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08-033 327 COLES MEADOW RD BP-2019-1435 GIS u: COMMONWEALTH OF MASSACHUSETTS MWBlock:08-033 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2019-1435 Proiect k JS-2019-002318 Est.Cost:$10100.00 Fee:S40.0o PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: TIMOTHY DUBAY 100292 Lot Size(sa.ft.): 68824.80 Owner. GRIFFIN DENNIS P& ROSEMARY L TRUSTEES Zoning: RR(100)/RI(91 VWSP(9V Applicant: TIMOTHY DUBAY AT: 327 COLES MEADOW RD Applicant Address: Phone: Insurance., 36 EDENDALE ST (413) 781-2533 WC SPRINGFIELDMA01104 ISSUED ON.*&q&2019 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 q 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: FeeTyBe: Date Paid: Amount: Building 6/1820190:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northa plo of P MR Building Depa me t Curb uVD veway Permit 212 Mains reel JUN i 7 2p� ew r/Sep cAvailabiliry Room 1 0 War rNVel Availability Northampton, AOA _ cntnLQ�y NSpE ats Structural Plans phone 413-587-1240 ON.IMAC, it Pans e ity APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION &C,- t 9- /L 35 1.1 Property Address � J This section to be completed by office 3Z32-4- CADLV AFS MCACOL-) Map 67 Lot o Unit Zone OverlayDisMct Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner at Record: i-I IF 3 Za- Cmr ar N19OaO JQ .J Name(Pn ) Current Mailing Address: Telephone JO Sig ture 2.22 Authorize t: [ LT_/ L 4 /� tS/ Name sprint) Current Mailing Address: Sig alum Telephone SECTION 3-ESTIMATED CONSTRUCTION CO3T3 Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building /o /DOr O Ci (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) R(ter v 5. Fire Protection / 6 Total=(1 +2+3+4+5) Check Number 1-3 -37 This Section For Official Use Only Building Permit Number' Date Issued / p Signature: 6-18 Building Commissioner/Inapector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING ML Information Must Be Completed. Permit Can ae Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be Ned in by Building Depamnent Lot Size Frontage Setbacks Front Side LR L. R Rear Building Height Bldg.Square Footage Open Space Footage (Lm area minus bldg&laved #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW © YES IF YES: enter Book i 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 Q , 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 © NO 0 IF YES, describe size, type and location: E. WII the construction activity disturb(clear ng,grading,excavation, or filling)over 1 acre or Is It part of a common plan that will disturb over 1 acre? YES © NO IF YES,Mena Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoolicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Rooting O Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[l Other[0[ Brief Descnppppgqnn 4 Propoased Work SFi/� nr/ re✓na S f/K a.S T Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet tw If New house and or addition to existing housino. 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? I. Method of heading? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance farm attached? F. Type of construction i. Is construc5on 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? Yss No. I. 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 I, (�C-7saJ.vyS (-Sk/eCzs as Owner of the subject Property hereby authorize J to ae on my ehalF,in all matters relative to authorized by this building permit application. Sig Own Date •I, � / , as Owner/Authorized Agent ereby dedaratthe statements and information t e foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. / ii/✓/ d 74tc Print Name —17-17 / Signature of OvmerfAgent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvisor: Not Applicable 13 Name of License Holder: / f; 3S /� License Number tea- all., Add. Expiration Date 78/243 Signature Telephone 9.Renistered'IjHome Improvement Contractor: Not Applicable ❑ +�tibys- /JIBS Todr-f / 9'/ 7// Company Name re /G Registration Number Addy ZZ- Z_l r� Expiration Date m/1— aTelephone 7V/2ST,? SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.IF §2506)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affdavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton j Massachusetts z DBPARTrdQ1T OF BUILDING ZNSPBCTZONS (.}^ 212 Mein Btraet a Municipal Building n`rafp Nocthem n, MA 01060 .y.� AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction,alteration,renovation,repair, modernization, conversion, improvement, removal,demolition, or construction of an addition to any pre-existing owneroccupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building'be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of W ork: W66 XFy_ Est.Cost: erd /O O O a Address of Work: 3 Z 7 // Coles pye t d M✓ A41 Date of Permit Application: w -17- 19 I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): Building not owneroccupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: 6 -17-1 kilnL�tsa� 18'/ 77/ Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Maasachusetta t DBRARTNBNT OF BNZLDING ZNBPBCSIDNB -t 212 1 in Strut • Municipal Building Northampton, M 01050 Massachusetts Residential Building Code Section 110.R5.1.2 Homeowner: Person (s)who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or fame structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work,then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on thejob site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. r" City of Northampton 1 Massachusetts DBpARS1tQfl' or B=WXAG SB8pBC1'IOBs � 111 Min Gtr t •Mmicipal 6uildiny North- ton, M. 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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: / .977 Co les (Please print house number and street name) Is to be disposed of at: / i Please��r�� wvs� yyaynrN� ( print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 1 Signature of Permit Ap nt 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 ulkriters'Compencention Department of IndustrialAccidents 7 Congress Street,Suite 100 Boston,MA 02174-1017 wwrv.mass.govldia Insurance Affidavit:Builden/Contranors/El"hicians/Plumben. TO BE FILED WITH THE PEP-NUTTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/OrganizalioNlndividd/ual): / aZ L J�/lf�$ X trj_ Address: 2S F—giei4k- S/ City/State/Zip: 5 pjI ✓1y# 0'//G Phone#: 78e/zs33 Ararat,an empleyer!Cheak the appropriate more Type of project(required). I. Iamaemployewith�e'"pbYaslfWl rutin pro-final' 7. Near construction 2. lamasolepmpriemrorpaanershipmdhavememployeesworkingf m 8. Remodeling any capacit,[No wwlosi comp insumoce massed.) ❑ism.homeowner doing all work myself[No warkers'corn,immana ov, d.]' q. ❑Demolition 4.❑i am a homeownv and will sc hhing contractors to conduct all work on any pmpaty. I will 10 ❑Building addition me roman coutramrs either have workers'ova Wasrry mace or are sole Il.❑Electrical repairs or additions propaemrs conn.w cmpbyea. 12.[]Plumbing repairs or additions 5f:1 I not ageneral—tractor and I have hued the suhKonmctors loud on the anachNska. aa13.�Roof repairs These sub-conrmwtms cove rmployees d have cookers comp.inswavre. 6.❑W,are scorporroon and to olicershaveua of Nenrightofexemptionper MGL c. 14.❑Othm 152,$1141,and we have no anployers.[No workers'com,imurana ns ati<d] 'Any applicant Nat cloaks has#I nun also fill ord the section below showing Neu wodren'comprmaion policy inforaists n. t Homeowners who submit this affidavit in Bening they are doing all work end Nen hire outside ,ontracmrs most submit a new aniMvit indicating such. :Contractors Nat check this box most coached an additional shwa showing the now,of die sub-cnntrncmrs and sate wheNer or not Nose entities have anploycss. IfNe subcanwnon hove employees.Ney masa provide Nen workerscomp policy number. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. (Ane- Policy ,.� /^ / A Insurance Company Name: Nr- ne, Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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,p25A 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 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. /do hereby cerdfy an rT a pains andpenaldes ofperjury that the information provided above is trues and correct Si nature: Date: Phoned 7s,/ 33 Official use only. Do not write in this area,to be completed by city or Iowa official City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 1.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Penna: Phone#: 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 ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of m 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 ofpublic 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 sub-contmctur(s)name(s),address(es)and phone number(s)along with their cenificate(s)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 Toxo 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 permiNicense number which will be used as a reference number. In addition,an applicant that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under`Job Site Address"the applicant should write"all locations in_(city or town)."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. Anew affidavit most 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, Suite 100 Boston, MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia DUBA81111QC7 CCL REI CERTIFICATE OF LIABILITY INSURANCE ° y1f"°19"" THIS CERTIFICATE IS ISSUED AS A }ATTER 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),AUTHOFJZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER IMPORTANT: N m earlifica a Wder is an ADDITIONAL INSURED,the policy(los)most have AMMONAL INSURED provisions or IM endorsed. N SUBROGATION IS WANED, subject to the bmB and conditions of the policy,certain policies my ration,an endorsemanL A wedement on this cartMcate does not co for d91LM to tlM owltil 1,holder N lieu of suc h snlonammils). ..Ce. R11rE� _ McClure lnsuranco Agency,IrN. FMOMe 413 7815/11 FAX NS 737-05/8 WesVan Sp grwld,�MA 01089 �°'� 1 1 WSr`FS 1 Ami. SJFFFORdNG COV611Q I —0 NSUam A:Endurance American Specialty M.MW MSURMS:Ace American Ins.Co. Dubay Brothers Roofing enc. M.RC: 35 Edendale Street INSURER s: Springfield,MA 01104 YLSURER E: WSUREAF: COVERAGESCERTIFICATE NUMBER: REVISION NUMBER: 71115 IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOWIWVEBEpIlS TOTHE WSUREDNAMEDABOVEFORTHEPO}1CYPEILOD INOICATEO. NOTVARISTAND ANY REQUIREMENT, TERM OR CONIXTION OF ANY CONIRACTOROTHERDOCUMENr4 RESPECTTOWWOCHTHIS CERIFICATE NAY SE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES•DESCRIBED HEREIN IS SUBIECT TO ALL THE TFRMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAW SEEN REDUCED BY PAID'CLANIS. eM lYrteFINSUMNC6 AWLA1aN MOMCy MU Nm POIIEY Ware A X leareEAC1ALfiEN9tK UABurr FACHOLCURIEIJLE .} 1,000,000 . cLAMe.MADE X OCCUR PACT1534M 7/71/1018 7aval19 pq I } 100,E MED�V' .'. 's 5.000 FENsduL4Aw wury ,s 1,000,000 GFMAGIXEGAIEMMTAPPLES Fuc L;BJERµA(asNEtr,TE t 7,000.000 X POLICY, XI M ,Lac I FaoOucTs-cownw Acc _F 7,000.000 AVIOOTHER YANIT• �M OSINGLE LIMr } ANYAVrOOnaso IaLpILY INJURY(f4pMtm) ,y AAVrOSOFAY AUTOS I.. I�eBOOLYIWLRY(iWa=d o'I . T&oN,Y �� .InrsuKdYl .} YIBELAWa OLCIM EACH MCMPENCE ,} EPOMISWa CIAMS'W'OE. AGGREGAn } CED REfEfRgN} pip B WOIIII9M CfMIPBIHAl1(W X!EIATOIE 1 I IIt 1 Am91FLAYFRYLumen v/M ', U89F44274419 21112019 '' 2MrMn 00 t 100,0 AM'PROPRIE EaMN XEm LU1NE •''NIAID 'SEL FACNALCnENr 1I{ �) I j I SEL.DISEASE-FA FAiLL1yEFl} 190. rc bwb utiv I -(( �ggD SCR Of OPEMTN]HSbba -PoLCYIert. DIEW' mCNOE 014R,Llgr®IId:ATMMa/9MMNOOIU 1M.Ae/re/ l - d' YaVIIR "aaWYaesaaraaaYwMaaO CERTIFICATE HOLDER CANCELLATION SHE E ANYOFTHEABOVEHEREOF. OTIOES L CM DELIVERED BEFORE Proof Of AC EXPIRATION DATE THEREOF. IMS. WILL BE OEIIVERED M GeYereQe ACCORDANCE WNN TME POl1CY PROW910N9. AurxormEo mNESEVAmE ACORD 25(2015103) ®1988-7015 ACORD CORPORATION. All dgm reserved The ACORD nowneI and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improverri-&.C1bntractor Registration Type: In llvtdual nMOTtfrotnTAv Reglstra0en: 181711 35 EDENDALE STREET : - l E1iIiindian: 04/27/2021 SPRINGFIELD,MA 01104 -- i ! Update Address and Return Card. su r a aauavn aM M coruranr Aiwa 6 MlrMsa n.amrm. IIDYE MPROV9rBfrdual TOR Reg retial valid individual use aNy TYPE IllbdtlE before tho ont u ner doh. a found return to: I3l .-.. Orta Ashburton Consumer Affairs and Business Regulation 181T71-�- 04rC7l1021 One Ashburton Plane-Suite 1301 Boston,MA 02108 TO.IOTHY IXIegY-,"., -: q TIMOTHYDUSAY :: 35 EDENDALE STREET:--' SPRINGFIELD,W M . Ung,, Not valid without signature Currvnontyea0h of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constru&ioO Sdgd vt'Specialty CSSL-1011292 n Ellfires: 10/15/2020 •l, TMOTHY J BURRY '•'� W EDENDA ZISTRr£L SPRMGF14Dr411011M" .` l-,_ J Commissioner VL