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32A-017 -`� Y" ,� �� f • .:±4. _ _, ..„. ..,..„.„ •.:. Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 135399 Type: DBA Expiration: 4/1/2012 Tr# 294166 A & J HOME IMPROVEMENT ANDREW DEREN `— 60 WASHINGTON AVE. — — _ —� —_ SO. HADLEY, MA 01075 -- - -- Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card Office of Consumer A ffa i rs & 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 Type: DBA HOME IMPROVEMENT 4 _ 3EVl+ DEREN / i ASHINGTON AVE. �G--.„ - I IAOLEY, MA 01075 Uudcrsecretrny .__ � r - na tur • tiot Gelid without signature i , l- ! iiti-.:': - ! ! i of l'iii,ii, . it,1,1,.(1 .1t' !'ttil.iiti:; 1{c...t.i,t6ntt•. .Intl :t'. ... t.i,; t- r,; , =S :;. 101017 p:,1:;r71,.:0'I :: RF,WS ANDREW DEREN p k 396 ROCKRIMMON STREET BELCHERTOWN, MA 01007 G. _ -- .ciai li.!r,: 11/16/2011 . . . 101017 • • r CERTIFICATE OF LIABILITY INSURANCE OP ID DM DATE (r.'N' /YYYY) 08 033/10 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. MPORTA I I t e ce - ca e o . er s an • IP • • `AL I SURED, the po cy lee) must • en. orsed, II c - • . 0 IS W • IVED, sub ect to :he terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the :ertificate holder In lieu of such endorsement(s). DOUCER l+VN1HU NAME: Remillard Insurance Agcy, Inc PHONE t a Ed): I FAX No): E.MP:L 79 Lyman Street ADDRESS: M 0 1075 PHODUCER South Hadley CUSTOMER ID a: AJHOW 1 Phone:413- 538 -7862 Fax :413- 538 -7179 INSURERIS)AFFORDINGCOVERAGE 4 NAICA USED I N S U R E R A : Western World Ins . , Co . , A &J Home Improvements Inc INSURER E Not-tonal v on Pi,. sn., Co. 60 Washingtoh Aye So Hadley MA 01075 /INSIJSERC: Safety Insurance Company I 39454 INSURER D: 1 I INSURER E : 1 I INSURER P: 'VERAGES CERTIFICATE NUMBER: REVISION NUMBER: HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE IN6URE NA;,pO ABOVE FOR THE POLICY PERIOD ID :CATED. NOTLAITHSTAI D:NG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VWH :CH THIS ERTIFICATE IAA'? BE ISSUED OR loAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. XCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. T — ^— TYPE OF INSURANCE IVSR a -• POLICY NUMBER (!rd - �h POL!UY 1 JW LF ITS _ _ ) (MM'DD/YYYY) i GENERAL LIABILITY EACH OCCURRENCE S 1000000 • a • u v - X I COM%IERC(AL GENERAL LIABILITY NPP1260682 / 04/22/10 04/22/11 PREMISES (Ea cccurrenes) s 50000 + MEDENP(Any one porson) S 5000 CLAIMS-MADE 1 X J OCCUR i ! PERSONAL & ADVINJURY 51000000 I ) I GENERALAGOREGATE S 2000000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG , s 100 0 0 0 0 S POLICY PEC LOC C OMBINED S INGLE LIS9T AUTOMOBVLE LIABILITY I S (Ea acdem) Ill ANY AUTO X 243 2 426 11/24/09 / 11/24/1 0 BO C IL Y I; N J U R Y (refpee5..) 5 250, 000 ALL OWNED AUTOS ! I BODILY INJURY (Per ecadert) $ 500 , 0 00 - 3E/ SCHEDULED AUTOS ! I i - PROPER1l'DR s 100, 000 i HIRED AUTOS J (Pot 'L) i NON•O NEO AUTOS I �$ I IS UMBRELLA LIAB I OCCUR ! ) EACH OCCURRENCE IS EXCESS LIAB I ! CLAIMS•MADEI f I I AGGREGATE I S DEDUCTIBLE I 1 i j I } R!(( RETENTION S 1 ! I 1 I S TIO' _ OMP ' .TION I 7 C• • • .1 4 05/11/10 05/11/11 X TORYLIA!RS • ER _, AND EMPLOYERS' UAB'IITY y/N E.L. EACH ACCIDENT f 5 1000OO ANY PROPRIETORIPARTNERIEXEGUT)V OFFICER I,!e:MBER EXCLUDED? +�f / A E.L. DISEASE -EA EMPLOYEE 1S 1 O OOO O (Mandatory In NH) DESCRIPTION daacnbe OF O EL. DISEASE - POLICY LIMIT s 500000 DESCRIPTION OF OPERATIONS below f t RIPTION OF OPERATIONS! LOCATIONS! VEHICLES (Attech ACORD 101, Additional Romarke Scbeduto, If more spoon Is roqu'rod) FIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE CESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION BATE THEREOF, NOTICE WILL BE CELIVEREO IN ACCORDANCE WITH THE POLICY PROVISIONS. 111!!!!!!!!!!!!"� AUTHORIZED REPRESENTATIVE 4 '#' � � ©1 1,411.-4 2 09 ACORD C RPORATION, All rights reserved, W 25 (2009/09) The ACORD name and logo are registered marks of ACORD A &J Home Improvement Inc MA Reg# 135399 60 Washington Ave Conn Reg# 600705 South Hadley, MA 01075 Phone: (413) 467 -1500 Cell: (413) 575 -1290 Customer Address Eliot Levine 11 Walnut Street Northampton MA Description of Duties: 1. Pull permit for all work to be performed 2. Strip existing metal roofing on Rear of House (credit on recycled metal roof) 3. Install new 1 /2" CDX Plywood on roof deck 4. Extend broken vent stack 5. Install ice and water barrier 3 feet along all eves 6. Install synthetic roof paper to all other areas. 7. Install new 8" metal Drip Edge around perimeter 8. Install new 30yr GAFELK Shingles to roof to manufacturers specification (pewter grey) 1 3 9. Install new ridge vent and cap shingles (pewter grey) 10. We will remove all debris and leave property in broom swept condition. Total Cost of Shingled Roof $ 6000.00 1. Install new seamless aluminum gutter n downspout on Rear of House and re attach front gutter Total Cost of Gutter work $ 350.00 Remove material from existing flat roof Install new 1 /2" fiberboard over flat roof deck Install new TPO Membrane roofing system to manufacturers specifications Total Cost of Flat Roof $ 1800.00 Repair Flashing on front porch Total Cost of Flashing $ 200.00 We Stand behind our Labor for Ten Years / Manufacturer warranty is for 30years Agreement bonded to furnish materials and labor according to the description above. We carry Liability and Workmans Comp to cover any accidents or injuries on the property. Total Cost for entire project $ 8,350.00 This quote guaranteed for 60 days. Any changes or additional charges will be made so in writing Signature Date Accepted: I hereby authorize A &J Home Improvement to perform work to the above specifications. Payment is agreed for 1/3 down at the start of job and balance to be due upon completion, with warranty paperwork. P .as- it and return one copy and return to the above address. T You. .� — Phone coei Date `,' 1; Signature �` The Commonwealth of Massachusetts _r _ =? Department of Industrial Accidents T.: __ l Office of Investigations �: 600 Washington Street x,�' Boston, MA 02111 y 4 , s, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): n t mQ. f ,rn FLOve4y1(jl) j.0 L Address: C ) c ; � ) l N J jr'l Ae fl u — City /State /Z `. SJ �t c , fit U )? P hone #: Li t h1( 7 6 Are ou an employer? Check the appropriate box: Type of project (required): 1. l I am a employer with - if 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. I 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. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12. [Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13. Other *Any applicant that checks box 111 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 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. 1, g , Insurance Company Name: 1 V alk)i �w I U i1 t 0l Policy # or Self -ins. Lic. #: .. 00 3'7 9 (:, 1 Expiration Date:y�`` b — i i - � , O w i ( Job Site Address: 1 1 (ki. 1 V\tiy &Ned City/State /Zip: _ 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 nder the pain and penalties of perjury that the information provided above is true and correct. Signature: //6 V Date: 1 ''[ — I 3 (( Phone #: L 'J L.' '1L? ) S 0 0 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : aim.) l b I 01 7 ` License Number 3` c V C.mw n S f1-c I�-u- 11.14 ° U 11 Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Anme Ttleir0 '. LI — 1 '(:0 Address � SAN Expiration Date (O cO k1 1 ' 1 iv�t s ue. � — Telephone 41.e/ oU kJ 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 No...... ❑ 11. - Home Owner Exemption 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) Roofing d Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [DI Other [D] Brief Description of Proposed F itculok � e Work: lk Si.K +t �iot1 6 t o, 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, (.) I- mV.CA/W ,A as Owner /Authorized Agent hereby declare that the btatennents and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name tut- it Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage 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 Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES (3 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 Q 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. RECEIV Department use only City o Northampton Status of Permit: B u il ling Department Curb Cut/Driveway Permit I 2011 212 Main Street Northampton 100 Sewer /Septic Availability R Water/Well Availability D EP.OFBUILDINGINSPECTI rt hampton MA 01060 Two Sets of Structural Plans NORTHAMPT�l 5 RP - Fax 413- 587 -1272 Plot/Site Plans Other Specify 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 Map Lot Unit I l.00tA CIU' Std Zone Overlay District NL a.r,c} , JAA- Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 'Flat Leone S C I1II1 ,, A N dehthk. Name (Print) Current Mailing Address: O 15cis Telephone Signature 2.2 Authorized Agent: A libme Try.l •retntavk (C G3a.S ^ 5,41 frttL /14 Name (Print) Current Mailing Aress: :'-' SignatureTelephone 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 Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection ( ) 75 3 Check Number 9 )3.77 (.4034 6. Total= 1 +2 +3 +4 +5 ���;: This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date a r 11 WALNUT ST BP- 2011 -0864 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 017 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 -0864 Project # JS- 2011- 001422 Est. Cost: $8350.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: A & J HOME IMPROVEMENT INC 101017 Lot Size(sq. ft.): 3441.24 Owner: LEVINE ELIOT Zoning: URC(100)/ Applicant: A & J HOME IMPROVEMENT INC AT: 11 WALNUT ST Applicant Address: Phone: Insurance: 60 WASHINGTON AVE (413) 323 -7847 WC SOUTH HADLEYMA01075 ISSUED ON:4/29/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE REAR ROOF & FLAT 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 4/29/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner