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30B-043 (3) 291 RIVERSIDE DR BP-2020-0938 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30B-043 CITY OF NORTHAMPTON Lot: -001 I'ERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2020-0938 Project# JS-2020-001594 Est.Cost: $2150.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DICKY MATOS 105917 Lot Size(sq.ft.): 17990.28 Owner: CZARNIECKI ADAM zoning: URB(100)/ Applicant: DICKY MATOS AT. 291 RIVERSIDE DR Applicant Address: Phone: Insurance: 3 GLEN ST (413) 530-5335 WC HOLYOKEMA01040 ISSUED ON:2/19/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-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 Sienature: FeeType: Date Paid: Amount: Building 2/19/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner r �N Department use only City of Northampton R, Status of Permit: Building DepartmeO ^• Curb Cut/Driveway Permit A. 212 Main Streets F� ewer/Septic Availability Room,100 9 Wa rMell Availability Northamptori, Md'�f3 C0_, T sets'of Structural Plans lr phone 413-587-1240 FaX-4'1 -, -4 72 1 ot/Sit Plans ther pecify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE 4Z DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office �f v e rs/�� ���,_ Map_�J Lot �! __?1_> Unit Zone Overlay District �t Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: L P C �Ot"r<�GC( N e rin Cu/ % �y(lie &ijephon Si ature 2.2 Authorized A en 1-7 N me rin Current MaJPKg Address: Sig a ure I'd -T_ Telep SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee �oCJ 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) Check Number This Section For Official Use Only �. o Building Permit Number: Z0 Date Issued: Signature: Ja o Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House F-1Addition ❑ Replacement Windows Alterations) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [[] Siding [0] Other[pJ Brief Description of Proposed Work` a i i•9 '!�A, Z, Alteration of existing bedroom Yes V/No Adding new bedroom Yes V---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 c <zf- G�i'17 Pte, as Owner of the subject property hereby authorize C4 f to'act on ehalf, in all ma ers relative/o work authorized by this building permit applic tion. /. ignature of nerDate/ 12 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 un a the ins and p ties of perjury. Pr i e '/, Signature of Owner/Agent Dat SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:—./],�i��/ /li( / �J` -g/-;, License Number lc�f D o a._3 ,30 X? Addre Expiration Date Signa ure tl Telephone $.Registered Home Imorovement Contractor., t fi Not Applicable ❑ sD�c V o2D Company Nam6 Registration Number' Addres I Expirati n Date Telephone l �� 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 buildi ermit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton tax.,. Massachusetts l %�c DEPARnONT OF BUILDING INSPECTIONS �s 212 Main Street a Municipal Building 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 he registered Type of Work: /70 v` / Est. Cost , Address of Work: 02Z 11010-6/1 Date of Permit Application: o?�o� 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 t owner: tea► CC /��cpe ate Contra for 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 MassachusettsAli Qom' J s { DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street *Municipal Building `'b Northampton, MA 01060 rSyrry;�� 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 street name) Is to be disposed of at: i12 1 �:��­e-1-7-V (Please print narrA and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit 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 n. Department of IndustrialAccidents 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. Aimlicant Information Please Print Le ibl Name (Business/Organization/Individual): ", Address: /2;7,/l City/State/Zip: /G'VW Phone#: Are you n employer?Check the appropriate box: Type of project(required): 1.m a employer with employees(full and/or part-time).* 7. New construction 2.M I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.) 3.E]I am a homeowner doingall work myself 9. ❑Demolition y [No workers'comp,insurance required.]' 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. 00f repairs 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 c. 14.[]Other 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. +Contractors 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. Iam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. _ Insurance Company Name: GLV/ Policy#or Self-ins.Lic.#: / Expiration Date: Job Site Address: �r• 1pr�/�LZ /� City/State/Zip: Attach a copy of the workers' compensation policy declaration p6ge(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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify Wt 4er-the pains and penM*eserjury that the information provided a ove is true and correct. Signa Date: Phone#: 6411-3) Official use only. Do not write in this area,to be completed by city or town official.' City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1 4 r ruur�onwealt4 of Mascghy f3xq its oYYProfessionat".Ur opi6rs arcs of rt ftReguiettN. 4 COrf$f[ ri CS-105917 rtnires: 03/30/2020:, YI, z DICKY MATOS 3 GLEN STREE� HOLYOKE MA i .I ar Cqonwis Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement=Contractor Registration DICKY MATOS Type: lndMdual S GLEN ST. He9isUabon: 166207 HOLYOKE,MA 01040 ExPiraiion: o5/o6/2020 'CAI c1 20M-05117 Update Address and Return Card. 011108 of Consuni"Aftm IF Business RegulationHOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration valid for Individual use only 166207 05/ b"Ore the Office of CotWIra Born date. It found roMm to: DICKY MATOS One Ashburton Place suite13130,sinass Regulation Boston,MA 02108 DICKY MATOS 3 GLEN ST. HOLYOKE,MA 01040 Undersecretary Not valld without signature ------------ DATE(YYlDD/Y'rYY) CERTIFICATE OF ILIABI--ITY INSURANCE 02/22/2019 IS I ATE IS ISSUED AS A MATTER OF INFORMATION ONLY A JD CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CE RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, E}TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE k CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. ImrORTANT: If the certificate holder is an ADDITIONAL INSURED, the pDlic les must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the f licy,)certaln policies may require an endorsement. A statement on this certificate does not confer rI hts to the certificate holder in lieu of such�ndorsement(s) PRODUCER O'RACT _Heather Fleu _ t 869 I CHI Insurance Agency,Inc. FIi7NE (413)532-0 � 416 Maln Street A_D_ RF hfleury@chlagency.com ___-- AD RESS:_ -... _.. INSURERS)AFFORDING COVERAGE _ __ __ NAIC Y Holyoke 22667 ----- NSURED –-_ -- -- ---- - _—_ MA 01040 INSJRERA_ACE AMERICAN INSURANCE CO _ _ -- INSJRERB' Dicky Matos dba DMR Roofing INSJRER C 3 Glen Street INSURERD: __ — -- -- ANS,IRERE_ -- Holyoke MA 01040 INSJRER F OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 3Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEi N REDUCED BY PAID CLAIMS. �sR ADDL SUB _ - -POLICY EFF POIJCY EXP - LIMITS I .TR TYPE OF INSURANCE INSDi WVDy POLICY NUMBER IYYfDDIYYYYI IYYIDDM/YYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ '— -dAAAA—G�70 R�f7TFJ5 S I _ T CLAIMSMADEOCCUR PREMISES(F2 occurrence) MED EXP(Any one Person) PERSONAL&ADV INJURY 5 r _ GENERAL AGGREGATE 5 GENL AGGREGATE LIMIT APPLIES PER —_.__...y POLICY^ PRO- . JECT LOC PRODUCTS-COMPIOP AGG i S OTHER S �1 AUTOMOBILE IJABILlTY COMBINED SINGLE LIMIT S (Ea acc+dentl ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident)I S AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY " AUTOS ONLY (Per acaaent) S �S I UMBRELLA UAB OCCUR EACH OCCURRENCE I S EXCESS LIAB CLAIMS4AADEI AGGREGATE IS DED RETENTIONS $ WORKERS COMPENSA71ON X STATUTE ER AND EMPLOYERS'LIABILITY �,I N ANY PROPRIETOR/PARTNER/EXECU7IVE UB1K$36443 E.L.EACH ACCIDENT S 100.000 4 OFFICER/MEMBER EXCLUDED? ❑I N I A 03/1 2x20191 0311 272020 Ues. (Mandatory In unaNH) E.L.DISEASE-EA EMPLOYEE, S 100,000 K es,aesmbe unser DESCRIPTION OF OPERATIONS t,6ok E.L.DISEASE-POLICY LIMIT i s 500,000 1` I ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,m,y be attached If more space Is required) ,ertificate Issued as evidence of insurance. I ERTIFICATE HOLDER C;.NCELLATION T—. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1 dE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I I,CCORDANCE WITH THE POLICY PROVISIONS. AU i HORIZED REPRESENTATIVE I CORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are mgistered marks of ACORD 00 3 Glen St �, Holyoke, Ma 01040 413-530-5335 � CS105917 HIC-166207 Date Feb 17, 2020 s .dKfR CT- 0639705 P.O. Terms Bill To Rich Czarniecki Ship Via 413-563-9000 Ship Date 291 Riverside Dr Florence, MA 01062 czarx2@hotmail.com Qty Description Unit Ext 5 NEW ROOF 400.00 2,000.00 Tear off entire roof Inspect plywood (if any damage will be and additional cost of 60.00 per sheet 1/2 inch and 75.00 3/4 plywood. Install ice water barrier 6 ft and valleys Install syntectic underlayment to rest of the roof Install limited lifetime warranty architectural shingles Color: DUAL BLACK Seal all pipes and vents Install 8"drip edge Remove all trash and debris Install a Tamko Rapid Ridge Vent Building Permit included 2 3/4 plywood up charge 75.00 150.00 Total (7) $2,150.00 I Page 1 of 1