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17A-199 AGURO` CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DWYYYY) 1/4.----. 05/3012013 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 policy(les) 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 Phone:413-538-7862 NAMEACT Debora Mello rf _ 79 Lyman ddy Insurance Fax 413-538-7179 PHONE 413-538-7862 J talc,No):413-538-6010 79 Lyman Street _Mat Ext)__ South Hadley,MA 01075 ADMDRESS:deborameIlo @fieldeddy,com Stephen E.Radon INSURER(S)AFFORDING COVERAGE _• NAIC it INSURER A:AIM Mutual Insurance Company, INSURED R&H Roofing, LLP INSURER a:Safety.Insurance Company — 39454 Henry Hopkins _..-_--.__.._............_ . _..__...._......._..._ -- �----____-- p INSURER C:Scottsdale Ins Co. 59 South St. _—. Easthampton,MA 01027 INSURER D:National Union Fire Ins.Co. INSURER E_Hanover Insurance Company 22292 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. INSR TYPE OF INSURANCE ABbC51J R POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/OD/YYYY) IMMIDO/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 C X_ COMMERCIAL GENERAL LIABILITY BCS0030279 05/26/2013 05/26/2014 PREMISES TED nce).___• $ 100,000 CLAIMS-MADE {—Xi OCCUR _MED EXP(Any one person) $ _ not covere PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY 1......_..1!pa pi LOG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ B _ ANY AUTO 2433476 08/26/2012 08/26/2013 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS X AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS ,.{Per accident).........-._._........._........_...........--------------•._.__....._...._..._._.... $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 6,000,000 D X EXCESS LIAB CLAIMS-MADE BE067658017 06/17/2012 06/17/2013 AGGREGATE — __ _$ DED 1 X I RETENTION$ $ WORKERS COMPENSATION x WC STATU- x OTH- AND EMPLOYERS'LIABILITY TORY LJMII ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y N!A AWC7017424012012 10/24/2012 10/24/2013 E.L.EACH ACCIDENT _ $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 IIyes,describe under ..._..............__.-.._._._.....__......__._.._.__.._.._- ..�._—_ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Equipment Floater RBN9329678 01/22/2013 01/22/2014 Property 5,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN R&H Roofing LLP ACCORDANCE WITH THE POLICY PROVISIONS. 59 South St Easthampton,MA 01027 AUTHORIZED REPRESENTATIVE i ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1* Massachusetts - Department of Public Safety ��f Board of Building Regulations and Standards Construction Super■isor License: CS-042781 ttr �t HENRY E HOPKINS `-- 59 SOUTH ST - EASTHAMPTOI*MA 01027' ,t,znsnissao .{ 06/02/2014 � C'ne (6 90 ♦ wean 4f /JJaduUJP/a 9_ ii_-,,,1_ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 105948 Type: Partnership Expiration: 7/21/2014 Tr# 227142 R & H ROOFING Henry Hopkins 59 SOUTH STREET Easthampton, MA 01027 — - Update Address and return card.Mark reason for change. ffl Address 7 Renewal 7 Employment ❑ Lost Card SCA 1 0 20M-05/11 J/e*6 o l!-?llea.,fre n.:e/G License or re istration valid for individul use only \_Office of Consumer Affairs&Business Regulation g OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office a istration: 105948 Type: Office of Consumer Affairs and Business Regulation ° - 9 10 Park Plaza-Suite 5170 —_-_-- x iration: 7/21/2014 Partnership p Boston,MA 02116 R&H ROOFING Henry Hopkins i 59 SOUTH STREET .= ',..r..4,-.---,63...5.—_ `` Easthampton, MA 01027 Undersecretary Not v•lid without signature P Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 7-2010 www.mass.gov/dia The Commonwealth of Massachusetts Print Form j Department of Industrial Accidents ' =� Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 Ac-„, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): IS I i i• Address:31 .SL �tTr-/ S772E` 7 City/State/Zipt mi` Pi?ly (Y)Pt--OK)9 1 Phone #: (4)3-5-a-7 - i 3 7 Y' Are you an employer?Check the appropriate box: Type of project(required): 1. F! I am a employer with I e)--- 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 ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. [' 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.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13. Other 100,6 r- �' 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 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. ,n �„ _ / Insurance Company Name: P 1 mU I UA t. �SU� Iv COCA�T"v"1 Policy#or Self-ins.Lic.# C 1 G LI q O I ( 3-- Expiration Date: )6/91-/ / / 3 Job Site Address: J'7 I City/State/Zip:f (Z A.0 / 11/1P' 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 p�'ns dpenalties of perjury that the information provided above is true and correct. Signature: I Date Y //0/i 3 Phone#: 411,3 -,.3 01-7 i3 7.)'' 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 Applica ble ❑ Name of License Holder:Mt- " � i k P / s ` S"OLI (9- License Number sC1 sc (AYR . try P TON/ / (Yl D I Oat CD Addre-s Expiration to Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable S/`\ /LLSi�I—/Il) j i LLP Company Name Registration�� Number waTt4 5T -STil-Wrrn art , m, - ( ca9 7 7 i I i y Addre Expiratio Date (13 Telephone .5-3-7-93 7 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 !E! Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding[O] Other[D] Brief Description of Proposed �{ WorkRtlnoo .SH7N6L.4., rloc),= 7 /NSIR'LL- N LW L five;Lr lL'Ck)r' Alteration of existing bedroom Yes X. No Adding new bedroom Yes (< No Attached Narrative Renovating unfinished basement es D.c. 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 l Ce e.1Q ,as Owner of the subject property o1 hereby authorize ft 120—/ .lamLL! t LL� I+� j � P iC os to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 40\-1-(Z /,., 1-1-0(7 K J As , 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. / E Ja-Li l-÷57 SCI MS Print Name L A Signature of Owner/Ag: t Date - Qa 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/Fin ing ever been issued for/on the site? NO © DONT KNOW 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 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO 46 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, - -vation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 1 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only RECEIVED City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit .111 2013 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans DEPT.OP BUILDING INSPEC a 413-587-1240 Fax 413-587-1272 Plot/Site Plans NORTHAMPTON,MA 01 �""" Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address:4 / 4/ i fl, p 5rkeerY Map Lot Unit flOi6eA)CC' M i , Zone Overlay District Elm St.District CB District • SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: V- C:e c ikci L Cl-dr,o) 14-1 t*b r*k Nit o-06 5 e vt Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: f) ar)OfiA (r7 , L,O° 59 LOU 1 S I: , E `T / � Name(P nt) Current Mailing Address: yip4 2 (33-)r Signat Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2vo`i� / fI 9-�P/ _ 4 U (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 6. Total=(1 +2+3+4+5) 0 /// qqtee •00 Check Number /71455_ 443 S This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 141 NORTH MAPLE ST BP-2013-1178 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 199 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-2013-1178 Project# JS-2013-001936 Est.Cost: $11996.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R & H ROOFING 042781 Lot Size(sq ft.): 7535.88 Owner: HOLUB CELENA A Zoning:URB(100)/ Applicant: R & H ROOFING AT: 141 NORTH MAPLE ST Applicant Address: Phone: Insurance: 59 SOUTH ST (413) 527-9378 Workers Compensation EASTHAM PTON MA01027 ISSUED ON:6/11/2013 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 6/11/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Awr