29-121 (2) 64 FOREST GLEN DR BP-2020-0585
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 121 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-2020-0585
Proiect# JS-2020-001004
Est.Cost: $7750.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NRB EXTERIORS INC 99565
Lot Size(sg. ft.): 14157.00 Owner. NORTH SUSAN
Zoning: Applicant. NRB EXTERIORS INC
AT. 64 FOREST GLEN DR
Applicant Address: Phone: Insurance:
510 NEW LUDLOW RD (413) 563-6354 WC
SOUTH HADLEYMA01075 ISSUED ON:11/6/2019 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. 13uilding 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 11/6/2019 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 North,ampt us of Permit:
Building Department /ypvunveway Permit
,� 212 Magri Str t S IS ' r/Sep' Availability
ROOr1T 10 'r�c ���� rlWvailabilityNorthampton, M� Se of Structural Plans
phone 413-587-1240 Fax 41 - e Plans
Mq n �T% '810th Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE O E OLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION I>'0— ),o—6t —
1.1 Property Address:
This section to be completed by office
/
Map Lot 6 Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
S'1' �v /
Name(Print) Current Mailing Address: �/
�j. �ff
<-- t— L K&I
141-741141--& //7�6L� Telephone
Signature
2.2 Authorized Agent:
Name(P7' n / Current Mailing Address:
Sigrfature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 8695 (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) 7 S�(U , uJ 8695Check Number r
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature:
Building Commissioner/Ins ector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors i]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [0] Other[I]
Brief De cription of Proposed n
Work: ;r �a p,[i�►'°� �r v� L (� �'U' `'fix: fi R� �. SIM It
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
I > &`'L U + k� , as Owner of the subject
property \'
hereby authorize -k2`E �(J
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
rs 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.
gki i C l� ! A"-� ",
Print game
u Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /� Not Applicable ❑
Name of License Holder
r�1 .LL, y (P S L3-�✓n I `v
License Number
Address Expiration Date
r Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
T
Company Name Registration Number
</t, L- J
Address Expira ion 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....... No...... ❑
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 Please Print Legibly
Name (Business/Organization/Individual):
Address: S N IliJ ( ✓ "
City/State/Zip: a41(A4 / � Phone#:
Are you n employer?Check the appropriate box: Type of project(required):
1. I am a employer with__employees(full and/or part-time).* 7. E]New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in g. E]Remodeling
any capacity.[No workers'comp.insurance required]
9. El Demolition
3.F�I am a homeowner doing all work myself:[No workers'comp.insurance required.]t
4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. [will 10 E]Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.a Roof repairs
These sub-contractors have employees and have workers'comp.insurance.I
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0Other
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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors 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 thepolicy and job site
information.
Insurance Company Name: -'f/c1 _X L�
Policy#or Self-ins.Lf ic.#: (�Z 7 ct Uj--7 F S y 7G �' ` (7 Expiration Date:
W `✓5 �na
Job Site Address: �'0/t Y � ( � City/State/Zip: ��d✓P�c,c U, (r^
Attach a copy of the workers'compensation Olicy 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 un a ains and penalties of perjury that the information provided above is true and correct.
Si afore: Date: —
Phone#:
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#:
City of Northampton
r k,. Massachusetts -
I� t
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building a
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:
(Please print house number and str t 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)
Sig at of Permit pplicant 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.
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Corporation
Registration: 147961
NRB EXTERIORS INC i� I Expiration: 08/22/2021
510 NEW LUDLOW RD
SOUTH HADLEY,MA 01075 u
Update Address and Return Card.
SCA 1 a^a 20M-05/17
Office of Consumer Affairs&Business Regulation Registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
TYPE:Corporation
R -ai_tration Expiration Office of Consumer Affairs and Business Regulation
147961 08/22/2021 1000 Washington Street -Suite 710
Boston,MA 02118
NRB EXTERIORS INC
NICHOLAS R.BERNIER`:
510 NEW LUDLOW RD Not valid without signature
SOUTH HADLEY,MA 01075 Undersecretary
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
:;onstruction Supervisor Specialty
CSSL-099565 Upires: 05/28/2020
3"
NICHOLAS R BERNIER
510 NEW LUDLOW RD r
SOUTH HADLEY MA 01075
Commissioner
ACOROr CERTIFICATE OF LIABILITY INSURANCE DAnow "rm
06112/2019
THIS CERTIFICATE 0 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT F"TE HOLDER THIS
CERTIFICATE DOES NOT AF14RMATM9.Y OR NEOATMMY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES
DRAW THIS CERTIFICATE OF INSURANCE DOES NOT COMTRU M A CONTRACT BETWEEN THE ISSUN G WSURIEt(S),AUTHORIZED
REPRESENTATNE OR PRODUCER,AND THE CERZIICATE MOLDER.
holder sn #W )must law L MSURW W*visiaa or bs
If SUBROGATION M YINIVED,subject to dw turns aR4 owWtlons of tlw policy,antain Policies nay require an sodorssnmR. A sisamnt on
the owdtkm M doss not confer rishts to the osrWomb polder in Neu of such sadorsenarlt(s).
raoo1001111e Tierney Teem
Toney Qmw (419)682-7007
(888)271-2228
16 North Elm street lu him
PO Boer 760
NMC!
WNat!" MA 01086 INVAMAe Ruaet Bond A ComlwnyJCo"Instnarm OD
02URN PWAM 8: sob kwun n00 Conv" 12600
MR 8 E4 iore Inc vaultillitc: tA�CR18/frarelera
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COVERAGES CERTIFICATE NUMBER: CL1981200410 REId M lNUMU R.
THIS 18 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HOME BFJNL ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. W" WTHSTANOM ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO YMNCH THIS
CERTIFICATE MAY BE WKIED OR MAY PEITIAM.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS,
EXCLUSLONS AND CONDITIONS OF SUCH POLM&LIMITS SMOWN MAY HAVE BEEN RWUCED BY MID CLAIMS.
TL TYPEOFNOURW Ct PoLllLrfi
NMMNIG1Al QNdlRAL LIAORM i500.000
CW1148.MAOY ®OCCUR100.000
SubJsd b 11.000.00 Wducdble
AtO1CIL008936301 1?/23/2018 12/13/1019 5,000500,000
OENLAGOREGM WWTTAPPLIIellPtR: 1.000,000
POLICY❑ CECT ❑LOC 1,000.000
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DgCOMION OF OPtRA7gNi I LOCATION{I ve111C1.1 {ACORD 1e1.AMrlow RaamM fabs&66 aro be as mo N ars aPnr IS I
3041,WWW M+swBegan,Cwpanay area Rco&V area OutW W*90e6on
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COWW Vstepa Ap ulrnenta,181 Whet sorest,Vi,m MA
CORTWICATE HOLM
RNIOUI n ANY OF TMB ADM O99 R MW POUCOS U CAMM.L BD BYFORG
THE iXPIRATION DATE THEREOF,NOTICE WILL N DELP41M IN
V*Aon Corp ACCONIII AMCN WRTM THE POLICY PROWiMM
131 AWft Avenue Suile Al
AUT110RQlD R�flMTATIVY
YINM MA 01089 r
ACM IN(MIL" The ACORD rlattle and O 1 S ACORD reeerwd
logo aro raplstersd nada of ACORD
FullV ieensed and Insured t,:•s c� ` '� .b:may a� 510 New Ludlow Rd.
MA Reg#20-2()15718 South Hadley,MA 01075
.MA I.,ic#: 147961 ae►;
.NJA CS 1,#:99565 CeU:413-563-6354
413-707-ROOF
a� �r vr t Office:413-707-ROOF(7663)
,, ... .le !- •7
Fax:413467-9748
Stct.EC7' NICHOLAS IiERN1ER
Shinglettrlaster
" "° com RoofProsfa.'cc►mcast.net
I'nT,S,l;ubn ittcd LO: Phoneu h: c:
_..t .................-- Special requirements
strc't-
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City,state,zip code
proposal to furnish a d install the following
[ Re-roof fear-off flutter~
lt-l✓tve shalt acquire necessarN permit,,for all work
Complete Root Preparation
Home's exterior to be protected by tarps and plywood
YShrubs. landscapittx.trees to be protected,roofers buggy used
N/L."ntire existin-,routing materials to be removed to existing clocking,including flashing,etc.
1 5itc to be cicancd On a dally hash•:with roll magnet.de-brig to be removed at project completion by dumps ter
Z/ Deteriorated existing decking to be replaced at$50per sheet orplywotttl
.Complete CertainTeed Integrity Roof System
f imA Wimenniard ice d':i�itter bonier along bottcxn p 3 ft.of all roofs,M16 ft.
(z� Install Winwrt,_Yuard ice& water barrier around penetrations, in valleys and all critical areas
i;/lni;tall t'crt.13{l li'l:(I S�nthetir ttnderla_ymcnt to entire deckin'��
,,t/ lnm all X"perimeter metal Clashing to all edges oritil roofs.n white ❑brown
.install SiviftStart starter shingle to bottom and rakeedges of all mots
d/insudi CertainTeed shin
xles to manufacturers specifications,❑6 nails nails
install Certain Iced PVCridge vent to all peaks in heated areas
I�/Instaff Shallow Ridge to alt hips and ridges.override vent when:applicable
`rf'imtttll new lead counter flashing to chimney
,Ne.�4 flashing installed i�here necessary
install new pipe flashing to waste vent stacks
b'arranty options
naratttcc our labor/workmanship for 20 year;
,p,t•ade CertainTeed 4-Star Sure Start Plus,50-year nonprorated coverage
Ce-taineed Landmark -tab
Certain feed Lindmark Pro-color
A",broprts herchv to furnish materials anti labor-complete iu accordance with above specifications for the sum of:Total Due $ 1-7 sp1-Lb
ACCEP'E NCE OF PROPOSAL: fhe above prices specificai ms and conditions are - 1/3 Down Payment
satisfactory and arc hereby accepted.Vou are authorizcrl to do work as specified. Balance due
Parrneni wilt he 1/3 dawn at start of job,and balance due upon completion, upon completion $ 57001),00
Dat,:: 16 h sianature:
Date:_ �F•.stimator:(Print Named 1 V t' �� °`�l (Sign Name)
Y'stimates are honored for thirty(30)days from above date
ATTENTION 110M (ltb'NE14S:Please coverall personal belongings in the attic,garage or storage areas due to the
posslbtmy or roofing debris or dust in through cracks of the wood.NRB F;xtertors.Inc.will not be responsible for
debris or dust in the attic or storage areas.
A Ffnamcc C'harer of 1 !;"d.monthly MNINUAt.PERCiiN•fAGE,RATE 01: 18%)will be added to the unpaid portion of the balance due.i
spree it)pa;and or guaran{ce payment of rhes.charges.In the event of default of payment,I agree to pay reasonable Attorney's fees and
court Costs.'rhis arr•cmenl does not consutute a release of liability.By my signature below,acknowledge%an agreement orthc abort is