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16B-058 (3) 10 HAYWARD RD BP-2020-0224 GIs#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 16B-058 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-2020-0224 Proiect# JS-2020-000369 Est.Cost:$14000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: A & J HOME IMPROVEMENT INC 101017 Lot Size(sq ft.): 14374.80_ Owner: LEARY LISA H Zoning: URB(100)/ Applicant: A & J HOME IMPROVEMENT INC AT. 10 HAYWARD RD Applicant Address: Phone: Insurance: 60 WASHINGTON AVE (413)467-1500 () WC SOUTH HADLEYMA01075 ISSUED ON.8/21/2019 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: FeeType: Date Paid: Amount: Building 8/21/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner gP- zo- �a � Department use only City of North mptECE� - Status of Permit: Building De art r1 �✓ V r CutlDriveway Permit 212 Main St ret e r/Se tic Availability .R , Room 100 AUG 1 Wa er/W II AvailabilityNorthampto , MA 01060 2019 T Set of Structural Plans phone 413-587-124 F 7-1272 PI tlSite Plans T of Sb'tl_of her S ecify NORTHA INSP APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENO MOL SH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION f—� This s ction to be complete'"y office 1.1 Property Address. II �!Q/ Map L Lot Unit 10 HayWOrd Rd. Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Lisa Lean 10 Hayword Rd.Northampton. Ma. 01060 Name(Print) , Current Mailing Address: Telephone Signature 2.2 Authorized Agent: /44--) Name(Pring ) Current Mailing Address: ii`gnature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 14000 00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) �40 5. Fire Protection 6. Total= 0 +2+3+4+5) 14000.00 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Z/ zo I! Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 e DONT KNOW ® YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO (�) DONT KNOW © 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 () YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO 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 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 0 NO e 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 Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [M Siding[0] Other[O] Brief Depjription of Proposed + Work: Kms,Wl,nw (75 /1 C0 0 Jr�I[l t /✓1 S l / , ,d Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes 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 as Owner of the subject property 77 hereby authorizeJ � to act on my behalf, in all matters relative to work au o ized V Ihs building permit ap kation. ignature of Owner Date as Owner/Authorized Agent hereby declare that the stateAents 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 ame Signature of Owner/Al ent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor'. Not Applicable ❑ Name of License Holder: A. l�A 1"�� — ^ License Number Address Expiratio Date ignature Telephone 9 Registered Home Improvement Contractor: Not Applicable ❑ ompany Name Registration Number / 4 x/3//_0 Address J Expiratio6 Date Telephone( 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....... pe_ No...... ❑ City of Northampton Massachusetts tea`' �`c !{ 'A (r DEPARTMENT OF BUILDING INSPECTIONS y nx 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: ( lease prirtf 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: (Company Name and Address) Signature of ermit 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 f Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.moss.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 zip:ip: Ma, 01075 Phone it: (413) 467-1500 Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am an employer with Femployees(full and/or part time)' 1:17. 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 0 10. Building addition ❑4. 1 am a homeowner and will be hiring contractors to conduct all work on my property. ❑11. Electrical repairs or additions I will ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. ❑12. Plumbing repairs or additions ❑5. 1 am a general contractor and I have hired the sub-contractors listed on the attached 13. Roof Repairs sheet. These sub-contractors have employees and have workers'comp.insuranceA ❑6. We are a corporation and its officers have exercised their right of exemption per MGL. ❑14. Other c.152,§1(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 policy and Job site information. Insurance Company Name: L IVI Insurance Company WC531 S621875019 Expiration Date: 05/11/2020 Policy#or Self-ins.Lic.#: Job Site Address: 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 ty 'ng m ame in jf will act as my signature. Nam Date: Phone tt: (4 14 00 Email: ajhomeimprovements@yahoo.com �acoRD® CERTIFICATE OF LIABILITY INSURANCE FD�ATE(MMro0rYYYY) 05/30/2019 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. If 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). PRODUCERFAX NAME T Lynne Methot FOLEY INSURANCE GROUP PHONE (413)214-74740): n_DDaess- krlethot@foleyinsuran rou .com 37 ELM ST INSURER(Sl AFFORDING COVERAGE NA[C• - WEST SPRINGFIELD--------- MA-01089 INsuRERA: LM INS CORP 33600 INSURED INSURER B A&J HOME IMPROVEMENTS INC INSURERC: --- - INSURER D: — 60 WASHINGTON AVE INSURER E: -- - -- SOUTH HADLEY MA 01075 INSURER F COVERAGES CERTIFICATE NUMBER: 408535 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 WI 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 L SUB - - POLICY EFF POLICY EXP LIMITS L TYPE OF INSURANCE POLICY NUMBER M COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE EI OCCUR PREMISES o ernel $ MED EXP(Annyy onee person) $ _ NIA PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO- PRODUCTS-COMP/OP AGG $ POLICY❑JE 0 F LOC $ OTHER: MBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY Ea accident BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED Per accident HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAO CLAIMS-MADE N/A AGGREGATE $ S DED I I RETENTION$ WORKERS COMPENSATION XI STATUTE I LR AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT s 500,000 ANYPROPRIETORIPARTNER/EXECUTIVE WA NIA WA WC531S621875019 05/11/2019 05/11/2020 A OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandat(ry In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below � N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached K more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Wd/workers-compensation/investigations/. 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 MA 01060 Daniel M.Crow�y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. % dbi f IL DA ) ACo 4/23/22019019® CERTIFICATE OF LIABILITY INSURANCE 4/23 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 IN 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. If SUBROGATION IS WANED,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). NAME: nary Meori, Ext 108 PRODUCER PHONE (413)214-7474 FAX t413l2=4-7447 Foley Insurance Group Inc. AIC No: E.M"'L mmeon@foleyinsurancegroup.com 37 Elm Street ADDRESS: INSURERS AFFORDING COVERAGE NAIC N West Springfield MA 01089-2703 INSURER A:Atlantic Casualty Ins. Co. INSURED INSURERS:NGM Insurance Co. 14788 A 6 J Home Improvements Inc. INSURER C:Granite State Insurance Co 60 Washington Ave INSURER 0: INSURER E: South Hadley MA 01075 INSURE RF: COVERAGES CERTIFICATE NUMBER:CL1942312154 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 UBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER M MIYY MMIDD EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMA E O E ED 100,000 E IS Ea occurrence $ p� CLAIMS-MADE a OCCUR 5,000 X L185000704 4/22/2019 4/22/2020 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 PRODUCT'S-COMP/OPAGG E X POLICY jEOC cT- L $ OTHER: COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY accident) BODILY INJURY(Par person) $ B ANY AUTO ALL OWNED X SCHEDULED UMP740SE 11/24/2018 11/24/2019 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ X NON-OWNED Per accident HIREDAUTOS X AUTOS $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR AGGREGATE $ �DE ESS UA13 CLAIMS-MADE D RETENTIONPER OTH- WORKERS COMPENSATION X STAT TE R AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 500,000 ANY PROPRIETORIPARTNER/EXECUTIVE N I A OFFICERIMEMBEREXCLUDED? WC003796174 5/11/2018 5/11/2019 E.L-DISEASE-EAEMPLOYEE $ 500,000 C (Mandatory in NH) It yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addimattached U more space Is required donal Remarks Schedule,maybe IO ) 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 herr^�- )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!QRR.9A1d ARnpn rnRPAROTIAN All rinhte ranarwarl vi,i I e(C.t fll� Cly fC��GC,��1.�tl.C�%Gt.Gfl��l1 Office of Consumer Affairs and Business Regulation one Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type; IndiVidual Registration: 135399 Expiration: 03/31/2020 ANDREW J DEREN e0 WASHINGTON AVE. SO.HADLEY,MA 01075 • Update Address and Return card. � t:nmmam;lealth ol'rtassae:huacetls Oiw%vnv of Prol"Sional"Gensum Board of Htnldtncq Requlalions anti Standarrts GSSI.•101017 t xpirt�s. 1111Ei12(11� ANDREW J DEREN 60 WASHINGTON AVENUE SOUTH HADLEY MA 01075 �ommissi<�ner C'4 a .__ r