29-438 05/14/2012 HON 13 :18 FAX 4135386010 Remillard Ins. Agency 2001 /001
" AJHOM -1 OP ID: LL
AloR °f CERTIFICATE OF LIABILITY INSURANCE �►
lae --
05/14/12
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 poiicy(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 413 -538 -7862 war Linda Landry _ _ _
79 Lyman Street
FieldEddy Insurance 413- 538 -7179 AN ONE 41 T PAX ": No. Ext1: 3 -538 -7862 tAAC, Noy 413 -538 -6010
South Hadley, MA 01075 5x, lindalandrythfieldeddy.com
Remillard Ins. Agcy., Inc.
, , INBURERM AFFORDING COVERAGE NAIL a
_ M_. -._ _ INSURERATWestern World Ina. „Co. _
INSURED A & J Home Improvements Inc INSURER B: Commerce & Industry Ins. Co.
60 Washington Ave INSURER C: Safety Insurance Co 39454 _
So Hadley, MA 01075 -- - -
INSURER D:
- INSURER E : -__—
INSURER P :
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.
INS — — ' � _ 1ADDL SUER POLICY EFF POLICY EXP — �
LTR TYPE Cr INSURANCE IINSR WVD . POLICY NUMBER r$MFOOIYYYYI ,1MMIDOSNYY1 LUSTS
GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000
A X COMMERCIAL GENERAL LIABILITY NPP 1260682 04/22/12 04/22/13 PREMISES (Ea acur(0n96t a 50,
^ 000
1 CLAIMS -MADE " .-.l OCCUR MED EXP (An one person $ ._ 5,00C
PERSONAL & ADDV INJURY i $ 1,090,00C
,J _ GCNERALAGGREGATE s 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGO S 1,000,000
POLICY E 1 ('"
LOC _ S
i
AUTOMOBILE UABILJTY COMBINED SINGLE LIMIT
_LEa ec;ldant),_ _...».__....._ _5_- - -
C ANY AUTO ; 2432426 11/24/11 11/24112 BODILY INJURY (Per parson) $ 250,000
ALL OWNED SCHEDULED BODILY INJURY (Per acddent) 5 500,000
X
HIRED AUTOS AUTOS
NON-OWNED 12e 1 1AHI4t3E -- $ 100 000
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESSLIAB I CLAIMS-MAOE AGGREGATE S
DEO l RETENTION $ - $
WORKERS COMPENSATION j X IT 1R MITE 0TH-
AND EMPLOYERS' LIABILITY yyy (((r fNNNJ
B ANY PROPRIETOR/PARTNERIEXSCUTNE , I WC003796174 05111/12 05/11/13 E.L EACH ACCIDENT S 100,000
OFFtCERAAEMBER EXCLUDED? J i N I A
(Mandatory In NH) E. L. DISEASE - EA EMPLOYEE _ S ..,_. 100,000
H yes d s TION OF O oibe ur er PERATIONS mt. E.L. DISEASE - POLICY LIMIT i 500,000
DESCIUP
DESCRIPTION Of OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD $0f, Additional ROMarks Schedule, If more space Is requited)
CERTIFICATE HOLDER CANCELLATION
AJHOMEI
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
A & J Home Improvement Inc ACCORDANCE WITH THE POLICY PROVISIONS.
60 Washington
So Hadley, MA 01075 AUTHORIZED REPRESENTATIVE
I
C. 1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD
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....., e .
rairit‘ F
-- -- 7- .•= 7 : 4 11111 1 - -- "' —= .-\ Office of Consumer Affairs and usiness Regulation
- - - --1- -- - -7 7 10 Park Plaza - Suite 5170
, , • - --;--.__----7 --- 1
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 135399
Type: DBA-.
Expiration: 4/1/2014 Tr# 221971
A & J HOME IMPROVEMENT
ANDREW DEREN
60 WASHINGTON AVE.
SO. HADLEY, MA 01075 -- —
Update Address and return card. Mark reason for change.
ri Address Fl Renewal D Employment Ti Lost Card
3-CA1 0 50M-04/04-G101216
gA4 - 60/m4i2042Weald 04,0.WaadteMesea
Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
- --,-.--.
- -=---=--- @, HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
14.4 Registration: 135399 Type: Office of Consumer Affairs and Business Regulation
( Expiration: 411/2014 DBA 10 Park Plaza - Suite 5170
'''''----I Boston, MA 02116
A 8, HOME IMPROVEMENT
ANDREW DEREN
50 WASHINGTON AVE, e_.................sgc----exce ,,., V .,./, .._./.......__
SO. HADLEY, MA 01075 as/-
Undersecretary Not valid without signature
,
:“ -'■ in' - "Z , ti:1' It'()r , ■1
( , 01 f it i 1 ),) ')1111. , ■-,,, , 51 , k■ idit■
;en se: CSSL-101017
,..
ANDREW J DEREN ' 1.
396 ROCKR1MMON STREET - 1 ,
BELCHERTOWN MA 01007 ,
,--
1I tit” 11116/2013
•
The Commonwealth of Massachusetts
• t Department of Industrial Accidents •
it - Office of Investigations
• l i -; • 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): 1 t 3 I+ p me. J m h t o ri s
Address: Ld (,oash►n
City /State /Zip: SSA 1 . j14 0107,5 Phone #: 1 413 Lk, 7 - /5 00
Are ou an employer? Check the appriate box: Type of project (required):
1. I am a employer with 0 4. [i 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. Li Remodeling
ship and have no employees These sub - contractors have 8. Li Demolition
working for me in any capacity. employees and have workers'
comp. insurance): 9. [] Building addition
workers' comp. insurance p' 10. ❑ Electrical repairs or additions
required.] 5. Li We are a corporation and its
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.] ' c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
:Any applicant that checks box fi I 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.
-1 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.
Insurance Company Name: Co meRC-e + Ind c 4 IAs
Policy # or Self -ins. Lic. #: WC- 00378 C 7'/ Expiration . S" 11- !,
Job Site Address: 5 Clt ^o City /State /Zip: S I0v
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 certift nder th d penalties of perjury that the information provided above is true and correct.
Signature: � - ) Date: ZD "aa �--
Phone #: 1 1t3 Y41 'SOO
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. R � "
Certified Office / Fax: (413) 467 -1500 • Cell: (413
AJHomelmprovements @yahoo.com Li'7tt rS
HIC Lic # 135399 • GAF -ELK ID # CE17267 • CT Lic # 600705 / CS, SL, RF, WS # 101017
Proposal Submitted To: Phone #'s:
01 0.71) S Ur"' Home: 5 1 7 3 t , � Cell:
Street:
it - tz
City, State, Zip Code:
LiHouse ❑ Garage ❑ Other
Proposal to furnish and install the following:
❑ Re- Roof Citfear -off ❑ Gutter
Complete Roof Preparation
2rHome exterior to be protected by tarps and plywood
'Shrubs, landscaping, trees to be protected
� 000fers buggy shall be used where accessible with permission from owner
Q Entire existing roofing material to be removed to existing decking, including flashing, etc.
'Site to be cleaned everyday with roll magnet debris removed at project completion (included in price)
" D-teriorated existing decking replaced at per sq. ft.1 p cs� c
Agiv, /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 ins all lead to chimne
W e stall new pipe boot flashing
shall acquire all appropriate permits etc. for all roofing work
Co plete Roof System ft.
We propose hereby to furnish materials and labor - comp
the sum of:
Total Sale Price $
Down Payment ', '100, c7t d pon Completion $ 1 ZOO c
ACCEPTANCE OF PROPOSAL: The above prices, s • - ' ' ions and conditions are satisfactory and
are hereby accepted. You are authorized to do work
balances shalPaccrue interest at 18 °Ip per
signing, and balance due upon completion. Unpaid
Purchaser(s) will pay for all costs, expenses and reasonable
this ble attorney's fees incurred by
A & J Home Improvements, Inc. to recover any sums due under
% S' e /2-Signature: Phone # -rg‘1 2 - 1 Z--
Date: 11111_ Estimator's Signature:
ATTENTION HOMEOWNERS: Please cover all personal belongings in the attic, garage or storage
aroac chip to the possibility of roofing debris or dust coming through cracks of the wood. A & J
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Aftat4k ) )O I b Li
License Number
Ga
Was\wecy, Aut. &A 114 /14 II- ►(i - (3
Address Expiration Date
qt'a /SO a
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
lm 135 395
Company Name ', ^ Registration Number
to k),s\m / 4-DA �' �le�Gtb t 1 A Li- 1- I (-f
Address v Expiration Date
Telephone (- /47 , SO 6
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 17( 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 Q
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [O] Other [O]
Brief Description of Proposed
Work: Stet tp Vto- t)r OUS,(
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
(�
I, �Acout t€. I , as Owner of the subject
property /� rr
hereby authorize ]'J 4 7 - t
to act on my behalf, in all matters relative to work au orized by this building permit application.
Signature of Owner Date
J r6\ JYYti vr , as Owner /Authorized
Agent hereby declare that the statemeras and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains ddpenallties of perjury.
A Y1r w �
Print Nam'
� J 10 • ►2.
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 ® 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 ® Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO l
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 Q
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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1)
Department use only
✓ ✓ ✓� ,‘ City of Northampton Status of Permit:
: uilding Department Curb Cut/Driveway Permit
s 212 Main Street Sewer /Septic Availability
o oN 4?P ° o Room 100 Water/Well Availability
�U" PM �c Northampton, MA 01060 Two Sets of Structural Plans
� o
phone 413 - 587 -1240 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
69 L �7 I r∎ Map Lot Unit
� Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
C6 J s Th -c> SR &1I, lv., Rck F lov c ✓1'
Name (Print) Current Mailing Akira
E L i 73K
Sc -mac[ Cot.{ Telephone
Signature
2.2 Authorized Agent:
+S 4-4ome ( Shin ton Avc &x*L itoib I1#
Name (Print) Current Mailing Addr s:
� 1 1 46 - 7 /S OO
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
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ,Q�
6. Total = (1 + 2 + 3 + 4 + 5) _ elG 00 • U U Check Number .J a I T y� () 6
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner /Inspector of Buildings Date
59 ELLINGTON RD BP- 2013 -0506
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 438 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 -0506
Project # JS- 2013- 000811
Est. Cost: $2600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: A & J HOME IMPROVEMENT INC 101017
Lot Size(sq. ft.): 10018.80 Owner: THIEME CHARLES & MARIE ROGERS
Zoning: Applicant: A & J HOME IMPROVEMENT INC
AT: 59 ELLINGTON RD
Applicant Address: Phone: Insurance:
60 WASHINGTON AVE (413) 467 -1500 () WC
SOUTH HADLEYMA01075 ISSUED ON:10/30/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE FRONT 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 10/30/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner