07-061 (8) 367 NORTH FARMS RD BP-2017-1458
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:07-061 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-2017-1458
Project# JS-2017-002423
Est.Cost: $11200.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
• Use Group: DAVID BRODOWSKI 105957
Lot Size(sq. ft.): 24567.84 Owner: WOODMAN MARILYN 1
Zoning: RR(100)/WSP(100)/ Applicant: DAVID BRODOWSKI
AT: 367 NORTH FARMS RD
Applicant Address: Phone: Insurance:
(413) 531-6694 WC
SPRINGFIELDMA ISSUED ON:6/16/20170:00:00
TO PERFORM THE FOLLOWING WORK:STRI P & 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 6/16/2017 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
-r7- -Y6g
Department use only
a01.1.;. City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
`/ a 212 Main Street Sewer/Septic AvalabTity
;'I--.:( 1 Room 100 Water/Well Availabiily
Northampton, MA 01060 Two Sets of Structural Mans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
CO Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION ✓, '6 ' (% • AI '
L._.
1.1 Property Address: This section to be completed by office
Map O / Lot ( Unit
''') Zone Overlay District
3' / Ai P„.,„4 QI Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1.Owner of Record: f act Cyr III A Ir/andit-.ni 367 AL tsnj a!d
Na a(Print) J Current Mailing Address:
Telephone
Signature
2.2(Authorized Agent:
Dour aicjdn.scd 3k aw/id+pin ,t'}: SO it's
Name((FAnt)) Current Mailing Address:
J7N/3 - .0 47-G6Py
Signe urern 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 �! c! 1C-10
6. Total=(1 +2+3+4+5) x // Qoo /Check Numberr7
1/ This Section For Official Use Only
Building Permit Number: Date
Issued:
4_2_4)
�2^ �
Signature: illy — r‘/I31 7
Building Commissioner/Inspector of Buildings Date
httilffiffiNek
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervis(or. Not Applicable ❑
Name of License Holder'. Opal(/ sendttdul➢'S to S9s1
License Number
,r/. spud (KR
Addre - �/ r Expiration Date
sava4' • Wit SJ -4<79
Signature Telephone
9.Registered Home Improvement Contractor. Not Applicable ❑
Qrodatot t bloat ymffuvosent /691r`07
Company Name Registration Number
3B Ai( , ,r�
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,9 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 buildin rmit.
Signed Affidavit Attached Yes 9 No C
The Commonwealth of Massachusetts
Department of Industrial Accidents
_='1%j=; Office of Investigations
elite , 600 Washington Street
Mi� l= `_4
ir Boston, MA 02111
"-ir t. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ((�� Please Print Legibly
Name (Business/Organization/Individual): g6O 4,,, J.,,,„,.. ,„.7,„,,,,..,d-
Address:
.' fui�w.nr
Address: IA grate, Sh U
City/State/Zip: Set,8, tate Ging Phone #: y/S-S3/-669/
Are an employer?Check the appropriate box: Type of project(required):
I. 1 am a employer with_� _ _ 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(fill and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.f 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers'
comp.insurance required.] 13.0 Other
'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 their workers'comp.policy information.
I am art employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. 99
Insurance Company Name: L.e-40,-- 1nodLd]
Policy#or Self-ins.Lia #: LAIC 1 - 3 S • 371]36? -a/7 Expiration Date: 1/-9 - rgor
Job Site Address: 36r"
1 AL m3 ad City/State/Zip: nor,. fri
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 r the p ' and penalties of perjury that the information provided above is true and correct.
Signature: -A,r Date: ‘-z../-/7
Phone#: yrs• CJj-1t5,9
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#:
City of Northampton
y5
Massachusetts •
b • a w
Q IIC, � k D212x
OF BUILDING INSPECTIONS
212 Main Street a Municipal Building JCS
Northampton, NA 01060 P,4 \1
Debris 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.
The debris from construction work being performed at:
67 ,fit/, Ferns er)
(Please prin house number an street name)
Is to be disposed of at
.K 1 r✓ Lorhb $Ddid
(Please print name and location of facility)
Or will/be disposed of in a dumpster onsite rented or leased from:
All Li st- Q1 MR04
(Company Name and Address)
Signatu e o7 Per 'it Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
AC 113 CERTIFICATE OF LIABILITY INSURANCE SE D17 VEID TWO
Lem.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 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(es)must be endorsed. If SUBROGATION IS WANED, subject to
Ithe 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 NAME: Bridget Robare
Sumner 6 Toner Insurance Agency Inc jPAN�D�x0,EMa_�(4�13�)_5_�67-1051 AA
F NOIt(413)36'1-3151
1813 williams St E-slAl obare€sumnertoner.core
IHBURER(9)AFFORUMp COVERAGE NAIL/
!Longmeadow MA 01106 INSURER Western World =-- 1
INSURED INSURER a(Liberty Antal Ins Co.
David M Brodowski, DBA: Brodowski Rome improvement INSUREac:
138 rallston St INSURER O: I
I INSURER E:
''.Springfield HA 01119 INSURER F: ,
COVERAGES CERTIFICATE NUMBERCL1751005763 REVISION NUMBER:
I 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 WITH RESPECT TO WHICH THIS
CERTFICATE 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 SHO MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRI /(001. ARI pp�ICy FF pp�ICY EyP I
LTO TYPE OF INSURANCE IINRD DNA POLICY NUMBER IMYNIMen IalCol' YYII
LIMITS
X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I
$ 1,000,000
DAMAGE TORENTEO 50,000
A , [ I CLAIMS-MADEOCCUR PREMI.[ALA ,$
IIF IIS------SII I RPP03156131 7/15/2016 7/15/2017 I MEDEXP(My on.Pomo) .$ 5,000
IPERSONAL 6ADV INJURY '.$ 1,000,000
GENL AGGREGATE LIMIT APPLIES PER'. I I GENERAL AGGREGATE I$ 2,000,000
•
X POLICY L,PICT El LOC •
I PRODUCTS COMP/OP AGO E 1,000,000
OTHER
Misc Tools $ 10,000
AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $
occident}
ANY AUT177 O
Per acdden •$
BODILY INJURY
ALL OWNED I SCHEDULED BODILY INJURY(Pmxntlmp,$
AUTOS AUTOS
NON-OWNEO $
HIRED AUTOS 1 AUTOS I
PROPERTY
UMBRELLA LIAR
11--- I OCCUR I EACH OCCURRENCE 1$
I EXCESS LIR L i CLAIMS-MADE ' I ;AGGREGATE 1
SII ' I DED I RETENTIONS $
'WORKERS COMPENSATOR , I PER0TH- 1
AND EMPLOYERS'LIABILITY ' I STATUTE I I ER
ANY PROPRIETORRARTNERIEXECUTIVE Y/N 11 EL.EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED' I N N/A
B (MMrdMwy In NH) INC1-315-381367-017 4/9/2017 4/9/2018 EL.DISEASE-EA EMPLOYE 100,000
If yyen[describe under
,DESCRIPTION OF OPERATIONS bobs I ' E L.DISEASE.POLICY LIMIT I s 500,000
I
1 DESCRIPTION OF OPERATI)NS/LOCATIONS/VEHICLES (ACORD 101,A6dXbne Remarks Schedule,mey be attached II more Apace IF Enquired)
I
•
I
CERTIFICATE HOLDER CANCELLATION
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 REPRESENTATIVE
II W Sumner III/ROBARE `'4""_'��"-----
C1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
08/13/2017 12:11 FAX IZ 002
Marilyn Woodman
367 N Farms Rd.
Florence,MA
Brodowski Home Improvement
(413) 531-6694
Roof Quote
• Strip existing roof and dispose of(20 Yard dumpster onsite)being very cautious of shrubs,siding
etc.
• Install Ice& Water 6ft.up from the eves, around chimney,and in all valleys
• Install Palisade®synthetic underlayment on the remainder of the roof
• Install new (F8)drip edge
• Install GAF®Architectural shingles(Timberline FID®)
• Install Timbertex®cap
• Install new pipe boots where currently existing
• Install new stepflashing where currently existing
• Cut I If on both sides of the main ridge beams to allow for proper air flow
• Install shingle vent H ridgevent
• Step flash and lead chimney
• Permit included in price
10 yr.labor warranty
Ltd Lifetime shingle warranty
0 5% idiscount=$11,115
$100 dna uponsigning
✓ era
,000 due upon delivery of material
57 ��� O ci.et t w """- "
$7,015 due upon completion
Damaged Plywood-$50 a sheet installed
Ml Material is guaranteed to be as specified,and the above work was performed in accordance with the drawings
and specifications provided for the above work and were completed in a substantial workmanlike manner for
agreed sum of eleven thousand one hundred fifteen Dollars
($11,115 ._ ).
/
This is a Partial c Full invoice due and payable
by: 7 1 17
Month Day Year
in accordance with our o Agreement Proposal
No. 1 Dated 4 _ 21 17
Month Day Year