30B-032 (3) 05/14/2012 HON 13:18 FAX 4135386010 Remillard Ins. Agency 0001 /001
-""" 4 AJHOM -1 OP ID: LL
' -- '� ° CERTIFICATE OF LIABILITY INSURANCE DATE 05 / 1 4 D/YYYY)
05/14112
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 pollcy(ies) must 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 C
FieldEddy Insurance 413-538 -7862 Linda Landry FAX _ .,_ -
79 Lyman Street 413 j ° 413.5383862 (Arc. so): 13- 538 -6010
South Hadley, MA 01075 d alandry@iieldeddy.com
Remillard Ins. Agcy., Inc. . ___..- --__. --_ -- -
_ _ MISURE S AFFORDING COVERAGE NAIC e
_ _ __
INSURER Western World Ins �Co. _ ,
INS URED A & J Home Improvements Inc INSURER B : Commerce & Industg Ins. CO. _
60 Washington Ave INSURER C: Safe ty _ m Insurance Ca _a 39454
So Hadley, MA 01075 !?'
INSURER 0:
INSURER E :
I 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.
' L$R TYPE OP INSURANCE I A ES R LS POLICY NUMBER IIIM?OOIYYYYI ( _ UMTS
OENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
j 1:94744-238 tTerra----- " ____.
A X� COMMERCIAL GENERAL LIABILITY NPP1260682 04/22/12 04/22113 PREMISES (Es occM rence7 s 50,000
I � ] CLAIMS -MADE XJ OCCUR MED FRCP (Any one person) $ 6,000
PERSONAL a ADV INJURY , $ 1,000,000
YY _ ^� GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AUG ' S 1,000,000
1 POUCY n , L iLOC $
AUTOMOBILE LIABILITY COM1 cci en SINGLE LIMIT
C
—_
ANY AUTO 2432426 11/24/11 11/24112 BODILY INJURY (Per person) $ 250,000
ALL OWNED X SCHEDULED 5 ._ - 0
__ AUTOS _ ..__ AUTOS
BODILY INJURY (Pe accident) 5 500,000
NON -OWNED PROPERTY DAMAGE $ 100000
I HIRED AUTOS AUTOS _LPerdociciMti)..- -_....._ �__— ,
I ----I $
UMBRELLA LIAR OCCUR 1 EACH OCCURRENCE $
E)(CES$ LIAR cumms -MADE ! AGGREGATE $
+
OED 1 RETENTIONS .__.._--- 8 .
WORKERS COMPENSATION X T R I IY8I _ ER _..
AND EMPLOYERS' LIABIUTY
B ANY PROPRIETORIPARTNERIEXECUTNE YE N WC�796174 05111/12 05/11/13 E, L EACH ACCIDENT $ 100,000
OFFICER/MEEMBER ( j
(Mandatory in NH) Et. DISEASE - EA EMPLOYEE $_ __ ._, , 100,000
I It yes dsecdbe under E.L. DISEASE - POLICY LIMIT , $ 500,000
DESCRIPTION OF OPERATIONS beim
j
t
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 105, Additional Remarks SChedute, If more spice Is required)
CERTIFICATE HOLDER CANCELLATION
AJHOMEI
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTE WILL BE DELIVERED IN
A & J Home Improvement Inc ACCORDANCE WITH THE POLICY PROVISIONS.
60 Washington
So Hadley, MA 01075 AUTHORIZED REPRESENTATIVE
i
® 1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD
?rite -60.00noiteveiza Office of Consumer Affairs and usiness Regulation
1 0 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 135399
Type: DBA-.
Expiration: 4/112.014 Tr# 221971
A & J HOME IMPROVEMENT
ANDREW DEREN
60 WASHINGTON AVE.
SO. HADLEY, MA 01075
Update Address and return card. Mark reason for change.
Address L Renewal Ej Employment j Lost Card
,-CA1 0 50M- 04/04 -G 101216
eowymariuseeda #.24aaolitusea
Office of Consumer Affairs & Bitsiness Regulation License or registration valid for individut use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
• • Registration
egistration. 135399 Type: Office of Consumer Affairs and Business Regulation
Expiration: 4/112014 DBA 10 Park Plaza - Suite 5170
Boston, MA 02116
ArrilioME IMPROVEMENT
ANDREW DEREN
50 WASHINGTON AVE.
SO. HADLEY, MA 01075 —
Undersecretary Not valid without signature
\•-••"' `-;") , 3ttc, , , t' 1
'111‘, fl
CSSL-101017
ANDREW J DE11EN
396 ROCKR1MMON STREET
BELCHERTOWN MA 01007
92—
11116/2013
•
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
• Office of Investigations
• 600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): !'I t 3 14Om2 l mpeou/ CY1CU' , s Inc -
Address: (O Wasln,ne f)vcrs
City /State /Zip: ScaltN 14CtalvAi 114 01 075 Phone #: 1'/ 13 L11 -1500
Are ou an employer? Check the appriate box: Type of project (required):
1. I am a employer with 0 4. 0 I am a general contractor and I
employees (full and/or part-time).* have aired the sub - contractors 6. ❑ New construction
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. employees and have workers'
9. 0 Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[oof repairs
insurance required.] t c. 152, § 1(4), and we have no
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.
f 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. t
Insurance Company Name: COMete * tl�dc 4 I 'ts
Policy # or Self -ins. Lic. #: LJC. b0 37q 41 7g
Expiration . 11
Job Site Address: I U ,l bit_ o k City /State /Zip: 1004\ QWT\
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 ti ' ''ins and penalties of perjury that the information provided above is true and correct.
Si • nature: L Date:
Phone #: I,3 cf(c 7 jS O
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
Phone #:
Contact Person:,
A & J Home Improvements, Inc.
60 Washington Avenue • South Hadley, MA 01075 .74t\
Certified \
(413) c }
Office /Fax: 413 467 -1500 • 413 ��`'� �'��=�� �
AJHomelmprovements @yahoo.com 9 7 Psad
HIC Lic # 135399 • GAF -ELK ID # CE17267 • CT Lic # 600705 / CS, SL, RF, WS # 101017
Proposal Submitted To: Phone #'s:
G 1 ao L ,. Hom\ ' ej (1 I8 Cell:
Street: ! `
I 9 NOW/36A 4l/ `‘ City, State, Zip Code: Fla t uds U ., :k i t i v) -ti t t r c l c4
4 ) 40,41 MA cans . ot:.t► t ( V...Aibc.n. i vvs1- k.
/ (■t vw,‘ Rx;ts t- 31 Flak CAA Lek"
O House ❑ Garage ❑ Other
Proposal to furnish and install the following:
❑ Re -Roof G'Tear -off ❑ Gutter
Complete Roof Preparation
C_d exterior to be protected by tarps and plywood
l� Shrubs, landscaping, trees to be protected
LeRoofers buggy shall be used where accessible with permission from owner
Entire existing roofing material to be removed to existing decking, including flashing, etc.
f ite to be cleaned everyday with roll magnet debris removed at project completion 9 decking replaced p q F included in price)
eteriorated existin deckin re laced at ' er s . ft. 'i t 6 P t' 1 wc,; i C etotoi
Ir. ____ rown liacb.metal drip edge installed at eaves and rakes ❑ White /Brown 5 inch for re -roof only
•New flashing will be installed where necessary / i lead to chimney's
[i l stall new pipe boot flashing
e shall acquire all appropriate permits etc. for all roofing work
Complete Roof System ❑ 3 ft.
We propose hereby to furnish materials and labor - complete in accordance with above specifications for
the sum of:
Total Sale Price $ 1= 00 00 Down Payment $ O( >, ) Upon Completion $ L 600 ,0;,
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and
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: e -2 /_ Signature: , , e e ,,� e "›...‘...__, Phone # 59 - ' %
Date: 8 - ,C . i J Estimator's Signature: ` L Z
ATTENTION HOMEOWNERS: Please cover all perso al belongings in the attic, garage or storage
araac rhea fn the nnccihility of rnnfinn rinhric nr rig rnrrtinn +h rnI Erik nrolnLc• ..f +hn .•.nnrl A Q. I
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: (( Not Applicable ❑
Name of License Holder : t ) 3e-rte", i/\ 1 01011
License Number
GO C hv Av-c S* It —
Address Expiration Date
£- 1 e? IS
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
P4fi 1 s 3 9
Company Name Registration Number
o Luastl,. / 4w, (S 1 act f /Mk-
Address `r/ Expiration Date
Telephone L. C,e 71,5t _) LI
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 11Y 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 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 Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ® YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained CI) , Date Issued:
C. Do any signs exist on the property? YES Q 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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [D] Other [CO
Brief Description of Propose S�
�+ -r , i
w� � 1 4 . ) , ( 1 1 ,2vt rxt
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, ..) ) 00.-k � ( , as Owner uthorized
Agent hereby declare that the s tements and information on the foregoing application are true and accurate, to the best of ge
and belief.
Signed under the pains and penalties of perjury.
A na-C Dejla-v■
Print Nam / Signature of Owner /Agent Date
Department use only
RECEIVE[ ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
SEP 2 212 Main Street Sewer /Septic Availability
al Room 100 Water/Well Availability
N rthampton, MA 01060 Two Sets of Structural Plans
DEPLOF BUILDING IN 0: 41 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
NORTHNA - • �,,
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 9 /0o W®os) A.14. Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Meti5 1 4 /ofwfxh 4.,.
Name (P ) Current Mailing Address:
i , � Telephone S 9 ( t ,• I Li D
Signature
2.2 Authorized Agent:
1)17 fio 1 VY19 .o k &O 104,00t. SciA 146 114 Owl
Name (Print Current Mailing AddMEss:
I L) f S "
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building — MOO L (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 (J
6. Total = (1 + 2 + 3 + 4 + 5)',} Check Number (3 /d" V
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
14 NORWOOD AVE BP- 2013 -0323
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B - 032 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- 2013 -0323
Project # JS- 2013- 000521
Est. Cost: $7300.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: A & J HOME IMPROVEMENT INC 101017
Lot Size(sq. ft.): 1 1891.88 Owner: NICHOLS GREGORY D & REBECCA J FLETCHER
Zoning: URB(100)/ Applicant: A & J HOME IMPROVEMENT INC
AT: 14 NORWOOD AVE
Applicant Address: Phone: Insurance:
60 WASHINGTON AVE (413) 467 -1500 O WC
SOUTH HADLEYMA01075 ISSUED ON:9/21/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE UPPER ROOF & RUBBER ON
BOW WINDOW
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 9/21/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner