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35-160 (2) q mod SAWYE-1 OP ID: DB f~or`41�^L� c °�C LIABILITY v �+ p p A' C DATE(MM/i7 D/YYYYI `..„- CERTIFICATE E OF LIABILIT I INSURANCE 04/19/13 _ 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 policylies) 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 413-534-5343 a,",t'_A"T Mark A. Pijar A.J.Pijar Insurance, Inc. PHONE 413-535-1627 413-534-5343 FAX 1793 Northampton St. (A/C,Nn,Ext): (A/C.Noy 413-535-1627 Holyoke, MA 01040-1955 i A' ft=SS mpijar @pijarinsurance.com Mark A.Pijar,CIC INSURER(S)AFFORDING COVERAGE NAIC H INSURER A Safety Indemnity Insurance Co. 33618 INSURED ALL EXTERIORS INSURER 13 Essex Insurance Company .39020 Jeremy A. Sawyer DBA 21 Rolf Ave. INSURER(; Chicopee, MA 01020 I INSURER D_ INSURER F_ INSUHL±I<F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: `HIS IS 10 CEklIFY THAT THE POI(LIFE OF INSURAN(;I I ISII ED BFIOW IIAV1 BE EN ISSUI I) II.) IFII:- INSURED NAMED ABOVE FOR THE POLICY PERIOD INDII AI1ID NOTWIIHSTANDING ANY IC(JUlIA MC NI TI M 00 (IND I)IN OF ANY (ONIRAE I OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CT PIP icAir MAY 131. ISSUED OP MAY PERTAIN THE, INSURANCE AEI-E1RDF D BY I HF POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM:,. EXIT USION S AND CONDI I IONS OF SUCFI POI ICES LIMOS SHOWN MAY HAVE Bl LN REDIJE A,D BY PAID CLAIMS INSR ADDY SUBR POLICY EFT POLICY EXP LIE TYPE OF INSURANCE_-.--- .INSR MD_-- i POLICY NUMBER LMM/DD/YYYY MM/DDIYYYY OMITS GENERAL.LIABILITY E ACI I OCCURRENCE $ 1,000,000 B X I Oi l l)I))I�I GI N RAt unBll II TBA 04/15/13 04/15/14 ror�-Inc E Io RENTED P,wm1s s Fa o II c„cn; `; 50,000 CIAIV,;I MADE X '1(.0)0 MI a LYr,ED v .,F 5,000 N,rs050) a ADE INilIRY ,F 1,000,000 c1 NI RA1 0001-4 GAIL 2,000.000 cif.N I ',G(IRILIV,)I I imi 1 A ei 11 S PI I) IPODUI.I, C1,MP:r)P AGO S 2.000,000 PR„ X poi ICY JLI3 1 uc Etnp Ben. 4, 0 AUTOMOBILE LIABILITY --_-- - - CoNIRINGD SINGLE LIMIT --- , A ANY ll A li BINDER#:COM0062321 04/11/13 04/11/14 110111!Y INAIRY,Pe.p,•,,,,, 100.000 UI u1NNII) ELI))DUI.1 1I 300,000 i.Il lt):; X /AUIUS IUIi NIY IN IHRY I ,.,�ee NUN OVINE I' "Ri)I I R I I'DAMA':1 1111/1D ADIOS AUitJS P, 100,000 UMBRED_A 1_IAB x;cuP. I -CI l t ',;�.utRrNCE EXCESS LIAR CI AIMS-MA1)1 1i:1l1 I ,A I I` I i II 111 5110N.l'. WORKERS COMPENSATION WC SIAM 'OD I AND EMPLOYERS'LIARS ITV Y(N I OI Y I IMITS f.R fKYEPOPI>II 10101 AI INI.W1 x,,.uIIVE SEE ATTACHED NOTICE OF 04/16/13 04/16/14 1 i I Al II AIGII)ENI 1 1 I I 1 F 111 MIKY I L1C1 I LEI, N A (Mandatory in NH) y ASSIGNMENT I ,1ISI ASI I A ENID)05)3 c I II yt, 1 I ,n I SCAM I ION 01 OPERA RA I ION I I F I III A�E-III ICY LIMIT I • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional RI mark.Schetfide.a more space Is Ieyuved) REMODELING OPERATIONS-RESIDENTIAL CONTRACTOR CERTIFICATE HOLDER CANCELLATION ADAMQ-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AU T IIORI7FD REPRESEN IA T IVE 1988-2010 ACORD CORPORATION. All rights reserved, ACORD 25 12010/05) The ACORD name and logo are registered marks of ACORD AD ] xterior Roofing, Flat Roofing, Siding, Windows, Repairs, Snow Plowing 21 Rolf Ave. Chicopee, MA 01020 MA H.I.0 Registration#174528 CT H.I.0 Registration#0636067 MA Construction Supervisors License#106836 Jim & Beth Rice 5/3/2013 779 Ryan Rd. Florence, MA (413)586-0575 1) Remove 3 layers of roofing on the flat dormer down to the deck and dispose of the debris in a proper landfill. 2) Inspect the decking and replace any damaged or rotten boards for$75 per sheet of plywood. 3) Provide and install new%"fiberboard and new perimeter wood nailers mechanically attached to the deck. 4) Provide and install a new TPO roof system mechanically attached to the deck. 5) Provide and install new C6 edge metal around the perimeter. 6) Provide and install new pipe boots, chimney flashings, and new cap shingles to match the existing roof as close as possible. Provide Owners with a 1 yr workmanship warranty on the work completed._ Contract Total:$4,975.00 Down Payment: $1,659.00 Balance Due Upon Completion:$3,316.00 Estimates are honored for 60 days from the above date. Acceptance Of Proposal: The above prices,specifications, and conditions are satisfactory and are hereby accepted. You are authorized to complete the work as specified. Payments will be 1/3 down at the contract signing and the balance the day of the job completion. Estimated start date: a -` Estimated completion date: Date:`> - Owners Signature: ,, = Date: Estimators' Signature:f X (413)478-1536 City of Northampton t _ Massachusetts '" ` DEPARTMENT OF BUILDING INSPECTIONS Sk ?a,' 212 Main Street • Municipal Building Northampton, MA 01060 ¢` INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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 backfil), 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 of Industrial Accidents 1 '" Office of Investigations =mill= 5 600 Washington Street 3 =7 MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): .Sr Teri .S 4 �.i y. r / i✓// 7�r c rs' Address: ,� ( 470 if /9 v.t / - City/State/Zip: C ii r<or" 7'7/9 O/O?D Phone #: Cam//3) `V7 r-/ 6 Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with 1 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling These sub-contractors have ship and have no employees 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.111 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I.Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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: if r 'to I ,- h so rc, e Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: '7 S ' y 't Ck City/State/Zip: F/e renee /17/9 ©/06;-- 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 un er t e `ns and penalties of perjury that the information provided above is true and correct. Signature: Date: 4^E °7 3 Phone#: ri 3) L/ 7 /c3 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 Contact Person: Phone#: J SECTION 8 CONSTRUCTION SERVICES S. 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: re/-7 Sir c.lc, /D6 / License Number C9. I i?o t' iC .�✓-e L 6i r coi(-e /1/9 O/o 0 Address Expiration Date /13) y7 Fr-/513 6 "natter' Telephone 7,9 egrstece oiaie mproireinen :Codtra or. ,r , Not Applicable ❑ /l Ex4e riot-3 L 7 41 sa 8' Company Name Registration Number r 2 4 d c4 cop r''7 0/0. 1? p _a6 -_ Address Expiration Date Telephone 03) 4'7 exra ;SECTION I0-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 lid No ❑ ® om ...'ne .tix .l p,- on 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 • J SECTION 5=DESCRIPTION OF PROPOSED WORK.(check all a"pplicable) ,, New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [Dl Decks [p Siding[p] Other[O) 1 • Brief Desc'ption of Proposed/�V Work: t e p reel t'�fo root-107 brl ciofr`v Alteration of existing bedroom Yes X No Adding new bedroom Yes )( No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet rho sewn® or�addiifitan to:existin ,hoiusing orrip.a e lie:ollowcng: 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 EWHEN -:.. OWNERS AGENT OR`CONTRACTOR,APPLIES FOR BUILDING PERMIT ri ? •..,+v4 x. .:._. ._. .ls z.r .. 'n t'vz. rY, 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 , as Owner/Authorized Agent hereby declare that the statements 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 Sign f'Twner/Agent Date • J Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information r Existing Proposed Required by'Loning This column to be filled in by Building Department Lot Size l l l l i. f i s Frontage i . Setbacks Front = ��----� Side L:` I R:€ 1 L:L R:E E L____.1 I Rear Building Height = —T Bldg.Square Footage l l % ! I Open Space Footage (Lot area minus bldg&paved I I l I parking) #of Parking Spaces ( I Fill: 1 _ __ _ _. (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: I i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 1 Pagel and/or Document#1 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 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 F IF YES, describe size, type and location: 1 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 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. F –'RECEIVED City of Northampton S ��' �� MAY '6 2013 Building Department E ® a � = 212 Main Street � `` - . .k as L . . Room 100 y �� � � ; DEPT.OF BUiLDiNG INSPECTIONS . NORTHAMPTON MA 01080 —Northampton, MA 01060 °� a ® "t �a � "` phone 413-587-1240 Fax 413-587-1272 4 Wit , w ® 5pe QA 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 •y office , " i S �" "'4 Y 3 bi' R#� �k g.. kid. S. ih 54 '6 4. i44;4+/�� fns � � 40.04v',,- y�,C3'•a +� N kLO k� � r��s#s y'��'?�'�. .'tr.,i,"*°.c`�`z - v�"•. / It Cs✓? `+?:� S �.. '�?k #° '�". • mya. °�Y '" `, i. rya /C,re✓/C- P7 01 'Zoned � -m� n Overly Dis ict/ SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED_AGENT r '.? a 2.1 Owner of Record: .z_/ c t3t'1- c c P 7 7 j y �,� '< F1dl���r rlfl x/06 Name(Print) Curr nt Mailing Address: (6/13) .S - D,5°75` Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: 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)'E.' timate`d.Total Cost of - Construction froii (6) - 3. Plumbing Building Permit Fee, 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number ." , This Section For'Official Use Only . Building Permit:Num•- Date Issued. Building Commissioner/Inspector of Buildings' Date• • 779 RYAN RD BP-2013-1051 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35- 160 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-2013-1051 Project# JS-2013-001736 Est. Cost: $4975.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEREMY SAWYER 106836 Lot Size(sq.ft.): 43385.76 Owner: RICE BETH M&JAMES W Zoning: Applicant: JEREMY SAWYER AT: 779 RYAN RD Applicant Address: Phone: Insurance: 21 ROLF AVE (413) 478-1536 WC CHICOPEEMA01020 ISSUED ON:5/6/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF DORMER 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 5/6/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner