38D-081 (3) May -17 -2011 08 :26 AM Remillard Insurance 14135386010 1/1
• , ' • OP ID: LI E
k • �° � CERTIFICATE OF LIABILITY INSURANCE °� 05117/ 1 Y''
05/17111
THIS CERTIF CATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICA c DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TH S CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENT • TIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
- IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(Ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms an conditions of the policy, certaimrAlcles may require an endorsement. A statement on this certificate does not confer rights to the
certificate ho der in lieu of such endorsement(s).
PRODUCER 413 -538 -7862 E Li nda Landry
Remillard Ins ranee Agcy, Inc 413- 538 -7178 PH ONE 413-538-7862
FAX
79 Lyman St - -t e Via• ax): (A�, Na): 413 -538 -6010
South Hadley, MA 01075 )%ocR ss: IIndalandr (y�remiliardinsurance.com
PRODUCER
Remillard Ins. ' gcy,, Inc. CUSTOMER ID#: AJHOM -
INSURER(S) AFFORDING COVERAGE NAIL S
INSURED A ; J Home Improvements Inc INSURER A :Western World Ins., Co.
60 Washington Ave INSURER a: National Union Fire Ins. Co.
So Hadley, MA 01075 INSURER C : Safety Insurance Company 39454
. - INSURER 0 :
INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CE - TIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. N .TWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE • Y BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS A 0 CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I L7q • E OF INSURANCE IADDLISUBRI POLICY EFF POLICY EXP LIMITS
INSR I 4WD POLICY NUMBER MI MlDD/YYYYI (MMDJ
IDYYYY)
GENERAL LI • :'CITY I EACH OCCURRENCE l $ 1,000,000
A ]
--� GE TO CJMMER IAt ENERALLIABILm
DAMAGE
NPP1260682 04/22111 04/22/12 P oocurlena9 $ _ 50,000 • (CAI £•:BADE X OCCUR MED EXP (Any one person) $ 6,00
PERSONAL & ADV INJURY s 1,000,00a
GENERAL AGGREGATE 5 2,000,001
GEM . AGGRE 4 ATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $ 1,000,000
7 POLICY I 1 ,PWFCOT I — 1 Lac 3
AUTOMOBILE 'ABILITY COMBINED SINGLE LIMIT $
accident)
C ANY AUT• 2432426 11/24/10 11/24/11 BODILY INJURY (Per person) S 260,00C
ALL OWN: 0 AUTOS BODILY INJURY (Per accident) • $ 500,000
X SCHEDU 0 AUTOS
PROPERTY DAMAGE $ 100,000
_ HIRED AU. OS (Per accident)
NON-OW 0 AUTOS
$
— $
TUMBREL - LW9 _ OCCUR EACH OCCURRENCE
EXCESS • _e CLAIMS -MADE AGGREGATE L.:
_ DEDUCT'S E $
I RETENTIO $ $
WORKERS CO • ENSATION V WC STATU- 0
AND EMPLOYE S LIABILITY ZQR LIMITS i TH-
ER
B ANY PROPRIET•RIPARTNERIEXECUTIVE Y(�7 NIA WC003796174 05/11/11 06/11/12 E,L.EACH ACCIDENT S 100,000
OFFICERIMEMB: R EXCLUDED? l 1
(Mandatory In N ) E L. DISEASE - EA EMPLOYE9 3 100,000
t(ee, de u er
DESCRIPTION • F : OPERATIONSbe ow E.L. DISEASE - POLICY LIMIT I $ 600,000
I
_J DESCRIPTION OF OPE - TiONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedute, Irmare apace le required)
CERTIFICATE H • LDER CANCELLATION
ANDYDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
And, Deren ACCORDANCE WITH THE POUCY PROVISIONS.
AUTHORIZED REPRESENTATIVE
• ��'��y -t 4 Cam
.� ` /
U 1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009 09) The ACORD name and logo are registered marks of ACORD
(% , 64'1 iW L11> ,Kbe o- , t_ //'Gfr/Jdaakeed l
=_ , Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 135399
Type: OBA
Expiration: 4/1/2012 Tr# 294166
A & J HOME IMPROVEMENT
ANDREW DEREN �— 4
60 WASHINGTON AVE. __ _-_._ -_ - _..._______
SO. HADLEY, MA 01075 - - ---- - - -- -
Update Address and return card. Mark reason for change.
Address ' ---- Renewal Employment " Lost Card
?? ;/;e: l_! GL'atif•.i ll:e-C(!a (. /•.• I!!tl we Av:•. %4;
Office of Cartsurner Af fairs c� Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration: 135399 10 Park Plaza - Suite 5170
Expiration: 4/1/2012 Tr# 294166 Boston, MA 02116
Typo: SBA
HOME IMPROVEMENT i
2EW DEREN 1 �/
ASHINGTONAVE. "- -e53c f5. I (. j _ , __..
IAOLEY, MA 01075 Undersecretary I _ -- / ' T
Not valid without signature
i
• - `I. t - llt.piii lit i•iwii, -
.
cy
d lt,rdl'(1 t IIii,ji II :: (C;"t .111 1 :r: .
r_i, :ii,„: : :5:,;, 101017
i! ::.;: i 1 +:: RF,WS
;,..,1 ..,,4 , r .i. .
ANDREW DEREN.
396 ROCKRIMMON STREET
BELCHERTOWN, MA 01007
-,4— - ---' _.- �e ';1% tl +!rt: 11/16/2011
. 101017 .
- A & J Home Improvements, Inc.
11111111/4", 60 Washington Avenue • South Hadley, MA 01075
Certified Office I Fax: (413) 467 -1500 • Cell: (413) 575 -1290
Weather Stopperaootkig AJHomelmprovements @yahoo.com
HIC Lic # 135399 • GAF -ELK ID # CE17267 • CT Lic # 600705 / CS, SL, .RF, WS # 101017
Proposal Submitted To: Phone #'s: c axl 3 4 7 4.4 c -io ,
�►�E 1 11 - Home: Cell:
Street: .J Y 0 . k � e ,l� Re ►n�� 1
w Sp Rat
City, State, Zip Code �'� W �!' `� tnm,
NO0k)O.YrfirfN / IA 010140 \ covn p fir. kc< < A i cicj 6,M4-0
YHouse ❑ Garage ❑ Other
Moir, Pmv,c1.� O uoiNe t_ u A 'JSle — P i t4Jrikkw.
Proposal to furnish and install the following: GAF 6- M
❑ Re -Roof C4"Tear -off ❑ Gutter
.iN5t t jt ( Oi ro f deo,
Complete Roof Preparation
at exterior to be protected by tarps and plywood
/F / Shrubs, landscaping, trees to be protected
'Roofers buggy shall be used where accessible with permission from owner
Entire existing roofing material to be removed to existing decking, including flashing, etc.
iSite Site to be cleaned everyday with roll magnet debris removed at project com I�etion (included in price)
LiDeteriorated existing decking replaced at $2.50 per sq. ft.
11 Brown 8 inch metal drip edge installed at eaves and rakes ❑ White /Brown 5 inch for re -roof only
New flashing will be installed where necessary / Instalhlead to chim
Install new pipe boot flashing
1: _ We shall acquire all appropriate permits etc. for all roofing work
Complete Roof System
We propose hereby to furnish materials and labor - complete in accordance with above specifications for
the sum of:
Total Sale Price $ 00 Down Payment $ ,a000, Cc) Upon Completion $ 3 c, Od
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory anc
are hereby accepted. You are authorized to do work as specified. Payment will be 1/3 down upon
signing, and balance due upon completion. Unpaid balances shall accrue with interest at 18% per
annum. Purchaser(s) will pay for all costs, expenses and reasonable attorney's fees incurred by
A & J Home Improvements, Inc. to recover any sums due under this contract.
Date: 91 22 10 U Signature: (, 2 L Q !! f� Phone # V
Date: Lf - D.-lOit Estimator's Signature: ` V
ATTENTION HOMEOWNERS: Please cover all personal belongings in the attic, garage or storage
areas due to the nnssihility of rnnfinn debris nr duct rnminn thrnunh cracks of the wnnri A R .1
The Commonwealth of Massachusetts
Department of Industrial Accidents
►* = 1. _ ' Office of Investigations
::r�``
_
,_ _� 600 Washington Street
dr '�
' Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information `J' Please Print Legibly
Name ( Business /Organization/Individual): A � 'r(�� ..L m Q }} iIV of 1 ` S -I••'(,
Address: (0 Wash to " A A ve
LC
City /State /Zip: SotYAN ntao Phone #: 413 4 16 - 2 ES
Are you an employer? Check t)e appropriate box: Type of project (required):
1. DV I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7 • ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12. oof repairs
insurance required.] t employees. [No workers' 13.0 Other
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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: S�'C If5o' J Q Crnp
Policy # or Self -ins. Lic. #: WC. V o3 7 17 a
y q E xpiration Date: � - I � - ��
Job Site Address: i5 tiavyvvim, C , ; i City/State /Zip: Ant- o 114
Attach a copy of the workers' compensation policy declaration page (showing the policy number and 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 $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. 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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: (l,�s r ��.• Date:
Phone #: '1/3 qI2 ? /J oC)
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: _-. Not Applicable ❑
Name of License Holder : j \ 1�1 10100
License Number
396 R. t, ; -lle adl�
Address Expiration Date
ZelcSive4a ilk 0100-7
Sign lyre Telephone
9. Registered Home Improvement Contractor
T ` ' Not Applicable ❑
fl +� e ne Tvo .a- 135399
Company Name Registration Number
11 0 W,, ,A A75411 1 4- - a0►
Address Expiration Date
CSa Y " 1 11 � » ?I56 Telephone it(k DO
SECTION 10- 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 CV No ❑
11. Home Ovrie`remlori!
The current exemption for "homeowners" was extended to include Owner occupied Dwellings of one (1) 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 Official, on a form acceptable to the Building 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 undersigned "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 Addition Replacement Windows Alteration(s) n Roofing rr
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [0] Other [Di
Brief Description of Proposed n r
Work: - T
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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 Woodstoves 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 No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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
I, 6 4— lipm Tyr, W - eip—teA , as Own-r /' •orized
t hereby declare that the statements and information on the foregoing application are true and accurate, to the best o • -.ge
ar belief.
Signed under the pains and penalties of perjury.
• (
Print Name
c wt
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incompleti Mtn-ration
f _
Existing Proposed Required by oni
This column to fille in by
Building Depa ent
Lot Size
Frontage .. ___ __... 'ic..;
Setbacks Front �_.....
Side L. _.._. R.., , ..._.__. L . __..,....._ R .._.... ?
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
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 0 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 0 NO 0
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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
a
Department use only ---7-7.7. -. D City of Northampton Status of Perrnit
fw_Lit' M Building Department Curb Cut7� veway Perms n t
212 Main Street Seinrer/SepticAvatlabdlity = a
3 2.t Room 100 WateriWell Availability
ti, orthampton, MA 01060 TwctSets of Structural Plans . ,
- i .- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
Other S
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
�j
3 Map Lot Unit
I S N0.13Nc � e(1 & i.aN Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Cv�� (O � � si r Nv �tp,, Pi /t"
Name (Print) C urrent Mailing Address:
67s 03o;
Telephone
Signature
2.2 i e_ T Authorized Agent: p / p R y,� p
Ampt tt� w Sh+ SO Ji� � A I'7 OIC1S
Name (Print) Current Mailing Add s:
if 'I 13 1- i 47 1,500
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) ; Building Permit Fee
2. Electrical (b)', Estimated Total Cost of
__-J Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Piulection
6. Total = (1 + 2 +3 +4 +5) 57 'a • �, Check Number ,�) �j Q ( p 3s—
This Section For Official Use Only �'
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
15 HAMPDEN ST • BP- 2011 -0986
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D - 081 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit# BP- 2011 -0986
Project # JS- 2011- 001612
Est. Cost: $5775.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: A & J HOME IMPROVEMENT INC 101017
Lot Size(sq. ft.): 7492.32 Owner: MCBRIDE DANIEL G C/O GARY D DOLGOFF
Zoning: URB(100)/ Applicant: A & J HOME IMPROVEMENT INC
AT: 15 HAMPDEN ST
Applicant Address: Phone: Insurance:
60 WASHINGTON AVE (413) 323 -7847 WC
SOUTH HADLEYMA01075 ISSUED ON :5/31/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE 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 5/31/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner