18D-067 (4) 10 PINE BROOK CURVE BP-2019-1332
GIs a: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D-067 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-2019-1332
Protect i1 JS-2019-002148
Est Cost $17450.00
Fee:-P-Q-O-Q PERMISSION IS HEREBY GRANTED TO:
const Class, Contractor: License:
Use Group GARY C REHBEIN 31003
Lot Size(sa ftj: 15812.28 Owner: BORAWSKI KATHLEEN
Zoning: URBn00)/ Applicant. GARY C REHBEIN
AT: 10 PINE BROOK CURVE
Applicant Address: Phone: Insurance:
24 CUNNINGHAM ST
SPRINGFIELDMA01107 ISSUED ON.5123/2019 0:00.00
TO PERFORM THE FOLLOWING WORK:ST RI 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 W Foundation:
Driveway Flash
Final: Final:
Rough Frame:
Gas: Fire Daoartment Fireplace/Chimney:
Rough: �: 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 Occuoancv sig to e:
FeeTWDe: Date Paid: Amount:
Building 5/23/2019 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 Northam ton f P
Building Depart end CurbC11,01,14-slyPermit
212 Main Str et MAY 2 1 2EAERoom 10 I Northam ton, M 01p [}� Ly anep `�la' z-INSphone 413-587-1240 F iia 4 s
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION r7� ir ✓ 3a'
1.1 PropertyAddress: This section to be completed by office
Map I F D Lot 1:)&'7 unit
10 Pine Brook Curve, Northampton MA 01060 Zone Overlay District
Elm St DIMct CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Kathy Maiewski-Borawski 218 Audubond Rd, Leeds MA 01053
Name(Print) Current Mailing Address: 413-536-5474
1 w rAn.6.ti Telephone
Signature
2.2 Authorbed Agent: �1
413-536-5474 1.1.E ,MEI IgAI13-536-5474 T� j tAlp I—) _- Z H61Y/tlLe Q'
Name IPdnQ Current Mailing Address:
413-536-5474
Signature Telephane
SECTION 3-ESTI ED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 17450.00 (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) 17450.00 Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature: y S-Z5- Zd iq
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all eDOlfeahle)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing Q✓
Oro
s
Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [p Siding[I71 Other[a
Brief Description of Proposed Stip existing ashpait shingle roofand dispose of,Imran 16"standing aeon,roof,to iclade 1�and water barrier.
Work:
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.If Now house and or addition to existing housing Complete the followlOIL
a. Use of building:One Family Two Family Other ROOF
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?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In Type of wnstmction
I. Is construction within 100 fl.of""lands?_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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT� OR CONTRACTOR
CONTRACTOR APPLIES FOR BUILDING PERMIT
ry-»+� as Owner of the subject
property,
US METAL ROOFING DISTRIBUTORS INC
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
sit greturn o er Date
I, C2E p r r Re
as OwnerfAuthonzed
Agent hereby decl 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.
Print Name
Signature of Owner/ In Date
Section 4. ZONING All Information Must ae Completed. Permit Can ae Denied one To Incomplete Information
Existing Proposed Required by Zoning
Tbis column m be filled in by
Building Dmanmmt
Lot Size
Frontage
Setbacks Front
Side L' R: L:' R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Int arca minus bldg&revert
e,kin
#of Puking Spaces
Fill:
vOlYme&t sfi0n
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 O YES O
IF YES: enter Book '., Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O 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 O , Date Issued:
C. Do any signs exist on the property? YES O 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 O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it pan of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION a-CONSTRUCTION SERVICES
8.1 Licensed Construction Summisor: Not Applicable ❑
Name of License xoldar: Gary CRehbein
License Number
24 Cunningham Street, Springfield MA 01107 CS-031003
Address Expiration Date
05/19/2020
Signature �j Telephone
V 4135365474
S Realstemd Noma lmprovemetd Comnetor. Not Applicable Cl
134'l` o
Company Name Regismation Number
US /tIL 20
Address Expiration Date
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.S 25C(S))
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...... ❑
City of Northampton
i
•. '•'
Massachusetts
c
z
'� OBPAR1fffi!T OF BUILDING INSPa XONS i
212 Nein Straat •Municipal
9 Building Oc
Morthaug+ton, M1 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 property licensed solid waste disposal facility, as defined by MGL c 111. S 150A.
The debris from construction work being performed at:
10 any 5'wt 13rcw�C CWN e tUOVA^P .UR .
(Please print house number and street name)
Is to be disposed of at:
Com !� � <poral yY� AfA OlODU
(Please pont name and locationNolof facility)n
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
S11,511
Signature cc,rmit 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.
A v® CERTIFICATE OF LIABILITY INSURANCE
0712&2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIDELY 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),AUTHORQED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT. If the carlificate holder h an ADDITIONAL INSURED,the policy(les)must haw ADDITIONAL INSURED proVlSlom or W endorsed.
N SUBROGATION IS WAIVED,subject W the terms and conditions of the Policy,certain policies may require an endorsement A statement on
this T.9rtiRoate does not confer rights to Me coNRcam holder In lieu of such endoraemengs).
PNOOUCER NAME: Md.Feeley
VgBbber 6 Gunnell uciia�: (4131586-0111 FAX Am.AM (113)5B6S481
8 Norh King ShEAL AOORESS: al ealeygreebbareTWgrnnell.tom
INSURERISI AFFORDING COVERAGE Rude
Nonhamplon MA 01080 INSURERA: Coninanlal MlestaTIACadia
INSURED INSURER B: UNION nidAca i3 25840
U.S.Metal Roofing Dlstributom,Inc. INSURER C. W'CAR-LibMy Mutual
AM:RAIN NAMED INSURER O'
740 High Saaet INSURER E
Holyoke MA 010/0 INSURER F'
COVERAGES CERTIFICATE NUMBER: EXP 72019 REMSION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMEDABOVE FORTHE POLICY PERIOD
INDICATED. NOPMTHSTANDINGANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH 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 CI-AIMS.
INm TYPE OF INSURANCE INSD POIICYNUMBER MMNO MX EXp IIXITe
x COMMERCRLGErvERA LIABILITY EACH OCCURRENCE S LO30,OW
GIAIMGMAOE ®OCCUR 799777;z S 300'000
MEDE%PIAo—Wacn) E 5,000
A CPM31MO110 0712512018 0712&MI9 PERSONAL.ACv IATURY S 1,004000
GEN'LAGGREWTE LIMIT APPLIES PER GENERALAGGREGATE 51094 WO
POLICY D JECT LOC PRODUCTS-COMPNPAGG 3 2,000,000
OTHER- r
AUTOMOBILELIAOLITY CECMBPeMrreGNGLE LIMIT E 1,DJ'0000
ANVAUTO GODLY INJURY(Per Ninon) E
B CANNE. rvLv SSUi05ULEo MAA5312BO210INYR 0712612018 072&2019 BOOLYINIURY(P—de,13 $
AUTOSHIRED NORLOVAED PROPERnoAMAGE S
x AUTOS OHLV AUTOS ONLY Pm cvapen
DnhoUrad motor&BI E 104000
UMBRELLA WB OCCUR EACHOCWRRENGE S
EXCESS WB CLAIMS-MADE AGGREGATE E
OED I I RETENTION E E
WORKERS COMPERGAGON $TA UTE 0TH.
AND EMRCmider LIABILITY ER
C ANY PROPMETORFGRTNERFxECUTVE O xIA M231SS1697Q18 07I2&2018 0]2&2010 EL EAcHAOCLCENT E 504000
OFFICERMEROEM EXCLUDIP 500,000
mrtuISE45E
eNye..) EL G. EMPLOYEE E
If xnMeunem
DE$CRIPTON OF OPEMTIONSMW EL DISEASE-POLICY LIMIT E 5f/J,DDO
DMCRIMDN OF OFERATIOIIS ILOCATMS IWHMLE3 14CORD tm,AMXbnel RemcXa RIMUM,mry Ee NecM!firman Fpce In 1pul,Ml
CERTIFICATE HOLDER CANCELLATION
BHOIILD ANY OF THEABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NONCE WILL BE DELIVERED IN
Evidence of InsumnCe ACCORDANCE WITH THE POLICY PRO RSIONS.
AUTHdiMED REPRESENTATIVE q /1
Fj'�-- � --
0IM-201SAOOM CORPORATION. All rights moment.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
�\ The Commonwealth ofMassaehusetts
Department of Industrial Accidents
1 Congress Sheet,Suite 100
Boston,MA 02114-20177
www.massgov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbere.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant If rmatio Please Print Leidblv
Name(Business/OrgmimtioMndividual):US METAL ROOFING DISTRIBUTORS
Address:740 High St.,Suite2
City/State/Zip:Holyoke MA 01040 Phone#:4135365474
Are you an employer?Check the appropriate box: Type of project(required):
LE]I am a employer with 6 employees(hall and/orpan-time).' 7. ❑New construction
2❑lamasole prtpriemror partnership and have rw employees working formein g. ❑Remodeling
any espacity.[No workers'comp.insurance unloved]
3.71 aa homeowner doing all work nn x f.[No workers comp.insumncesequired]* 9. El Demolition
m
4.❑1 am a homeowner and will be hiring cunnectom to conductan work on my pnteny. Iwill 10 Building addition
en are that an contractors eithv have workeri cosnpaumion msuance nr arc sole I L[]Electrical repairs or additions
Parturition with no employees. 12.[]Plumbing repairs or additions
Srl l..general contractor and l have hired the sub-connactcrs listed on theattechN sheet. 13.❑Roof repairs
These sub-cona actors have employees and have workers'emnp.insumnre.t
6.�We area),and we h and its officers have exercised their sight of exemption per MGL c.
14.❑r OtherROOF
152,§I(4),end we have no employees.[No workers'comp.irmmavce required]
*Any applicant that checks box#1 must also fill out the section below showing their workers'con tiondion policy information.
I Bo neem s who submit this affidavit boosting they are doing all work and two hire outside cennactors most submit a new affidavit indicating such.
iContremors that cheek this box mu t anached as additional sheet showing the name of the sub-contrecmrs outdone whmM1er or not those cnnkas have
employees. If the subcontractors have employees,they must provide their workers comp.policy numbet.
lam an employer that is providing workers'compensadon insuraneefor my employees. Below is the policy and job site
information.
Insurance Company Name:Liberty Mutual Insurance
Policy#or Self-ins.Lic.#:WC231S616974018 Expiration Date:07/26/2019
Job Site Address:10-12-14 Pine Brook Curve Cit,/State/Zip: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 MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerdfy under tthefp'aaiins1 a\ndpenames ofperjury that the information provided above is true and correct
Signature' X ^lil4 • no.
Phone#:41
35365474
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Corporation
Registration: 134740
U.S.METAL ROOFING DISTRIBUTION,INC. Expiration: 01/18/2020
740 HIGH ST.SUITE 2
HOLYOKE,MA 01040
Update Address and Return Card.
SCAT fi 20M-05117
OMee ME IMPROVEMENT
MPR ar Allain a CONTRACTOR
HOMEIMPPOVEMENTation, CTOR before Beexpirdon data. If found
umetur
only
TYPE:Connotation, Oefore of
Affair and Bu iness, to:
Re13474bn Wllaieon OMpof Conwmer Affairs and Business Regulation
134)40 01/18/2020 10 Part Nares-SuOe 5170
U.S.METAL ROOFING DISTRIBUTION.INC. Boldon,MA 02116
GARY C.REHBEIN
740 HIGH ST.SUITE 2 ` _ N valid without signature
HOLYOKE.MA 01040 Undersecretary 9
Commonwealth of Massachusetts
�i Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-031003 Expires. 05/1912020
' GARY REHBEIN
24 CUNNINGHAM STREET
SPRINGFIELD MA 01107
Commissioner C4
U.S. METAL ROOFING
740 High Street • Suite 2 • Holyoke, MA 01040
1-800-232-0399 . 1-413-536-5474 - Fax 1-413-533-81667777
M Paoro u roeElp sa
www.usmetalroofng.net F7/,iy 7
susD7DM PNCNENNMMRS
S1flEETl .N:B LOCAPGN
I � _
CIV,$LME AND LP COOS
�t1
DIPECLIONS
We will furnish and install new Englert Standing Seam mechanically locked system, 24 gauge as listed below.
Work is guaranteed for years and the manufacturer wamenties the finish on the metal Or 35 years.
COLOR: SPECIAL INSTRUCTIONS /COMMENTS
ROOF:
SOFFIT:
FASCIA:
PLYWOOD:
RIP/REMOVE:
OTHER:
HOUSE:
PORCH:
ADDITION:
GARAGE:
GUTTERS:
DOWNSPOUTS
REPAIR:
Contractor will begin work on or about (date).Barring delay caused by circumstances beyond Contractors control,the
work will be completed by (date).
All mnfinn nnnela are Oiietnm fahrirated on-site with state-of-the-art rollformina eauioment.
Contractor will begin work on or about rt (date).Barring delay caused by circumstances beyond Contractors control,the
work will be completed by (date).
All roofing panels are custom fabricated on-site with state-of-the-art rollforming equipment.
'As with any rollform steel panels,a certain amount of waviness or oil canning may become evident at certain times of the day when
sunlight hits them.This is standard in the industry and does not affect the integrity of the metal.This shall not be construed as a product
defect and shall not be cause for rejection.
Contractor does not perform or assume any responsibility for any painting,staining or wood or wall finishing on interior or exterior.
The contractor does further agree with the owner that(a) he will begin work within a reasonable time after the execution thereof,and will
prosecute it diligently and with due care,and in a good and workmanlike manner; (b) in doing the work, he will comply with all statutes,
rules, regulations and ordinances applicable thereto:
Contractor to procure all permits required by law.Contractor shall provide public liability insurances.
Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on behalf of the
owners to enter into this agreement.
We Propose hereby to furnish material and labor-complete in accordance with above specifications for the sum of:
dollars($ - ).
Payment to be made as follows:
.- - Name ContrerlorAesipnebU flepNnm
% ($ I upon signing contract; U.S.MMETAL ROOFING DISTRIBUTORS,INC.
Street A..
j upon start of lob; 740 High Street,Suite 2,Holyoke,MA 01040
ro-
-! 1-800.232-0399
% Is ) upon 1/2 job completion: Rmomioo rl,
MA#134740 CT#602546
% ($ ) shall be made bnhwilh upon completion Name of newsman _
work under this ventrad
Norm:No agreement for home improvement modem g mix shall require a down payment ammhssd Sei
(advance deport of more Man ane-thlm of the total moteot price or Me food amount of all
deposits or payments whim the mntrador must make,in ativame,to order and/or othermse
obtain delivery of spemd order materials and equipment whichever amounts areaftr. To M approved by nahlce
Acceptance of Proposal I have read both sides of this document and accept the prices, specifications and conditions stated.
I understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified.Payment will be
made as outlined above.
You,the Buyer,may cancel this transaction at any time prior to midnight o fthe third business day after the date of
this transaction.Cancellation must be done in writing.See accompanying cancellation.
DO NOT SIGN THIS CONTRACT IFTHERE ARE ANY BLANK SPACES
Signature _ ' Date signature Date