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24D-249 (8) 76 CRESCENT ST BP-2017-0960 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D-249 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-2017-0960 Project# JS-2017-001651 Est.Cost: $168750.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MAHAN BUILDING & SLATE ROOFING CO 006760 Lot Size(sq. ft.): Owner: FERGUSON TOM Zoning: URC(100)1 Applicant: MAHAN BUILDING & SLATE ROOFING CO AT: 76 CRESCENT ST Applicant Address: Phone: Insurance: P O BOX 2860 (413) 330-8622 WC SPRI NGF I ELDMA01101-2860 ISSUED ON:2/22/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE EXISTING SLATE ROOF AND REPLACE WITH SAME TYPE OF SLATE 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 2/22/2017 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File 4 BP-2017-0960 APPLICANT/CONTACT PERSON MAHAN BUILDING&SLATE ROOFING CO ADDRESS/PHONE P O BOX 2860 SPRINGFIELD (413)330-8622 PROPERTY LOCATION 76 CRESCENT ST MAP 241) PARCEL 249 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERM APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid, f Building Permit Fined out "j Fee Paid Typeof Construction: REMOVE E TIN ATE ROOF AND REPLACE WITH SAME TYPE OF SLATE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 006760 3 sets of Plans(Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION PRESENTED: Approved Additional permits required{see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Penult With Sire Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding _ Special Permit Variance* Received& Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Pemdt from Elm Street Commission Permit DPW Storm Water Management 2 - 7x 77 Si_-. reofBuil. m Offi .1 Date Note:issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission, Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning& Development for more information, Department use only City of Northampton Status of Penmt Building Department Curb Cut/Driveway Permit 2 � ,.- 212 Main Street SeweMsepticAvallebitfy 0 \ Room 100 WateMWagAffillabdity \ - ; ' 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 1.1 Property Address: This section to be completed by office 7G GR&SCEN I SYtEET Map Lot Unit t oKTi{A-M?ToNA , MA 0110 60 Zone Ove IayDist District Elm St Disbict CB District SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 21 Owner of Record: TOM FEfCGU crJ 76 CZ TCT. uOKTNA -ceTO,v Name(Print) -'I Current Mating Address: MA O;o o 4- ++— / r". Telephone !/ -t R.664,- ______,, � / `r Signature / alit- 66).— R.664F L2 Authorized Agent: 43-01-1ti1 frIPtIAN Po. 13oX a-860 C'eRimc-fieLb,1-taMot Name(Print) Current Mailing Address: Signatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant t Building I k�/ p 7 C a (a)Building Permit Fee 0 2. Electrical O (b)Estimated Total Cost of l- Construction from(6) 3. Plumbing a Building Permit Fee 4. Mechanical(HVAC) O 5.Fire Protection 6. Total=(1 +2+3+4+5) I GS r7So Check Number:6479/04 7Q This Section For Official Use Only Building Permit Number: Date Sued' Signature: Building Commissionerllnspector or Buildings Dale Section 4. ZONING Alt Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column m be filled in by Ruilding Departmem Lot Size Fronnac Setbacks Front Side L R: C: R: Rear Building Height Bldg. Square Footage Open Space Footage % ........ fist area minus bldg&paved jarkinui N,of Parking Spaces Fill; (uvlume&location) A. Has a Special Permit/Variance/binrd�ing ever been issued for/on the site? NO 0 DONT KNOW 1a YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document it B. Does the site contain a brook, body of water or wetlands? NO 0 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 . Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: �-.e D. Are there any proposed changes to or additions of signs intended for the property? YES O NO t yF IF YES, describe size, type and Location: Y-� E. Will the construction activity disturb(clearing,/""+� grading excavation,or filing)over 1 acre or is it part of a common plan til that will disturb over 1 acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all mono As) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0 Or Doors 0 Accessory Bldg. ❑ Demolition E New Signs [D1 Docks [MSiding(D] Other[CO Brief Description of Proposed Work:REnotek Exlctltil( SLATE KoaF Aui'� R PLACE W tTN CAME TYPE of SLAV Alteration of existing bedroom Yes X, No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes _No Plans Attached Roll -Sheet Ba. 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 ff.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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS ^AGIENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, I ONS 1" E K6-u sow .._. ... ,as Owner of the subject property /, hereby authorize T 3 3 }ApAci-V-ki OF mAi-tAk) ,SLATE ''OOF(h1(i- (O., IUG, to act on my behalf, in . afters relative to work authorized by this building permit application. / 4— / --„- iik<P „ - -2 ( 1 ( ,6L-' f Signature of Owner J (-- Date I. J0HLJ MAkAh OE ,U}HAN{ SLATE KOQF(AJ(r CO, . INC , ,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. 1—TOW I\.) MAHA Print Name Fg 2- 2/ 17 Siqnatur o Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable 0 Name et License Hoden s.)O 341\\ 14A1AAVyy CS -Oc677 © License Number P. D. 1. ox agco SPtVNG-HELX 11A 01101 04-/otil eek Address Expiration Date f.- /cid q13-7g' -VS i* Si. 'ature Telephone 9.Registered Home Improvement Contractor Not Appiicabk, 9 MA-1-14N) .L LATE Roof= 06- Co . , 1 u c. I GEOC7I Company Name Registration Number 4-3 R t. • 'E . Octin Address Expire ion Date &. LUNG-m640(,) , Mh ow).g, Telephone 8`7579 SECTION 18-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C160 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 uilding permit. Signed Affidavit Attached Yes _.`,"Est No C 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 ower a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to he.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 wilt 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 fur you under this pumtlt 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 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: 76 (KESCCEJY cT'gFF i The debris will be transported by: r1R RLA-TE ?ooi'ttile Co (Uc. The debris will be received by: /-l4NpoJ SLA-o- R./Ionic ( a, , Building permit number: Name of Permit Applicant TOMS wkFI4N J a.-a1170 Date Signature of Permit Applicant The Commonwealth of Massachusetts fie— Department of Industrial Accidents =creel Office of Investigations �,_ l- I Congress Street, Suite 100 ' Ing ! Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business'Organizationttndividual): F\ 414-k) SLATE TZ(,Z,EIAJ(r CO. , I iJc., _ Address:I), Q, T<oX o1p 60 City/State/Zip: (bUG-Fti11), ?4A _)tloI Phone#: 4-3- 78g-9s_a, Are pu an employer? Check the appropriate box: contractor and [ Type of project (required): 1. 4 ,�1 am a employer with � ❑ I am a general employees (full and/or part-time).* have hired the sub-contractors 6, ❑ New construction listed on the attached sheet, 7. 9 Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. ❑ Demolition an working for me in capacity, employees and have workers' Y P Y- 9, ❑Building addition [No workers' comp. insurance comp. insurance. require ] 5. ❑ We are a corporation and its Ion 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 12.0 Roof repairs insurance required] ` c. 152,§I(4),and we have no employees. [No workers' I3.ZOthergeoF F,EP44tErree JT comp. insurance required.] *Any applicant hat checks box 41 must also fill out section below showing their workers'compensation policy information, I.Homeowners who submit his affidavit indicating they are doing all work and then hire outside contractors must submit a new a ITWavit 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. lithe sub-co Tactors have employees,they most 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. Insurance Company Name7TIKAt / 6R S IKlbEfrui i i`( CO. pp Policy#or Self-ins.. Lie. N; a u 1.„ —�. `i . Expiration Date: i0.,./3 C7/1 7 Job Site Address: /n , , st S-11•6ET City/State Zip:WORTWthI TON,BASIID60 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 painspand penalties of perjury that the information provided above is true and correct. Signature: eco t _....... _....... Date: _e-,2/ /7 phone. 4l -7%8.:.::... , .......... .... .... 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#: /^'1 MAHAN-1 OP ID:KK a`ORO CERTIFICATE OF LIABILITY INSURANCE �ozjoz✓zTE o i 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 AMENb, 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 CONTACT PHILLIPS INSURANCE AGENCY INC NAME Kayla DrltlkWine PHONE 97 CENTER STREET E,p413-5945984 .c,No1413492-8499 CHICOPEE,MA 01013 Apoaess:Kayla@phillipsinsurance.com Joseph Joseph Phillips - - -- --- _ IN IRERISI AFFORDING COVERAGE ROJO p__ ____ ___ _ INSURER A:EMC Insurance Companies 21415 INSURED Mahan Slate Roofing Co,Inc. INSURER B.Nautilus Insurance Company Rick Mahan WSURERc:Travelers Indemnity Co. PO Boz 2860 - — -__ .__ ____ Springfield, MA 01101 INSURER D, INSURER E: 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 PERM() 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, INBR . AODL SD9r _ - POLICY EPOLICY EYP LTR TYPE OF INSURANCE INSO MO POLCY NUMBER MHN' MMID• UMTS -A X MRERctt GENERAL MAMMY? EACH ctCLYutNCE S 1000,011. C tMS.WADE II X OCCUR 4046352 12/30/2016 12/3012017 L s s ERCi]1tD :1�,1 $ _ 599,001 MED EXP(Any EIR PERI S MAO PERSONAL aADV INJURY S 1,000,001 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,00i __. POLCY X PRO. __ JECT Lac PRODUCTS.COMROP AGG a 2,090,0iI _. OTHER f AUTOMOBLE LIABILITY COMBINED SINGLE LIMIT a 1,000,001 A ANY AUTO 4Z46352 12/30/2016 12/30/2017 BODILY INJURY(PH.person) S ALLOWNED X SCHEDULED BODILY INJURY{Per accident) s AUTOS Allf05 X HIRED At1tO5 X AUTOWYNEO RTYOAFA.. .. S . Au405 rPer acntlen0 _.. I. 1 X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,00r B EXCESS LIAR CLAIMS-MADE AN024568 12/3012016 12/30/2017 AGGREGATE S DED I (RETENTIONS S WORKERS COMPENSATION X STATUTE RTH ARO EMPLOYERS LIABILITY __......_.. _. __. YIX C ANY PROP IETORIPARTNERxECDTIVE re6HUBNB74869-2-16 12/30/2016 12130/2017 E.L.EACH ACCIDENT S 500,001 RMEMBER EXCLUDED, N NIA (Mandatory In Nlll E.L DISEASE•EA EMPLOYEE 5 500,001 IQP under If yes. DESCRIPTION OF OPERATION eIw IAL.DISEASE-POLICY LIMIT 5 500,001 A eased/Bented 4C46352 12/3012016 12/30/2017 Oct Limit 55111 quipment Per Item 5,00r DESCRIPTION OP OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached X more space is requ w dl CERTIFICATE HOLDER CANCELLATION KELLEYB SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTAIWE 4/ arrttait (In, ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD • fit Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS. 6760 Construction Supervisor JOIN F MANAN P.O BOX s 2010 SPRINGFIELO MA 01*1 �--� r Expiration. Commissioner 04104/2011 Office of Consumer Matra&Business Regulator` HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only Type: Corporatnn before the expiration data, it found return to: $@glafratlen f%Fetation Office of Consumer Affairs and Business Regulation 161091 00/24/2018 10 Park Plaza-Suite WO Boston,MA 02116 Mahan Slate Roofing C Inc. John Mahan 43 Gerrard Ave ? L� E. Longmeadow. MA 01028 - r "lv`-- Undersecretary Not valid without signature