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39A-009 (2) 120 CONI ST BP-2020-0157 GIS#: COMMONWEALTH OF MASSACHUSETTS MW:Block:39A-009 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-2020-0157 Project# JS-2020-000263 Est.Cost: $13000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: A & J HOME IMPROVEMENT INC 101017 Lot Size(sq.ft.): 11935.44 Owner. LEE YOUNG KEE&KOON JA Zoning:NB(100)/ Applicant. A & J HOME IMPROVEMENT INC AT. 120 CONZ ST Applicant Address: Phone: Insurance: 60 WASHINGTON AVE (413)467-1500 (� SOUTH HADLEYMA01075 ISSUED ON.8/8/2019 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# 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: FeeTvpe: Date Paid: Amount: Building 8/8/2019 0:00:00 $100.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner - — Versionl.7 Commercial Building I'erniit May 15,2000 t 1j i- Department use only 'City OT Northampton Status of Permit: Build ng Department Curb Cut/Driveway Permit AUG - 7 2019 21 Main Street Sewer/Septic Availability — Room 100 Water/Well Availability rtha pton, MA 01060 Two Sets of Structural Plans DEPT OF GUll DItiG INSPFCTiOt r;ORTHAMPIOThone,41 t-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be complet d by office 1.1 Property Address: a 104 Cori/ St. Map �"l Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _. Young Lee 104 Conz St Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $13,000.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) rl ` 0 5. Fire Protection 6. Total = 0 +2+3+4+5) Check Number This Section For Official Use Onl Building Permit umber Date Issued �z - — Signature: Building Commissioner/Inspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑� Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑ Brief Description Remove old roof and replace «ith new .060 EPDM rubber roofing. Of Proposed Work: SECTION 5 -USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ ❑ A-4 ❑ A-5 ❑ JB ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 58 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA OFFICE USE ONLY BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) St 1 SI 2nd 2nd 3rd 3rd 4"' 4m Total Area (sf) Total Proposed New Construction(sf) Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public E] Private ❑ Zone Outside Flood Zone E] Municipal ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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 e DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO q) DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO 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 e IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable El Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Young Lee as Owner of the subject property hereby authorize A&J Home Improvement,Inc. to act on my behalf,in all matters relative to work authorized by this building permit application. 07/16/2019 Signature of Owner Date Young Lee ,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. Print Name 07/16/2019 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder Andrew J. Deren CSSL-101017 License Number 60 Washington Ave. South Hadley, Ma. 01075 11/16/2019 Address Expiration Date (413)467-1500 Signature Telephone _T SECTION 13-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 E) No City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 5�zL— The debris will be transported by: (��.� s The debris will be received by: C�� �� 1.IZ 2 ��— ��-� iIrl-- Building permit number: Name of Permit Applicant 4 v l Date Signature of Permit Applicant The Commonwealth of Massachusetts { Department of Industrial Accidents 1 Congress Street,Suite 100 +. Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Name(Business/Organizational/Individual):A & J Home Improvement,Inc. Address: 60 Washington Ave. City: South Hadley State: Ma. Zip: 01075 Phone#: (413) 467-1500 Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am an employer with®employees(full and/or part time)" ❑7. New construction 2. 1 am a sole proprietor or partnership and have no employees working for me in any ❑8. Remodeling capacity.[No workers'comp.insurance required.] ❑9. Demolition ❑3. 1 am a homeowner doing all work myself.[No workers'comp,insurance required]t 1:1 10. Building addition ❑4. 1am a homeowner and will be hiring contractors to conduct all work on my property. F111. Electrical repairs or additions I will ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 1-1 12. Plumbing repairs or additions ❑5. 1 am a general contractor and I have hired the sub-contractors listed on the attached F,/113. Roof Repairs sheet. These sub-contractors have employees and have workers'comp,insurance.± ❑6. We are a corporation and its officers have exercised their right of exemption per MGL. ❑14. Other c.152,41(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners 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 attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site information. Insurance Company Name: Liberty Mutual Policy#or Self-ins.Lic.#: WC531 S621875019 Expiration Date: 05/11/2020 Job Site Address: ) b u C to z / n'+r e;2 C r 0 0 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 certify under the pains and penalties of perjury that the information provided above is true and correct and that clicking this checkbox and typing my name in the field to - ill o s nature. Name: Andrew Deren t . 07/26/17 ajhomeimprovements@yahoo.co Phone#: (413)467-1500 Email: m ,l'l.Lf/f;Cl IG,(xlml�IE��rl Office of Consumer Affairs and -Stu to Business Regulation One Ashburton Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Individual Registration: 135399 Expiration: 03/31/2020 ANDREW J DEREN 60 WASHINGTON AVE. SO.HADLEY,MA 01075 • Update Address and Return Card. iLA t 0 ® co11 moll.'lealtll of,',assacllUtietts Div'slon of Nrnlf';swnai l.lrellsulce Boarcl of 13ulldillg Rrqulatlons and Standards CS51. 10101/ expires, i IN61201S) ANDREW J DEREN 40 60 WASHINGTON AVENUE SOUTH HADIEY MA 01076 Commissiclnrr From: C IJ To: Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, 1 request that you grant a modification to waive the requirement for construction control of the project at because the work is of a minor nature, will not affect structural elements, health, accessibility, life or fire safety, and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. Respectfully, Q )fns �e-KN ID rte.1&4 w,- A�® CERTIFICATE OF LIABILITY INSURANCE 7423/2019 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(les)must be endorsed. H SUBROGATION IS WAIVED,subject to the terns 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). CONT CT PRODUCER NAME: Mary McOri, Ext 108 Foley Insurance Group Inc. PHONE (413)214-7474 FAX (413)214-7447 A!C No 37 Elm Street ADDRESS.mmeon@foleyinsurancegroup.com INSURERS AFFORDING COVERAGE NAIC« West Springfield PIA 01089-2703 INSURER A:Atlantic Casualty Ins. Co. INSURED INSURER B:NGM Insurance Co. 14788 A 6 J Home Improvements Inc. INSURER C:Granite State Insurance Cc 60 Washington Ave INSURER D: INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER:CL19,42312154 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 ADDL SUER POLICY EFF POLICYEXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD M IYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 100,000 A CLAIMS-MADE OCCUR PREMISES Ea occurrence) X L195oo 0704 4/22/2019 4/22/2020 MED EXP(Any One person) $ 5,000 PERSONAL d ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG S 2.000,000 POLICY SCOT- El LOC $ N OTHER: C BI ED SINGLE LIMIT AUTOMOBILE LIABILITY a accident) $ 1,000,000 BODILY INJURY(Par person) $ B ANYAUTO ALL OWNEDX SCHEDULED �p•14092 11/24/2016 11/24/2019 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED accident) X HIREDAUTOS X AUTOS $ UMBRELLALIAB EACH OCCURRENCE $ OCCUR EXCESS LIAR HCLAIMS-MADE AGGREGATE $ $ DED RETENTION PER OTH- WORKERS COMPENSATION X STAT ITE R AND EMPLOYERS'LIABILITY Y I N E.L.EACH ACCIDENT $ 500,000 ANY PROPRIETORIPARTNERIEXECUTIVE NIA OFFICERIMEMBER EXCLUDED, Y 1r000J796174 5/11/2016 5/11/2019 E.L.DISEASE-EA EMPLOYEE $ 500,000 C (Mandatory in NH) It yes,describe under I E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached U mors space Is raquired) The certificate holder named below is included as an additional insured for General Liability coverage for ongoing operations on a primary 6 non-contributory basis if required by written contract, permit, or agreement executed prior to a loss. Waiver of Subrogation is included on General Liability if required by written contract, permit, or agreement executed prior to a loss. Proprietor/Partner/Executive Officer/Member exclusion applies on Workers Compensation. CERTIFICATE HOLDER CANCELLATION herit- >mez@comcast.r. 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 Brian Foley/LYNNE 0 1QRA.7niA Sr t*ipn t nRPnRATIAN All rinhta raaarvarl