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38A-082 (3) 48 CHAPEL ST BP-2019-0315 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38A-082 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2019-0315 Proiect# JS-2019-000509 Est.Cost: $12000.00 Fee; $100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DANIEL WEST 106004 Lot Size(sq_ft.): Owner: WILDWOOD COURT CONDO ASSOC Zoning:URB(100)/ Applicant: DANIEL WEST AT. 48 CHAPEL ST Applicant Address: Phone: Insurance: 11 PLYMOUTH AVE (413) 695-7311 WC FLORENCEMA01062 ISSUED ON.9/16/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & 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: FeeTyge: Date Paid: Amount: Building 9/16/2018 0:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner " " F ECEIVED Version 1.7 Commercial Building Permit May 15,2000 Department use only ity o Northampton Status of Permit: t SCfp 1 1 2M uildir g Department Curb Cut/Driveway Permit - i 212 Main Street Sewer/Septic Availability oom 100 Water/Well Availability NORTHAAMPTMPT G ON,MA 010 ��'�I DEPT OF 6INSPEC�ION�i,a pton, MA 01060 Two Sets of Structural Plans - - 240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION ( . 1 1 315 1.1 Property Address: This section to be completed by office ��4 Map Lot Unit Zone Overlay District �,..�. Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailiqg Addre s: f Net"" 7140 Signature Telephone 2.2 Authorized Agent. Name(Print) Current Mailing Address: _c ioL' -� Signature Telephone L SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building • -� l 1 (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 =0 +2 +3 +4 + 5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature �e /4_4p mrp-4,�L Building Commissioner/Inspector of Buildings Date ` `J Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofiing�< Change of Use❑ Other❑ Brief Description Enter a brief description here. Of Proposed Work: > SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: ... _ S Special Use ❑ Specify: . s COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(so 1s st 2nd _. 2 4 3`d 3 d 4th 4th Total Area(sf) Total Proposed New Construction s Total Height(ft) Total Height ft 7.Water Supply(M.G.L. c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public E] Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ _ * VcsiooL?Commercial Building Permit May l5.20OO 8. NORTHAMPTON ZONING I Existing Proposed Required by Zoning This column to be filled in by Building Department Frontage Setbacks Front Rear Building Height L Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved (volume&Location) A. Has aSpecial Permit/Variance/Finding ever been issued for/on the site? �� X7\ YES �� NO DON'T KNOW YE� �� IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Dvn / mxwvv YES ��\ �_�_ IF YES: enter Book Page and/or Document# '-- --' ' — �� �_��� B. Does the site contain a brook, body ofwater orwetlands? NO �0� DONT NNKNOW �_/ YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ��� Obtained x~� Date�_� �~� ' . C. Doany signs exist onthe pnopert �� ��y� YES ��� NO �~� � � ��� jl IF YES, describe size, type and location: | ��tl\ � � D. Are there any proposed changes to or additions of signs intended for the property? YESNO ' --- — -- -- - ' -- |FYES, describe size, type and location: ' E. Will the uonstruodonactivity disturb(clearing, grading,excavation, urfilling)over 1acre urisbpart vfocommon plan that will disturb over 1 acre? YES ��K l NO K��) �� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES- FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility .___�.......................... € ............ _ _._.._ ___ __ _ _ __._._. ..._ Address Registration Number i Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number ......�._ ........ ........ Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction i Address Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ® No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. Signature of Owner 13ate 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 unde e pais and penalties of er u .. ,�� Print Name Signature of Owner/A en Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number r. Address Expiration Date L// " S' Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6)) 7 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 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: `1 o�� swe_#� The debris will be transported by: r The debris will be received by: kltxk(�. (u\k Building permit number: Name of Permit Applicant a Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: D.L-Lu Address: �( - City/State/Zip: ".u4 4 . C(f>4e-Z- Phone#: CLI 13) (s-`�13 t Ar&Pi�am you employer?Check the appropriate box: Business Type(required): 1. a employer with Z employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• E]Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers'comp. insurance required]* 4.r-1Weare a non-profit organization,staffed by volunteers, 11.L] Health Care with no employees. [No workers'comp. insurance req.] 12.5?'Other tr (t-:x�-kra'sL{c r *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees& Bel w is the policy information. Insurance Company Name:IQ, i -��� (XiCAV - 1'� ��• �:� t Insurer's Address: ���'� City/State/Zip: Vv-),1 LAVA O�C�1r1 {,,v\A- c)( Cel Policy#or Self-ins.Lic. # I- Uj C." Lt co, iration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number aid ex iration 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 cer , unde t e Phins and enalties of perjury that the information provided above is true and correct Signature: 1• Date: Z� Phone 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.hnass.gov/dia Form Revised 02-23-15 D.L. WEST ROOFING CONTRACTOR 11 PLYMOUTH AVE. FLORENCE. MA 0106 Cell:(413) 695-7311 Home: (413) 586-527, - MA CSSL-106007 HIC 178327 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 178327 DANIEL WEST D/B/A D.L.WEST ROOFING CONTRACTOR Expiration: 07/16/2020 11 PLYMOUTH AVE FLORENCE,MA 01062 Update Address and Return Card. SCA 1 (y 2OM-05/1(77 �✓/17If(�I7179)R Nf/rP!/���1+��%�(IJJC/I'�//.1P(l1 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 178327 07/16/2020 1000 Washington Street-Suite 710 DANIEL WEST Boston, 02118 D/B/A D.L.WEST ROOFING CONTRACTOR DANIEL WEST 11 PLYMOUTH AVE C� FLORENCE,MA 01062 Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructio&SltpdM&or Specialty CSSL-106007 Kgpires: 07/0812019 DANIEL WEST 11 PLYMOUTH AVENUE FLORENCE MA 01062 ! Commissioner -- :q �. 2% . � . �y §�\ < »\®�\�� % �.�\/,� � . �\ � > , y . 2 A��® DATE(MMIDO/YYYY) CCCERTIFICATE OF LIABILITY INSURANCE 07/18/2018 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 have ADDITIONAL INSURED provisions or 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 Linda Powers,CRIS NAME: Webber&Grinnell PpHc No Ext): (413)586-0111 aC.No): (413)586-6481 8 North King Street E-MAIL (powers@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N Northampton MA 01060 INSURERA: Penn America/XS Brokers INSURED INSURER B: Citation 40274 Daniel West INSURER C: WCAR-A.I.M.Mutual DBA D L West Roofing Contractor INSURER 0: 11 Plymouth Ave INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 04/19 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 CONTRACTOR 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 CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE ©OCCUR PREMISES Ea occu enceS 100,000 MED EXP(Arty one person) S 5.000 A PAV0164270 05/01/2018 05/01/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2'000'000 POLICY ❑PRCT O F—]LOC PRODUCTS-COMP/OP AGG S 2000,000 JE OTHER S AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT S 1.000,000 Ea accident ANY AUTO BODILY INJURY(Per person) S B OWNED SCHEDULED BCDR59 04/1912018 04/19/2019 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED IX NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accdent PIP-Basic S 8.000 UMBRELLA UAB OCCUR EACH OCCURRENCE S 4EXCESS LIAB CLAIMS-MADE- AGGREGATE S DED I I RETENTION S $ WORKERS COMPENSATION PER OTH- ANO EMPLOYERS'LIABILITY r/N STATUTE I I ER C ANY PROPRIETOR/PARTNER)EXECUTIVE N f A AWC40070363902018A 05101/2018 05101/2019 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 100,000 If yes.describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Daniel West is excluded from Workers Compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD t=,