18C-122 (3) RECEIVED AUG 14 mu
CERTIFIC ATIrOF LIABILITY INSURANCE T 8/122014'
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 policyc(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to
the berms 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 Tierney Team
Tierney Group PHONE (413)562-7007 FAX .(888)271-2228
16 North Elm Street EMSS
P O Box 750 INSURE AFFORDING COVERAGE MAIC#
Westfield MA 01086 RERA:Penn America
INSURED wougop:Safety Insurance C 9454
N R B Exteriors Inc iNsugaRcOorkers Compensation Ratin &
7 Philip Circle INSURER D:
INSURER E:
Grahby MA 01033
COVERAGES CERTIFICATE NUMBER-CL1481200179 REVISION NIUMBER:
THIS-M TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTMIMATHSTANDING 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.
LIM TYPE OF INSURANCE IMMADDAlfM POLICY EFF POLCY EJCP LIMITS
GENERAL LIABILITY EACH OC $ 1,000,000 RENTED
X COMMERCIAL GENERAL LIABRIIY $ 100,000
A CLANS-MADE �OCCUR AV0016338 2/1/2013 2/1/2014 MEDEXP(Ary one Parow $ 5,000
X $1,000.00 ST De ttatible PERSONAL&ADV INJURY $ 1,000,000
X $2,500.00 PD Deductible GENERAL AGGREGATE $ 2,000 000
GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPJOP AGG S 2,000,000
F-1 Poucy PRa oc $
AUTOMOBILE LIABILITY u
B ANY AUTO BODILY INJURY(Per person) $ 500,000
ALL AUTOS AUTOS}( SCHEDULED 222362 /15/2014 /15/2015 BODILY INJURY(Per eccidert) $ 1 000 000
A HIRED AUTOS
NON-OVYNEO PROPERTY DAMAGE $
AUTOS 200 00
X
$
UMBRELLA LAO OCCUR EACH OCCURRENCE $RETErt—E]F o EXCESS LL AB CLANS-MADE AGGREGATE $
(' WORKERS GC>wAPENSATKNI VYL" A JOT"-
AND FMPLOYERS'LIABILITY Y/N
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100,000
OFFICERMMEMSER EXCLUDED? ❑ NIA ZZL18_2RO3175-4-14 /13/2014 /13/2015
( In N EL.DISEASE-EA EMP OYE $ 502,000
DE pe(pw follow from covemiy E.L DISEASE-POucvLIMIT I s 100.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addlfthat Remarks Schedule.K Icon Waco Is regal»d)
Siding, Window Installation, Carpentry, Roofing and Snow Removal/Ploxing
CERTIFICATENOL CANCELLATION
3ncphwmcd@ aol.corn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Richard Lowe ACCORDANCE WITH THE POLICY PROVISIONS.
70 Wenonah Road
Longmeadow, MA 01106 auTHORIZEDREPRESENTATWE
LAU LAX
ACORD 26(2010106) a 19$8 CORPORATION. All rights reserved.
INS026 poioos).ei The ACORD name and logo are registered marks of ACNtD
,w Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Super%isor Specialty
License:CSSL � z-Og M"
NICHOLAS R BE"
7 PHILIP CIRCLE
Granby MA 010A
r }o r
0% Expiration
0612812016
Commissioner
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 147961
Type: Private Corporation
Expiration: 8/23/2015 Tr# 242322
NRB EXTERIORS INC —
NICHOLAS BERNIER
7 PHILIP CIRCLE
GRANBY, MA 01033
Update Address and return card.Mark reason for change.
Address F� Renewal F] Employment D Lost Card
SCA 1 G 20M-05/11
�JftR�[l J?2•TI/OlLfllP.fA'li�Jl G�C/[�3JCICStCl38�J
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: 147961 Type: Office of Consumer Affairs and Business Regulation
`Expiration: 8123/2015 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
NRB EXTERIORS INC
NICHOLAS BERNIER,
7 PHILIL CIRCLE g — 'T
GRANBY,MA 01033 Undersecretary Not valid without signature
Proposal ubmitted to. Phone# h: c:
Street
. .
City.state,zip code
prop"to
Rey )of 'Few
(6, We shall acq ssary permits for all work
Complete Red 'inepatrati�u
s
S%ma'bs,bmd=q7ftig,ttes to be p
[ Entire existing roofing materials to be removed to existing decking,including flashing,etc.
L Site to be cleaned on a daily basis with roll magnet,debris to be removed at project completion by dumpster
DeterioraW existiV cie JdV to be mpLumd at$50 1wr sheet ofplywcad
1 guard ice&water barrier along bottom 3 ft.off all roofs a 6 ft, *° ✓ ° `'"w
Install Winter l�.�•
Install Winterguard ice&water barrier around penetrations,in valleys an
kj "Install 15#saturated asphalt felt pager to entire decking*ckisg
Install DiamondDeck Synthetic underlayment to entire decking
Cie
Install 8"perimeter metal lashing to all edges of all roofs,JWwhite D brown
Install SwiftStart starter shingle to bottom and rake edges of all roofs
Install CertainTeed shingles to manufacturers specifications;,Cl 6 nails 4 nails
knall S New It lam` "
Install Shadow Ridge to all hips and ridges,over ridge vent where applicable
Install new lead counter flashing to chimney
New flashing installed where necessary
Install new pipe flashing to waste vent stacks
Warranty options
We guarantee our labor/workmanship for 20 years
0 Upgrade CertainTeed 5-Star Sure Start Plus,50-year nonprorated coverage,including workmanship
Upgrade CertainTeed 4-Star S roratted coverage
CerbiRTeed om ,
CertaiaTeed Landmark Pro-color
We propose hereby to furnish materials and labor—complete in accordance with eve specifications for the sutra of z
Ail ' +(l�Plti Mme abla�ire , , - 1/3 Down Payment
sa"Oetory and are bereby acted..You are authorized to du work as specified. Balance due a M�
Psymeat will be IA down at start of job,and balance due upon completion. upon completion $
Date: Signature: «. l
Date: Estimator:(Print Name)
Estimates are honored for y(3o) from above date
)da 3's
ATTENMN HONWWI+iM:Please ever all personal belongings in the attic,garage or storage areas due to the
possibility of ring debris or dust in through cracks of the wood.NRB Exteriors Inc.will not be responsible for
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: -;7 A I P (- J
City/State/Zip: C-,.1 Phone #:
Are you an employer? Check the Jppropriate box: Type of project(required):
lam a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E]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 g. ❑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.❑ 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.❑ Roof 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#I 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. &4��n Insurance Company Name:
Policy#or Self-ins. Lic. #: Z Z Ll 6� Li t Expiration Date:
Job Site Address: / f 11 r City/State/Zip: 4 h•,
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 t ains and penalties of perjury that the information provided above is true and correct.
Si ature: Date: (U l
Phone#: T�%7 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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ _
Name of License Holder
License Number
1, �-- ) y- 1 G
Address Expiration Date
Sig ature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address ) Expiration Date
elephone
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 as sumes r ponsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning L d 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
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[[3] Other[E]
Brief Description of Proposed (� a
Work: &g&,—0-e— D
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.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
C, .���, �/C.L, as Owner of the subject
property
hereby authorize C(
to act on my behalf, in M matters relative to work authorized by is building permit appl ti n.
Signature of Owner U Date
a C , 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 and the pains anndd penalties of perjury.
/ " !C 1. z�c,S
Print Name
Signature of Oumer/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 ® DONT KNOW ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® 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 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 0 Obtained Q , 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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r
-;- Department use only
C' of Northampton Status of Permit:
DB [ding Department Curb Cut/Driveway Permit
12 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability,
&Gag mgN pton, MA 01060 Two Sets of Structural Plans
ttic,plumbing i -1240 Fax 413-587-1272 Plot/Site Plans
E1t� rlortham t -
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
f'�1 Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current ail' Addres
�2T- S 3-7
5Le=Cc*4,-j Ctf-!!f fi' Telep o e
Signature
2.2Authorized Aqent:
A
Name(Print) Current Mailing Address:
Si ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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
6. Total=(1 +2+3+4+5) 6 (� Check Number ® Q °
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
15 ALLISON ST BP-2015-0444
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 122 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-2015-0444
Project# JS-2015-000818
Est. Cost: $8550.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NRB EXTERIORS INC 99565
Lot Size(sq. ft.): 8058.60 Owner: GRAVES LINDA S
Zoning: URB(100) Applicant: NRB EXTERIORS INC
AT. 15 ALLISON ST
Applicant Address: Phone: Insurance:
7 PHILIP CIRCLE (413) 563-6354 WC
GRANBYMA01033 ISSUED ON.10/17/2014 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 10/17/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner