42-022 (4) 839 WESTHAMPTON RD BP-2019-0521
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma_p:Block:42-022 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:ROOF BUILDING PERMIT
Permit# BP-2019-0521
Proiect# JS-2019-000845
Est.Cost: $3700.00
Fee: 140.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: JAMES FLANNERY 103061
Lot Size(sq.ft.): 122403.60 Owner: TIEDEMAN-MAU ERIC J&ANGELA R KARLOVICH
Zoning: Applicant. JAMES FLANNERY
AT. 839 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
1 LOVEFIELD ST (508) 294-4052 WC
EASTHAMPTONMA01027 ISSUED ON.1013012018 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF, REPLACE WITH
METAL
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 10/30/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
` 1-..n. Ft —_-•_—
Dep WA use otdy
City of Nortliampion
Building De artm nt OCT 2 9 201f PWTW
212 Main tre Ate ,
Room 00 Avaltablitby
Northampton, MA bl�1P eun owc irlsPE I
THAMPTON.MAOI Structural Plans,
- phone 413-587-1240 ax - -
Odw Spey
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION �j�" R—6-a'' `
1.1 Property Address: This section to be completed by office
Map L10 Lot
Unit
v.
Zone Overlay District
` i Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
t tW- �T>�c�eiy),y) y1'7 a&� -
gar
Name(Print) Current Mailing Address:
--
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature v Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ins ""I`, (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 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
pe4KpfeFoe rnft( 'AOOF&6- 4J--C (C-P 6 imlli L , 6�"
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION b-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Aiteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [[J] Decks [❑ Siding[p] Other[[A
Brief Description of Proposed
Work: Sf A i P $h l"" (4 4( /Zt P hMC r o('-!L ri.,ol'ICr (Li�h a"tt i Al-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
e. If Xw how*etnd or addlfto to exist(housing comnleW the followltur
a. Use of building:One Family _ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms J
c. Is there a garage attached? /r
d. Proposed Square footage of new construction. Dimensiorts'--l'
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 buildinp.00nform to the Building and Zoning regulations? Yes No.
I. Septictank City Sewer Private well City water Supply
r�
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
l E P o e, l i e d.Q mPrAi "- M P(�— _ as Owner of the subject
property
T
hereby authorize Rm F-S F L,4NIV Ct2y 2)6,4 PFt4 K p E R F D R m4 C,C R 0 Flb G U
to act on my behqWLimall matters relative to work authorized by this building permit application.
Sigrikture of Owner Date
I -JgMES -J, FI-V}N,ryEP-y 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.
7 mE s T F4ANAJE9 V-
Print Name
Signature of Owner/Agent UDat
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of 1.1mme Holdor: JAMES J, PLA1yrU,e7P-y O S — 10-30&
License Number
/ Gyillra s Sf, /yoke ma OID�D :a/ Z20
Address I Expiration Date
y13- a43 — 5-8 S e?
Signature Telephone
Not Applicable ❑
P64x Pf-9 PoPmAN c.0 906FI/U6--, LIC c /?360'
Company Name RegistraNumber
"V,1- ;.old 5f, f-a s ma.rrr,��� Mq ZW DD 3- // 71ra 20
Address V (y,3) Expiration Date
Telephoneb3
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....... W"' No...... ❑
City of Northampton
Massachusetts f e�
qR Z"ARRlOC1NZ' OF BL7ZI.DZNG INSPECTIONS
212 Main Street •Nanicipal Building
Northampton, MA 01060
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:
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
14m olds loo ll-o IV, / zoomi s LUa y, r0s4Aa.rnr6U M19
(Company Name and Address) d a
Sign re o Permit 6plicant 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Vj 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Flectricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/organization/Individual): Peak Performance Roofing, LLC
Address: 1 Lovefield St.
City/State/Zip: Easthampton, MA 01027 Phone #: 413-203-5888
Are Vu an employer?Check the approprlate box: Type of project(required):
1,pV l am a employer with 4 4. ❑ I am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y p 9. F-1 Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions
q ]
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.VRoof repairs
insurance required.] t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp, insurance required.]
*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 aftida%it 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. Irthe sub-contractors have employees.they must provide their workers'comp.police number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Berkshire Hathaway Guard
Insurance Company Name:
Policy#or Self-ins. Lie.#: R2WC943835 Expiration Date: 4/27/2019
Job Site Address: M (,Ut9A0-in-Pk,1—) /`—d City/State/Zip: (16m n'I/q O 16&IF
o�
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 4perjury that the information provided above is tr a and correct.
Signature: 1111 Date;
Phone#: 413-203-5888
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#:
i(Berkshire Hathaway Ani6""'t'D="�" N wStock 5
GUARDCmpane M W`11573;
[1]Named Insured and Halling Address Agency
PEAK PERFORMANCE ROOFING LLC WEBBER&GRINNELL INSURANCE AGENCY,INC.
1 LONE OD STREET 8 NORTH KING STREET
EAS HAMtPTON,MA 01027 Northampton, MA 01060
Agency Code: MAMMN15
Federal Employer's ID 00-1191951 Insured is Limited Liability Co. (LLC)
[2] POiky PO 10d
From April 27, 2018 to April 27,2019, 12:01 AM,standard time at the insured's mailing address.
[3] COIAW ga
A. Workers'Compensation Insurance-Part One of this policy applies to the Workers'Compensation
Law of the following states: Massachusetts
B. Emplover's Liability Insurance-Part Two of this policy applies to work in each of the states listed
In item[3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident-each accident $100,000
Bodily Injury by Disease-each employee $100,000
Bodily Injury by Disease-policy limit $500,000
C. Refer to Residual Market Limited Other States insurance WC200306B
Endorsement-
D. This policy includes these endorsements and schedules:
See Extension of Information Page-Schedule of Forms
[4] Premium
The Premium Basis and,therefore,the premium will be determined by our Manual of Rules,
(]assiflcatlons,Rates,and Rating Plans. All required Information is subject to verification and change by
audit. (Continued on another Rage)
Total Esdnmftd Poly Premium $ 13,650
Total Svs+dRa-- Asaessnrant s $ 606.00
Total btlnRlhibad Goat 146256.00
RHEM&USE nx Page- 1- IWo m um Pape
WOR :R2VJC943835 wC 000001A
Date :04/0 /1019
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Office of Consumer Affairs and Business Regulation
One Ashburton Place- Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: LLC
PEAK PERFORMANCE ROOFING,LLC. Registration: 183996
1 LOVEFIELD ST. Expiratim: 11/03/2019
EASTHAMPTON,MA 01027
Update Address and Ratum Coni.
SCA i 4 2CM-05M7
�i�i�fnaer�Hmwa�l��"/tatta�u.:�✓!•
0111m of Conwmr Nhira&Busiesas Regulation
HONE IMPROVEMENT CONTRACTOR ReglskUlon valid for Individual use only
1h mfo 0 VW empirgdon Ch". If found return to:
1111011111111111211Lzalkildw L Office of ConeunMr Affairs and Business Regulation
103696 11/03/2019 10 Park Pleas-Suits 5170
PEAK PERFORMANCE ROOFING,LLC. Boston,MA 02116
JAMES FLANNERY
1 LOVEFIELD ST. r
EASTHAMPTON,MA 01027 Under6eCfetery va d wNhouit 819nature
C=Mwnweatih of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
Unrestricted-Buildings of any use group which contain
CS-103061 ftPiras;:QW2112020 Was than 36,000 cubic feet(991 cubic meters)of enclosed
•ry, iii I'
space-
JAMES J FLANNMY
1 WRMAMS ST
HOLYOKE MA 04060
Commissioner Fallore to possess a current edition oithe Messachuseffx
State Building Code is cause for revocation of this fit Mse.
For infornntion about this license
CaN(617)727-3200 or visit www.massgov/dpl