roofing & Siding
Name (Print) 83 Silver St.
ame
( ) Greenfield, Ma 01.301 Current Mailing Address:
5
k 413-775-2775
Signature Telephone
SECTION 3 - ESTIMATED CONNSTRUCTION COSTS
Item Estimated Cost (Dollars) to be _ Omcial Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
•
2. Electrical (b) Estimated Total Cost of
Construction fr (
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection /�!� ;
6. Total = (1 + 2 + 3 + 4 + 5)71 Check Number �i�
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissionerll of ttudaings Dat
'''':/::77..
0
222 NORTH KING ST BP- 2012 -0553
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18 - 027 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0553
Project # JS- 2012- 000924
Est. Cost: $3425.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TODD BOYNTON 079221
Lot Size(sq. ft.): 37810.08 Owner: LACHANCE WILLIAM J
Zoning: HB(100)/ Applicant: TODD BOYNTON
AT: 222 NORTH KING ST
Applicant Address: Phone: Insurance:
83 SILVER ST (413) 772 -8829
GREENFIELDMA01301 ISSUED ON:12/7/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL METAL 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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 12/7/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner