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46-011
78 OXBOW RD BP-2019-0500 GIs#: COMMONWEALTH OF MASSACHUSETTS MR Block:46-011 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-2019-0500 Proiect# JS-2019-000808 Est.Qost:$680(.000, Fee $40.00 PERMISSION IS HEREBY GRANTED TO. Cgng.Class: Contractor. License: Use Group: ROBERTS ROOFS CO INC 100333 Lot Size(sq.ft.): 43560.00 Owner: CUTLER WILLARD G JR Zoning: Applicant: ROBERTS ROOFS CO INC AT. 78 OXBOW RD Applicant Address: Phone: Insurance: P O BOX 1312 (413) 283-4395 Liability BONDSVILLEMA01009 ISSUED ON.10/24/2018 0:00.00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF ON HOUSE ONLY 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 I# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: alk. 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: Feehpe: Date Paid: Amount: Building 10/24/2018 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 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans r)thpr S ecify APPLICATION TO CONSTRUCT,ALTE 1,RE OLI A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION OCT 2 3 2018 1 1 boa—(q - 1.1 Property Address: / / This sec 'on to be completed by office DEPT OF GUILDINCECTION5 Ot O i 1 Unit NORTHAMPTON,MA 01060 78 Oxbow Rd Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Will Cutler Jr 78 Oxbow Road, Northampton, MA 01060 Na Print) Current Mailing Address: 413-427-6277 Telephone Signature 2.2 Authorized Agent.. Roberts Roofs Co., Inc. PO Box 1312 Bondsville, MA 01009 Name(Print) Current Mailing Address: �.._------ -- 413-283-4395 99r6ture 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=0 +2+3+4+5) $6,800.00 Check Number This Section For Official Use Only BuildingPermit Number: Date Issued: Signature: r� Building Commissioner/Inspector of Buildings Date info CCD robertsroofsinc.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING Alt 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 Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW Q YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q 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 © 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 © NO Q IF YES, describe size, type and location: E. Will 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 © NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all agglicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing X❑ Or Doors ID Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[p] Brief Description of Proposed Work: Remove&replace shingle roofing complete with all associated details on house only Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet 6a. 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. 1. 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 Will Cutler, Jr. as Owner of the subject property Roberts Roofs Co., Inc. /Brian Blanchette hereby authorize to a my beh f, in,,4 matter 0aiv o w authorized by this building permit application. i gnature of Owner Date Roberts Roofs Co., Inc. / Brian Blanchette 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 1L Sign ur 0wner/Agent �� Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Thomas R Roberts CSSL- 100333 License Number PO Box 1312 Bondsville, MA 01009 7/3/20 AExpiration Date ddrS P. t� % Signature Telephone 413-283-4395 9.Registered Home Improvement Contractor: Not Applicable ❑ Roberts Roofs Co., Inc. 128264 Company Name Reqistration Number 400 Franklin Street Belchertown, MA 01007 3/16/19 Addrej Expiration Date ✓✓ Telephone 283-4395 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§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 building permit. Signed Affidavit Attached Yes....... IN No...... ❑ City of Northampton Massachusetts ��• DEPARTMWT OF BUILDING INSPECTIONS �. 212 Main Street *Municipal 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: 78 Oxbow Road (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: USA Hauling & Recycling, Connecticut (Company Name and Address) ture of Per it ner 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 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Roberts Roofs Co., Inc Address: PO Box 1312 City/State/Zip: Bondsville, MA 01009 Phone#: 283-4395 Are you an employer?Check the appropriate box: Type of project(required): l.f] I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ E] 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 11.❑ Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12K] Roof repairs insurance required.]t employees. [No workers' 13.❑ Other 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 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 an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance company Name: Farm Family Casualty Insurance Company Policy#or Self-ins.Lic.#: 2008W6216 Expiration Date:4/17/19 Job Site Address: 78 Oxbow Rd City/State/Ziorthampton, MA 01060 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` Signature:' Date: to Phone#: -4395 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#: Commonwealth of Massachusetts { Division of Professional Licensure £ Board of Building Regulations and Standards Co,istructlo.n'�.+"Uperviscr Speciai'`.• CSSL-100333 Expires: 0710312020 THOMAS R ROBERTS,JR PO BOX 1812 BONDSVILLE MA 01009 jib Commissioner CAL Res tri ed to:Consttuetion Supervisor Specialty CSS" .Roofing Failure to State Building a c 9 Code is�aUent edition of Galt(61):orZZ7.3n0 or bo t ttis i.'on O th Massachusetts Ci W:n►ass.gov/dpi r'��F Yrr.»tnin7a[oea�l�c.�''�2��r.sa��.u�cltt- Office of Consumer Affairs&Business Regulation _ - HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Beaistration Expiration Office of Consumer Affairs and Business Regulation t2t32ti4 03/16/2019 10 Park Plaza-Suite 5170 Boston,MA 02116 ROBERTS CO,'ROOFS INC THOMAS ROBERTS JI; 400 Franklin St C �` rj � 2 Belchertown,MA 01007 _ Undersecretary Not valid without signature I DATE(MWDDIYYYY) ACORIA® CERTIFICATE OF LIABILITY INSURANCE 04/19/2018 THIS CERTIFICATE 18 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 cer0cata holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,subject to the[arms 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 Sean Rooney Sean Patrick Rooney,Sr.dba v11oNE 41387-8817 FAX 877-771-6087 Rooney Insurance Services DRESS: sean.rooney@farm family.COm 2341 Boston Rd. INSURER(S)AFFORDING COVERAGE NMC fl Wilbraham MA 01095 INSURER A: Farm Family Casualty Insurance Company 13803 INSURED INSURER 8: Roberts Roofs Company, Inc. INSURER C: PO Box 1312 INSURER 0: Bondsville, MA 01009 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 PERIOD 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. rA TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE FIOCCUR7ADDL3UBR PREMISES Ea occurrence $-100,000 MED EXP(An one $ �J 000 Business Owners Policy 2007XO329 04/17/18 04/17/191 PERSONAL SADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: r GENERAL AGGREGATE $ 2,000,000 POLICY ECT LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABII fiY Ea COMBINED SNGLE LIMIT $ aaider�t ANY AUTO BODILY INJURY(Par Person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NPROPERTY DAMAGE $ acddent HIRED AUTOS AUTOS D E UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS CORVT~TION AND EMPLOYERS,LIABILITY STATUTE ER TH ANY PROPRIETORIPARTNERIEXECIITIVE YIN N E.L.EACH ACCIDENT $ 1 WON A M C�EMBIn BER EXCLUDED? F NIA 2008M216 04/17/18 04/17/19 E.L DISEASE-EA EMPLOYEE $ 100,000 I yee deeaibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additlonal Rernarlce Schedule,may be attached If more space Is required) 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 Sean Patrick Rooney,Sr. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD