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30A-082
City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: The debris will be transported by: C�--)YvV (e�c- 'Di SPo s,,a L The debris will be received by: LWL IciA?- N -�d't- �c Building permit number: Name of Permit Applic nt V ��'" Date Signature of Permit Applicant ACC) CERTIFICATE OF LIABILITY INSURANCE_ °��`�'I°4 '15 .�._. THIS CERTIFICATE 113 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERIIFiCATE! DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y 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 po.licy(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 Ih:u of such endorsement(s), _ PRODUCER '_ NT"�7�_ -...-.•-•— _ ____ ---- __- Banas & F.ickert PKON Michael R. Banns FAx 413) 527-^2700 LAIC Nol; (413) 527^0849 Insurance Agency ADD`cRESS: mb @banasinsurance.com 63 MzLin Street INSURERiS3AFFOR01N3 COVERAGE NAIC# Easthampton, MA 01027 INSURER A:Admiral Insurance Co. 24856 INSURED -INSURER 8:SafAt Insurance Co. 39454 RCI Rooi°ing, LLP iNSURERC:Evanston Insurance Co. _ 35378 6 Line Street INS RERD tar Insurance Co. 24562 Southampton, MA 01073 INSURER E: INSURER F; _ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCES LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR COND11-ION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDTIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, 19-SR {itvt$UBTI —_ ----..__,_.....- OU'dK FI, PT�CY€XP LTR TYPE OF INSURANCE POUCYNUMBE:R MM/DD MMIDD'YYYY _ LIMITS A GENERAL LIABILITY X CA000020963-01 3/4/15 3/4/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GE NEPAL LIABILITY DAMAGE (raooc L TED $ 50,000 CLAIMS-MADE Cil OCCUR ME EXP A one persin) $ 10 1 000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2 OOO OOO GEN'L AGGREGATE LIMIT APP LIES PER PRODUCTS•GOMPIOPAGG $ 2,000,000 POLICY X_P'T LOC $ B AUTOMOBILELIABIUTY X 6201761 9/30/14 9/30/15 Eaaccldsre $ 1,000,000 . P14YAUT0 BODILY INJURY(Per poison) $ AL.LOVJtED X SCHEDULED BODILY INJURY(Per aocldenl) $ AUTOS AUTOS NON-OWNED PROPEFijY AAIANON-OWNED Peracci enl X HIRED AUTOS X AUTOS S G UMBRELLALIAB _OCCUR X CUBW'575791E5 3/4/15 3/4/16 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DIED X RETENTION$ 10,000 $TO—STAI VvVRKERS COMPENSATION 8 10/5/14 10/5/15 TORY LIMITS 0TH• D W AND EMPLOYERS'LIABILITY C0683405 ANY PROPRIETOR/PARTNER/I_XECUTIVE YIN NIA E.L.EACH ACCIDENT $ 1,000 000 UFFICE RME MER EXCL U0 EC1? (Mandatory In NH) E.L.DISEASE EA EMPL E 1,000,000 Ify es doeo DESCRIP710Nribe uOFnder OPERATIONSbetow E.L.DISEASE-POLICYLPv1R 3 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS iVEHICLES (Attach ACORD 101,AddldonalRenarks Schedule,If more space Isregdred) ROOFING CONTRACTOR. CERTIFICATE HOLDER _..�. CANCELLATION SHOULD ANY OF THE ASO E POLICIES BE CANCELLED BEFORE THE****REFERENCE ACCORDANCE WITH WITH THE P L SiO ICE WILL. 68 DELI _ AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) 'Phe ACORD name and logo are registered marks of ACORD Phone; Fax: E-Mall: .,��. ..-_,.__�;_-A�, ,.,R,,, �„� .,_,__� JIM Massachusetts - pepartrYient of Public Safety e Board of Building Regulatlons and Standards Office of Consumer Affairs&Busl6ess Regulation OME IMPROVEMENT CONTRACTOR Consh'uctio n supervisor eglstratlon: ,7-26,235 Type, License; CS-074334 r xpiratlon,.....51.6I2.OT Parinershlp `�` MARK T DELISL � . R.C.L ROOFING 59 Briggs ROOFING Street Easthampton MA7e 010 9 MARK DELISLE 6 LINE ST Expiration SOUTHAMPTON,MA 01`073' Undersecretary Commissioner 05/03/2016 mom' «0.. :OMM:ONIN _ f..TM:O�:M`A "�� HUS 'CT .. 10 9® • ::: it • , � IiC>T�E IPrIPR•£?V sI12,gN'�C-CON*fI A.(', SHEEN f�' SAL WOAD rR ;Tt C I Tc�7 C) IT�U;S�1,P 1 S.S U F S . 'H E f O'L:L.Q-W`kN,(� LI C E N'S E J' �1AST RESI R I CTED SOI 1073 la • Z MAf3K t DIE L I SLE N, ' W C./REG NQ,,,. F,FE I E" E P RES " „ .:11/30/2014 59 'BR I v 1-1IC,0624741' t ; E., ' MP;TON M>A 01027 1139 j SIGNED.. . . ...._.. .. _ .. _ .... _.._. .. .. 1 05/:Z'��-1 ;. 21841 • �i�t<:GOiV11V10N1JV�a`�'L'fF�,Q�'�11'II � ZeG1-�l'�� i T'S:.:c':::• >oA� 13.,09?, S'H E.E:' .; :.p:R;K;E;R:.S;. I SSlJES T# ' fOLl.Ol,I'CaG.. !l l C.C1f'�, i MAAK I . 1 0`.O f I Npa 1Y L P u 6 LIN'E 'W`F :UTHAMPTON M'A 01073 019, 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 miwmiass gov/dia Workers' Compensation Insurance Affidavit,, Bul-Iders/Co:titractors/FIecti•icians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationbdividual);_ P\--Q ," Address: CC, �. ,•r\ o-! 3 Phone #; (-q1;3) 5,41 `QF- 15 Are you an employer? Check the appropriate box: Type of project (required); 1.[Q-1 am a employer with Z U 4. ❑ 1 am a general contractor and,I 6, New construction � employees (fall and/or part-time).* have hired the sub-contractors 2, [1 1 am a sole proprietor or partneT- listed on the attached sheet• $ Remodeling I ship and have no employees These sub-contractors have 8. ❑ Demolidon working for me in any capacity• workers' comp, insuranct:• 9• ❑ Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions required, officers have exercised their 3. [] I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself, [Na workers' comp, c• 152, §1(4), and we have no 12• Roof repairs insurance requ.ired•3 t 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: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside mntraetors must submit a new affidavit uidicating such, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. l am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site information. [usuranee Company Name. Policy #or Self-ins. L,ia #. c Colo 3`l O _ Expiration Date; 10 � Job Site Address: _City/State/Zip; _ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date), Failure to sectue coverage as required under Section 25A of MGL e. 152 can lead to the imposition of crindnal penalties of a fine up to $1,500,00 and/or one-year imprisonment, as well as civil penalties ut the form of a STOP WORK ORDER and a floc of up to $250,00 a day against the violator, Be advised that a copy of this state.meat may be forwarded to the Office of investigations of the DIA for insurance coverage verification, I do hereby certify under the pains andpertalties ofperjury that the information provided above is true and correct; Date, Phone Official use only. .Do not write in thls 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: ;r: RC.1. Roofing Date 6 Line St. Estimate Southampton,Ma. 01073 11/26/2014 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Dr. Jay Fleitman Dr. Jay Fleitman 15 High Meadow Road 15 High Meadow Road Florence, MA 01062 Florence, MA 01062 Terms Rep Due on receipt Description Total Remove existing garage and breezeway roofs. 6,500.00 Furnish& install aluminum drip edge,pipe flashings, chimney flashings(if needed)and step flashings. Furnish& install CertainTeed Winterguard ice&water barrier along eaves and valleys. Furnish and install synthetic underlayment over existing deck. Furnish and install Lifetime CertainTeed Landmark Series shingle. Furnish and install CertainTeed approved ridge vent. All exterior roofing related debris to be removed by R.C.I. Roofing. All work will be performed according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I. Roofing. Add$2.50 per sq. ft. for wood decking replacement if needed. Customer is responsible for securing interior items and any attic debris from roof removal. Total $6,500.00 TERMS OF PAYMENT 5%Deposit re t Si Customer Signature Balance upon completion �GT � — Registration# 126235 Construction License#074334 Insured by Banas&Fickert Ins. Date (413)527-2700 � t. a � ♦ . A t N .. � �. � r y v � v a '�C s . .. �� r � r r r r �. :9 k .. � SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: May h Mel 1 1 5 1`p, t7 g q ,3 3'1 j� License Number 51 ES Munk St.- EaSt�mblon . Ma. oloal �5 - a3 -�'� Address Expiration Date 1 Signature Telephone S.Registered Home Improvement Contractor: Not Applicable ❑ 8.0• Z. 11o6 12l&235 Company Name i Registration Number 5 19 Acluoke- Street - P. 8- x 309 5-DG-14 Address i Expiration Date Eas tharil nfior►. a. 010 j7 Telephon�!1 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....... 0 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 Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [❑] Other[❑] Brief Description of Proposed at}.arh�'d Work: 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, , 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. aL'acheJ Signature of Owner Date I, ayh 1)e�'�e. -as a(jL,6daeJ aQ l as Owner/Authorized Agent hereby declare that the statements and information on the foregoing a&lication are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name �- �- 2,2 �cS Signature of Owner/Agent Date Department use only 'City of Northampton Status of Permit: ,'Building Department Curb Cut/Driveway Permit ' 12 Main Street Room 100 WaterNVell Availabilit Northampton, MA 01060 Two Sets of Structural Plans 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 1.1 Property Address: This section to be completed by office 157 Hl� k Map Lot Unit— Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: AttacheA Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: 010,Ll Signature felephone- Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building b o c) (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 This Section For Official Use Only Date Building Permit Number: Issued: Building Commissioner/Inspector of Buildings Date 15 HIGH MEADOW RD BP-2015-1209 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30A-082 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-2015-1209 Project# JS-2015-002288 Est. Cost: $6500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 141134.40 Owner: FLEITMAN JAY S&MARYLOU STUAR Zoning: SR(101)/WSP(17) Applicant: RCI ROOFING AT. 15 HIGH MEADOW RD Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.61312015 0:00.00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE GARAGE & BREEZEWAY 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 Sitinature: FeeType: Date Paid: Amount: Building 6/3/2015 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner