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23D-050 89 RIVERSIDE DR BP-2020-0152 GIS#: COMMONWEALTH OF MASSACHUSETTS MM:Block:23D-050 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-2020-0152 Project# JS-2020-000253 Est.Cost:$7600.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ROBERTS ROOFS CO INC 100333 Lot Size(sg.ft.): 25003.44 Owner: DURBIN BRENT M&REGINE A SPECTOR Zoning: URB(100)/ Applicant: ROBERTS ROOFS CO INC AT. 89 RIVERSIDE DR Applicant Address: Phone: Insurance: P O BOX 1312 (413) 283-4395 Liability BONDSVILLEMA01009 ISSUED ON.8/6/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE GARAGE 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: FeeType: I)ate Haid: Amount: Building 8/6/2019 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 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 Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION &�?-a,C) 1.1 Property Address: This section to be completed by office✓l 89 Riverside Drive Map 3 Lot 05-0 Unit Florence, MA 01062 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Regine Spector 89 Riverside Drive, Florence, MA 01062 Name(Print) Current Mailing Address: t (510)290-6346 1:-1,� �I/A 4— Telephone Sign 2.2 Authorized Agent: Roberts Roofs Co., Inc. PO Box 1312 Bondsville, MA 01009 Name(Print) Current Mailing Address 413-283-4395 ture 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) 7,600.00 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: ��<-C.�-- .� ! 4-y.—y+ Building Commissioner/Inspector of Buildings Date info a robertsroofsinc.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) P 1`6 I� lit Section 4. ZONING All 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 ® DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® 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 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 applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ID Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[Cil Other ICU Brief Description of Proposed Work:Remove&replace roofing on garage with new lifetime architectural shingles. 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. 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 Regine Spector as Owner of the subject property Roberts Roofs Co., Inc. /Brian Blanchette hereby authorize to a n y behalf, in a atter elative to work authorized by this building permit application. g S_. Sidnaldrelf Owner Date l 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 S' re of Owner/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 Add Expiration Date 2.tjzs� W. Signature Telephone 413-283-4395 9. Registered Home Improvement Contractor: Not Applicable ❑ Roberts Roofs Co., Inc. 128264 Company Name Registration Number 400 Franklin Street Belchertown, MA 01007 . 3/16/21 Address 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...... ❑ Commonwealth of Massachusetts ®. Division of Professional Licensure Board of Building Regulations and Standards Construction-Supervisor Special:; CSSL-100333 Expires: 07/03i2020 THOMAS R ROBERTS,JR PO BOX 1312 BONDSVILLE MA 01009 Commissioner c "- Restricted Construct to: ion S uPervisor S cSSL RF_Roofing Specialty Failure to possess State Building Codeas current edition of For into r use for reVpcat'o^Massachusetts Call(617)727 matin`about this lice this license. 3200 visit i i Ala" Office of Consumer Affairs and Business Regulation 1000 Washington Street•Suite 710 ? Boston,Massachusetts 02118 Horne Improvement Contractor Registration Type: Corporation ROBERTS ROOFS CO.INC. Rogistrstion- 128264 i PO BOX 1312 Expiralion: OY1612021 BONUSVILLE,MA 01009 I t I SCA I* UM4'17 Update Address and Return Card. Office or Co.—Affairs a nualness Regulation HOME IMPROVEMENT CONTRACTOR Regletralmn valid for Individual use only TYPE:Curporaean before the expiration date. If found return to: R}4tstlQD E-plrtioOHICC Of Consumer Affairs and Business Regulation i 120204 03116202' 1000 Washington Slrsot-Suite 710 RODER TS ROOFS CO.INC. Boston,/MA 02118 w I HOMAS R ROBERTS JR fj r t_ /77 YID V 400 FRANKLIN ST �p�,. �— i1�W BFLCHERTOW N,MA 01007 Undersecretary Not Valid Without signature i City of Northampton • ' Massachusetts �.��5`5 s,��`` 'I. DEPART2ENT OF BUILDING INSPECTIONS �. 212 Main Street • Municipal Building yJH CDS Northampton, MA 01060 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 owner-occupied 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 Work:Roca+ rt �Jy-- w. 4abn�-sg Est. Cost: 4-7600 ,Cio Address of Work: Sq vt,/4 ide- tN r �I vcv.L e PAA G%06*% Date of Permit Application: !c{ 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 owner-occupied _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: _ S I`1 Roberts Roofs Co., Inc. 128264 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 Massachusetts :c ''A h ; I DEPARTMENT 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: 89 Riverside Drive, Florence, MA 01062 (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 (Company Name and Address) `Sigxrature W 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. The Commonwealth of Massachusetts fu 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 Ley-ibly 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): 1. ] 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. t 7• ❑ 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 ME] 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' 13.0 Other comp. insurance required.] *Any applicant that checks box 41 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: 4/17/20 Job Site Address: 89 Riverside Drive City/State/Zip: Florence, MA 01062 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: �S I 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#: ACO O DATE(MMlDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/17/2019 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 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 CONTA Sean Roo y Sean Patrick Rooney,Sr.dba PHONE413-887-8817 F No: 877-771-6087 Rooney Insurance Services ADDRESS: sean.rooney@fann amlly.Com 2341 Boston Rd. INSURERS)AFFORDING COVERAGE MAIC f Wilbraham MA 01095 1 INSURER A: Farm Family Casualty Insurance Company 13803 INSURED - -_---� INSURER 8: Roberts Roofs Company, Inc. INSURERC: PO Box 1312 INSURER D. Bondsvilie, 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. -- - - INSR TYPE OF INSURANCE POLICY NUMBER MO DDY EFF MWD Y EXP LTR LMM COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F—I OCCUR PREM SET EaEoccurtence _ S 100.000 MED EXP(Any are s 5,000 A Business Owners Policy 2007X0329 04/17/19 04/17/20 PERSONALaADVINJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY JECT D LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) S ALL OWNEDSCHEDULED BODILY INJURY(Per acgdenl) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS t S UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EL EACH ACCIDENT $ 100000 A (Mandatory In NHR EXCLUDED? MIA A 2008W621 6 04/17/19 04/17/20 EL DISEASE-EA EMPLOY S 100:000— If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks 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(2014/01) The ACORD name and logo are registered marks of ACORD