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29-520 2 TARA CIR BP-2017-0562 GIS n: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-520 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeorv: ROOF BUILDING PERMIT Permit BP-2017-0562 Project# JS-2017-000909 Est. Cost:$10153.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERTS ROOFS CO INC 100333 Lot Size(sq. ft.): 5967.72 Owner: WINDT-BALDWIN KRISTINA zonine: Applicant: ROBERTS ROOFS CO INC AT: 2 TARA CIR Applicant Address: Phone: Insurance: P O BOX 1312 (413)283-4395 Workers Compensation BON DSVI LLEMA01009 ISSUED ON:10/25/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE & REPLACE SHINGLES ON STEEP SLOPES, INSTALL EPDM RUBBER ROOFING ON LOW SLOPE 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 ft 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 10/25/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 WateriWeil Availability 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 SECTION 1 -SITE INFORMATION C7 � { ( - 6-0a 1.1 Property Address: This section to be completed by office 2 Tara Circle Map Lot Unit Florence, MA 01062 Zone Overlay District Elm St.District Ca District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 7.1 Owner of Record: Kristina Windt-Baldwin 2 Tara Circle Florence,MA 01062 Name(Print) Current Mailing Address: 1 *3 -45'5-9592 /V' .,, Telephone Signature $.2 Authorized Anent: f1 �i(Axe r' t Qodis cc 60% 131) gerJsville fA into? Name(Print) Current Mad'i g Address: err aF3 s l ay 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)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) I(1i 153 00 10,153 Check Number 0Q(1 - VEb) This Section For Official Use Only j CL,f/y, y Budding Permit Number: Dale • un / Issued: Signature: � {� spectrnof Bui rgs Dale SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) n Rooting n Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [p Siding[0] Other[CO BrWork:Description of Proposed / S t/a✓Q.> Wgrk D escriptonace shingles oAay,Icry. Inaull EPDM rvbEo mofingwlow alga Jrnmn. v Alteration of existing bedroom Yes x No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes . No Plans Attached Roll -Sheet se. 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, Kristina Windt-Baldwin ,as Owner of the subject properly hereby authorize Roberts Roofs/Brian Blanchette to act op my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date 111111.111111 I, Roberts Roofs ,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. Brian Blanchette Print Name �r.L Signature of��r/ gent r' 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 Depattmem Lot Size _. . . Frontage _.. Setbacks Front Side L R:'. . L:.. R: Rear _. Building height Bldg. Square Footage - 'i % Open Space Footage (Int area minus bldg&paved nandng) #of Parking Spaces _._. Fill: (volume&Location) .. _.. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES Q IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: E. WII 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 O NO ® IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Hol r: Thomas Roberts 100333 License Number PO Box 1312 Bondsville, MA 01009 7/3/18 Address Expiration Date O'✓ 283-4395 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Roberts Roofs 128264 Company Name Registration Number PO Box 1312 Bondsville, MA 01009 3/17/17 Address Expiration Date .• Telephone 283-4395 -- SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§26C(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 0 11. — Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 ® Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-100333 Construction Supervisor Specialty THOMAS R ROBERTS PO BOX 1312 BONDSVILLE MA O1000 , Expiration: Commissioner 0T103/2a10 Construction Supervisor Specialty Restricted to: CSSL-RF-Roofing Failure to possess a current edition of Bre MassachuwRs State&Aiding Code is caufor revocation of this license. BPB Licensing ntorreaiionse visB�VANW.MASS.GOV/oP5 tvrst rrrotarc eta tat , , .f, Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120204 TYOe; Private Corporation Expingi n: 311712017 Tte 262824 ROBERTS ROOFS INC THOMAS ROBERTS _____________._______. ___ PO BOX 1312 BONDSVILLE, MA 01009 Update Address sod return card.Mark Heron for chaser. stns n nseavri I: Address I'_I Renewal El Employment 0 Lost Card (1t(e'etimrsrr nm»rf/A f fC fi unrAnwdh _ Office ofcaonmerAffairs&anises.Regmation License or registration valid for indivMul use only m�.� OME IMPROVEMENT CONTRACTOR before the expiration date. if fond return to: mtmtlon: 120264 Typo: Office of Consumer Attain and Business Regulation iExpiration: 3117120/7 Private Corporation 10 Park Plan•Suite 01'10 Boston,MA 02115 ROBERTS ROOFS INC THOMAS 0ROBERTS s� 1 400 FRANKLIN ST �-rs i. • —.. ttRle�sNc�rc'^P--_ BELCNERTOWN,MA 01007 Undersecretary Notvsgd without signature : 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: 2 Tara Circle Florence, MA 01062 The debris will be transported by: USA Hauling & Recycling The debris will be received by: USA Hauling & Recycling Building permit number: Name of Permit Applicant Roberts Roofs IOW • a w- ar ar Date Signature of Permit Applicant The Commonwealth of Massachusetts n eW=a Department of Industrial Accidents =0107=a Office of Investigations 'l_„0 1 Congress Street, Suite 100 :VAL.= AL. Boston,MA 02114-2017 or",7 www.mass.gov/dia 'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual : Roberts Roofs Address: PO Box 1312 City/State/Zip: Bondsville, MA 01009 Phone#:413-283-4395 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. Q I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.[ 9. ❑Building addition required.] 5. 0 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 Q Roof repairs insurance required.] 1 c. 152,§1(4),and we have no employees. [No workers' 13111 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 contractors must submit a new affidavit indicating such. IConfactors that check this box must attached an additional sheet showing the name of the sub-conk ctms and nate whether or not those entities have employees. If the subcontractors have einployeee they must provide their workers'coop.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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: 2 Tara Circle Florence,Florence, MA 01062 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 under the pains and penalties of perjury that the information provided above is true and correct. _ 10/4/16 Sin aturc: ' - Date: Phone#: 4834395 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone It: Net / ' DATE IMMNDIYYYVI A�O® CERTIFICATE OF LIABILITY INSURANCE TE(MWOD,A 16 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(ies)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 NAM"FCT Mark Bradley ONE FAMILY INSURANCE AGENCY LLC ,PHONE Fm. (978)621-5256 FAX.NAY ADDRESS, acalvillo128HLiyahoocom 63 FAIRMOUNT ST REAR INSURERIS)AFFORDING COVERAGE NAI_ , FRCHBURG MA 01420 INSURER A'. TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B ORELLANA CARLOS DBA ORELLANA CONSTRUCTION INSURER G. INSURER D: 312 WILBRAHAM ST INSURER E: PALMER MA 01069 INSURER F: COVERAGES CERTIFICATE NUMBER: 49934 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 WTH 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 LTp TYPEOFINSURANCE POLL SUER POLICY EFF POLICY EMP IMO WVD POLICY NUMBER IMMDDIYWY) I AVED/W YI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S -6KISKOTfirr£MTEr CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ _ — MED EXP(Any one peoon) $ N/A PERSONAL SADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ PRO POLICY TELT LOC PRODUCTS-COMP/OP AGO $ — OTHER $ AUTOMOBILE LIABIIJTY $Ea GERI AGGREGATLIMIT $ ANY AUTO BODILY INJURY(Per parson) $ ALL OVJNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) S AUTPROPERTY DAMAGE EHIREDAUTOS AUTOS (P $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMSMADE N/A AGGREGATE S DED RETENTIONS $ WORNFRSCOMPFNSATION �//X ;MUTE ETH AND EMPLOYERS'LLABILRY vim A ANNFPRwueme�zcwoEOECUTIVE NM NM N/A EL EACH ACCIDENT S 1,000,000 ]PJUB9F55030116 03/14/2016 03/14/201] (Mandatory In Nm EL DISEASE-EA EMPLOYEE S 1,000,030 ICRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT S 1,000000 N/A DESCRIP11ON OF OPERATINSI LOCATORS(VEHICLES(ACORD 101,Additional Remarks schedule,may be anached If more space Is required) Nhrkers'Compensation benefits wilt be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 0308 B.no authorization is given to pay claims for benefits to empbyees in states other than Massachusetts if the insured hires.or has hired those employees outside of Massachusetts. This ceriicate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration dale on the above policy precedes the issue date of this cerRcale of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www..rnass gov/MWxorkersmmpensation/investigationst Sole proprietor has not elecled coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ROBERTS ROOFS ACCORDANCE WITH THE POLICY PROVISIONS. 400 FRANKLIN ST AUTHORIZED REPRESENTATIVE � 4 G" - SELGHERTOWN MA 011]0] Dan_iel M.Crow y,CPCU,Vice President-Residual Market-WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD