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17C-037 (5) 113 NORTH MAPLE ST BP-2017-0500 GIS;8: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-037 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: ROOF BUILDING PERMIT Permit# BP-2017-0500 Project# JS-2017-000822 Est.Cost: $6900.00 Fee: 540.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 19471.32 Owner: BROWN WILLIAM W&HEATHER A DRUCKER Zonin_: URB(100)/ Applicant: RCI ROOFING AT: 113 NORTH MAPLE ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation S O U THA M PTO N MA01073 ISSUED ON:10/19/2016 0:00:00 TO PERFORM THE FOLLOWING WORK: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: FeeTvpe: Date Paid: Amount: Building 10/19/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Gepart natit tf0,0r1y c. City of Northampton taus oP Pafnd • 00 q E enceng Department cis v.IHD Sews, Peenit / tb .a 212 Main Street sewalleaptlo auallablpty_ �� A\ in Room 100 WatotnN.EuA,, llablolg_._..___._- 4 Northampton, MA 01060 �Two'6ots;of Structural Pars_-„,,�,, < ”' phone 413-587-1240 Fax 413-557.1272 w)ovalte<Rlans �\'v �6 her Spgo(fry 4/CATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE�^ OR DEMO 1(;bi A ONEOR TWO FAMILY DWELL;NG —I 1-O.N 1 •SITE INFORMATION ��1 St( 1 `J e or» 'r e,' lids ,sestTop to tze completed by of flea 113 N. maple St- Map - ___ Lor Unit Ferrety, , it(A Zone,-„__ __� Oveaiay Disiziot___, Elm St D etHek�___,.._ ca DisK'et� 1 . _.,TCN 2 • PROPERTY OWNERSHIP/AUTHORIZED'AGENT I I , r it O tmer ol „ecoLd 1/0.clhtutin fav ait7__ 113 K AftkplLaJ%nrifria/Aa air ba __ 3me pPn m.) Current Melling/*Pess: Vi -3;2D - toeg _.— sPQ-¢. Cl7TTd Telephone e SIIo,2`C Aaeyl,'U \/ h b_ISLEg__:__L, C . t rlr 1--i i 1 nt?. `}l 1n r44vet tm i rn to A ()4La. Piet r„i Ourrerl Mailing Address. ;Igraiins ....__-.-._---...__ Telephone L. ',ON 3. ESTIMATED Dr NSTRUCTION COSTS _r. -- Estimated Cost(Dollars) to be Official UseOnly 1 _T�__ nam -I_eteS h e R;lf d •liepnt _dtling (a)Building:e.Ormll:Fee no,i rtn..- /0400. - : EieeUmal `^J (b)Estimated Total Cos; o1 Construction from (B) srmirg Building Pe rnit,Fee r Imeehenic&l(HVAC) Ego Protection _ lova(=(l + Pr8+4+g) f04fie – I Check Number oG 4 `Ar `Zt/ Thls Section For Official Use Only__� LI ,.,g Permit Number'. - Iss e ued ;ig na 0..'e; — ,. ---—_— _ Building CommI $1Dfer/Inspector of.Bulldings Dale, :.BCTION G, DESCCRLPTIQN CE P.RI]PPSED WORK usheckall apr#NceiM h.>V house [_ Addition C i Replacement Windows Altevatlon(s) 7 I Roofing II Or Doors C _ __ ocessory Sl=dg. [_ Demolition , New Signs (0) Decka jCl Siding (pl Other lam; rasion of Proposed t _sILB Q 4(1,d1P7t ., —__ -nermitori of existing bedroom Yes No Adding new bedroom Yes No ?ached Narra.ive Renovating unfinished basement__Yes __No • mans Aaaohed Roll r Sheet_ Ce If New housj and nueatilltfon yc,exPsTtge hoUe4ge4 comple44.=b 1,allowhnel: use of ruiild;ng One Femlly Two Fanily Oteer____ ._ Number of rooms in each family unit', Number of Bathrooms_—__,_ there a garage sitaored? n ronosed Square footage of new construction, —Dimenelons rmrrber o'stories? ieurod of heeling?_ Fireplaces or Woodskoves_ Number o' each_ ._ Energy Conservation.Compliance. Maeschech Energy Compliance form attached? 7,,:e of coastructon— s conseuction within 100 ftof wetlands? Yes No, Is construction within 100 yr. floodplain Yes„ So Depth of basement or colter floor below finished grade, ii min bislang coviem to the Building and Zoning regulations? Yes No Septic Tarn City Sewer_ _ Private well City water Supply„__ SECTION ?a -OWNER AUTHORIZATION •TO BE COMPLETED WHEN D'OaSERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _l___.� I u_41- ! C0 p ri _,_. — ,as Owner of the s+nject eey ei y outnnrize N1\rt_t\ \41){21}Q Q (in 12) , C . T., tzvrr-icic" LLP ---- t on my behalf, in all matters relative to work authorized by this building permit aR lcation. l L('in_B(/ _,— f0 - 5-167 ,r.analure of Owner Date � _NtChr' ry €t Q (1.S (d lr_lha:- Pg fo( Csrr" ,as Owner/Authorizer: ? erg hereby declare that the statements and information ondre foregoing application are true and accurate, to the best of my knowledge ted oehef Pipped under the pains pains and penalties of perjury h `Jeno' --.+ -s--/6 _ II •^, nth OnmerAunt i Date _y—_ - __,� 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: l/3 N Aitifio St: F/Oyer te, /1//9 3I'aOa- The debris will be transported by: Lenin left /)r,S poSlr / The debris will be received by: t-16 ic/,0 /rah s, e/41CA.:(4 -y Building permit number: Name of Permit Applicant R e 1 Roo hi. L.LP Date L1 , 5../4 Signature of Permit Applicant • `'- --' +, Massachusetts Department of Public Safety — 3a1 o axnosm. VI Board of Building Regulations and Standards .__ ... 1-� Licence; CS-074334 ,e`F rveal!/c D/( r a/Awwt$ Lbnst:IlcHon Supervisor � Office of Cons uA[falre&➢ s efsRegulatlo I'3 HOME IMPROVEMENT CONTRACTOR MARK T BELISLE Registration 126235 Type, 59 BRIGGS STREET 1� ° ' I vy 6^ i1. Expiration, 516/?098 Partnership EASTHAMPTON MA 01027 R.0 I. ROOFING MARK AELISLE /r (�,.M Expi3ati1n', 6 LINE ST s._ - - Commissioner 05105t4018 SOUTHAMPTON, MA 01013 Undo secreen:y_ a•sige ria _ r {{ JSk for T7S-ONW ' 1 rK 1A3 : i•, IQ CIF I ESNOO OM' IfFR iW 9N'1ICON RACTOR 7N SNeE'S t^aTAL NSGIR�FPS „lvIti 01+i Ca 2tj,Y ,, i., „� S5W48 �'W@ °0[0,4V>UNG-CJ'CENSS s `LINS4 it t tt ,eyr a A haseslPic Le „ . SQIJ[SI I1,0` `! ri4 610737T1 ,1 r 1 I�P h'A$ - t 6011SLE —LIC /REP Nd Ib 13 y! x TAlr-- ,• Ree, `; IN �ni2ola 59 ailapa a� hi y'r(IrvN ,;4?)-;t rS,A'x,Tli Ay`P'(pN rAj�A D1027 173 C 6624147�i.p10Y 1OS `ttt �L.,. ,,....., t t; / 1 1,2° .. . rrsa�c'in a' � R( Ip,{e a'S9 COMMONW ALTH OF MASSmCHUSErT:S,. ' "< `tioivisiot4YSE'FRovEssiOPNA'tUCEtNSORE :' BOA/HD/OP SHEET.META..tvORKRS ISS11,ES 1 HE)FOLLVAI N4 LIOENSE AS A SUlNeas:s �xx M9R+SoELIBLE “V. Ffc�I ROORNQ61.kR 1i1 )//1. $ LANE.SI S1L - , e,2� goy EASTE+,AMPTON,MA OtOtr. ' ' Hri: r e I; 601 + 09/0812Q1d -c1; 2406 T” x ._ SENUMR R y.. ENPIR TION T. -�.. ;SERIALNUMBER' iC N a CONSTRUCTION SERVIC:ES itstsi,a Lgpetrueti Oli(SS�upervbiop Not Applicabl((e�� ❑Cp _ l tiering l'I ej Py[' +-0I _ ... 722_1 License Number l±oneiron CiA t11C,r7:� O �O __t8 Irma Expiration Date R 5 rl ' '-I(1r75 ___- un Telephone rehialz.tei eljai Tie (Marcy jgga ti robtraintoril Not Applicable ❑ Sas. ioU _ __.__ io ;k rs_ 'ID2=rvNaame Reoislratlon Number 6_1rl _ ns Uca la (niece i Expiration Dale SalAta ✓t LtrO C)\01")b Telephone (Lil )))hiCL, :.2±t5 'hill!ON lith WORKERS' COMPENSATION INSURANCE APFIDAVIT a 162, § 260'{-8)) rkers Compensation Insurance affidavit must be completed and submitted with thie application Failure to provide this affidav;l will resell ire oeniai of the issuance of the building permit. red Riiideelt Aitdrhed hos..,,,,, V NO. ,,,, ❑ 11 g.+?-trueeOFA: et Xeoril oz The current exemption for"homeowners"was extended to include occupied Dwel(ines of one(1) or Iwo(2)feint;ies and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts AS etiQeiv(sor, CM}t 780, Sixth Sdttion Section 108,3.51. Deiinitioli of Hommowne,l Person (s) who own a parcel of land on which he/she resides or intends to reside,on which:her re,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and(01 fans structures,j.petsgn who constraets more than one home in hvo.ve r pgliod shall not he considered a homeowner, Such"homeowner"shall atibmit to the Building Official,on a form acceptable to the Building Official that helots shall he responsible for gLl such work Performed under the building Pe-mit As acting Construetton Silo arvtsor your presence on the job site will be required from time to time, during end 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 or Iviassachusetts General Laws Annotated, Homeowner Signature 1a , .1 ____� The Commonwealth of Massachusetts l-� -s ' Department of Industrial Accidents a F S 1 Congress Street, Suite 100 1 > Boston, MA 02124-2017 _. i www.mass.gov/die Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �/ Please Print Legibly m Nae(Business/OrganizatioNlndividual)I RCI Rohr4,1 LLP Address: tv Lint St. _ City/State,Zip:jou'f'hd,mp 'n, 4111 0/073 Phone#:_&` i3) s,.. 7 - 11975 _ Are you an employer?Check the appropriate box: Type of project(required): LIX am a employer with o2-0 employees(Mt and%or part-time)" 7, Q New construction 2 L I am a sole proprietor or pailnership and have no enipl oyees working for me in g. ❑Remodeling any capacity.[No workers'compinsurance required.) 3.10 I am a homeowner doing all work myself [No workers'comp.insurance required.]' 9. ❑Demolition 4.01am a homeowner and will be hiring contractors to conduct all work on my property l will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole II.❑ Electrical repairs or additions proprietors with no employees - 12.0 Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.©'R(lOI repairs These sub-contractors have employees and have workers'comp.insurance: 6.Ei We arc a corporation and its officers have exercised their right of exemption per NIGLc. 14,E Other 152,§I(4),and we have no employees.[No workers'compinsurance required.) *Any applicant that checks box NI must also t tl out the section below showing their workers'compensation policy information. r 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-conuactors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comppolicy number. I am an employer Mat is providing workers'compensation insurance for my employees. Below is the policy and job site information. ('�/ Insurance Company Name: Utas- .4.12'ttn/rt/ Policy#orSelf-ins. Lie.#, t(IC 0Coi31/425- Expiration Date: /0 -.5- /7 Job Site Address: P97 f,rfc Yf yew City/State/Zip:SO/!/tGC. lh/A O/LNaa-- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t do hereby certify un/der t aloe n d penalties of perjury that the information provided above is true and correct. Signature: .....-�" Th...-.- Date: 10- /9 - 1 4 phone#: ( i ) ,5.027— 4/775- _ Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License#i Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityifown Clerk 4.Electrical Inspector 5, Plumbing Inspector 6.Other_, Contact Person:_ Phone#: Oct. 5. 2016 9:50AM Na 0218 P. 1/2 ACORD0 OATS OVAMDDIT YTi 1/4.,..+P"' _CERTtFiCATE OF LIABILITY INSURANCE 10/5/161 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 GOES 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 policNies) must be endorsed. II SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies tidy require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endersement(s). NPODICER CONTACT NAME: Michael R. Sanas Danas 6 Richert PRONE —TIAs tQ131 SZT-0845 &inNafn. (413) 5E7-270(1 IAmanNEL Insurance AgencyAllet RDD Ess mlo@banaein:¢urance.com 63 Main Street Easthampton, MA 01027 INSUER(SIAFFOROIN3 COVERAGE C NA1ca INSURER A:AdWiral Insurance Co. 124856 SURED INSURER R.Satety Insurance Co. 39454 ROI Roofing, LW :goRREr Ilvinston, Insurance CO. 35378 6 Line Street INSURER 0:star Insurance Co: 124562 Southampton, MA 01073 INSURER e; _ ._..— COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY TI-Ar THE POLICES OF INSURANCE Us1ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDCATED NOTWaHSTANDING AMY 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 TME POLICIES DESCRIBED HEREW IS SUBJECT TO ALL THE TEEMS. EXCLUSIONS AND CONDITIONS OF SOD-i POLICIES,LIMITS SHOWN MAY h vE SEEN REDUCED BY PAID CLAIMS, NSR Aunithe'A1 TFtiOtriVi If" ess LP -.—... .—•.--. -Tp TYPEOF INTERANce (N,xA ma! POLICY N'UMGER N9 M.T'M frvn 4'YmY L1eTT5 __ A GPNFAALUABIDTf X CA000020963-01 3/4/16 3/4/17 EqµOCCURRENCE s 1,000 000 I OnaeE To RENTED X cOre4ERCwLGENEMML LVH NTE .gractrwel t 50,000 JCLAS-MADE X OCCUR MD em l}gUV wrier S 10000 - — PEAS0isL a ADVINJURY $ 1 000,000 GENERAL AGGREGATE S 2 000,000 GEN'LA0OREf>ATE LIMITAPPUES PE R PRODUCTS-CDMPIOP ASM 5 2 000 sop 1PoLoYi1. 1 Roc 4 B . AUTOMOUILEUABILnY 1 X 6207761 9130/16 9/30/11 Q;aewCoymIGLUITLT - 1,000,000 ANY AUT BODILYYIIWURT(Per(asen) s ALLOWED 1. SCHEDULED EDICTS INJURY(P.,evlasnoIs AUTOS ALfTpg f . aFE' Y RAMA B6 y 1 X WREOAUTOS X AUTOS O PPP az.669m1 S ---1 C UMOEUSUA3 ocCuR X CUBw5757915 3f4/15l 3/4/17 EACH OCCURRENCE $ 5 000,000 1 I EGtSE LIAa CLAIMSMAOE 'AOSREGASE 4 5 000.000 1 DE X RETENTIONS _0. 00 5 ,4 D VCRKERS COMPENSATION WC0683405 SO/$/16 10/5/17111 4. tra U. iOtti- ANDEMPL6YCft5LJAnlUYIN TY co ANT PROPRIEMILPARTNEwExECpm'E MiA ` fE .E- 5AC OF1.4 s 1,0E0,000 P OKFGMEMP,ER EXCLUDED, 1MAT±Mory In NH) - E DIS I'SE-FA EMPLOY s 4 1,00D 000 D $CRMGWuotleO,t ON$bfl . ELOPMZE.POLICYLIMIT .s S,900 000 I 1 Cc SCRIPT/OS OF OPERATORS/LOCATIONS r VEHICLES (Attach AOORD 101.AVNitIonal Ra marks 50E405,if TOM. coPB,eq,J,µp LOOPING CONTRACTOR. the General Liability policy includes an Additional Insured endorsement that provides 'Uditional Insured status to the certificate holder, only when there is a written contract that1 requires such status, and only with regard t0 work performed on behalf of the named 0.nsured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF SHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DAIS THEREOF. NOTICE WILL OE DEDVERE° IN ***REFERENCE COPY*** ACCORDANCE Wfl4 TRE POLICY PROv13IENS, Au rill TENTATIVE m 19983Q10 ACORD CORPORATION. AH rights.reserved. ACORD 25{201W05) The AC ORD name and logo are registers d marls or ACO RD 'hone: cav 1.11 at E7-r._a 5 cm E.54-R. Line o g Estimate Date U Line St. Southampton, Ma.01073 IO/4/2016 Phone(413)5274775 Fax(413)527-8469 Name/Address Job Location William Brown 113 N. Maple St. Florence, MA 01062 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 6.900.00 Furnish &install IIT`plywood over existing decking. Furnish&install aluminum drip edge,pipe flashings, chimney(lashings(if needed)and step (lashings. Furnish&install CertainTecd Winterguard ice&water barrier along eaves and valleys_ Furnish and install synthetic anderlayment. Furnish and install Lifetime CertainTeed Landmark Pro 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 permit's will he obtained by R.C.I. Roofing. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total N6,900.00 TERMS OF PAYMENsitTTeS Customer Signature; `/i _.... Balance upon completion Registration#126235 Construction License#074334 Dares I(�VI3/1 Insured by Banns&Fickert Ins. 1 (413)527-2700 i Shingle Color Selection. Colonial Slafe