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25-028 20 RIVERBANK RD BP-2021-0991 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25-028 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-2021-0991 Project# JS-2021-001696 Est.Cost:$9000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JEREMY BECKER 106194 Lot Size(sq. ft.): 94089.60 Owner: HAGGERTY GARY P Zoning: Applicant: JEREMY BECKER AT: 20 RIVERBANK RD D Applicant Address: Phone: Insurance: 124 POINT GROVE RD (413) 626-2780 WC SOUTHWICKMA01077 ISSUED ON:3/10/2021 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. 5,2 b • . Certificate of Occupancy Signature:! FeeType: Date Paid: Amount: Building 3/10/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner RECEIVE oil 1 n 2021 n _T of r.,j ,,, O o llth o�f Massachusetts ,,,of-Bl guiations and Standards FOR W 1 -. Massachusetts State Building Code, 780 CMUNICIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling C�l'�a J'���Section For Official Use Only Building permit Number: (/� Date lied: 14Cvi a,5 3-10.2.0ZI Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address• Nv f} 1UH 0A bj0601.2 Ass ss s Map&Parcel Numbee g an R,verbunk ��. p 1.1a Is this an accepted street?yes Amino 1 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTYp OWNERSHIP' 2.1 Q iN;neRHa -.rf n10(0ham \VA AA o 060 Name(Print) �� y City,State,ZIP l a0 i.,.1t(bank ,(LA. 'Or bil-7yy5 jkoh;neawAvkibieJMAi1 .l,brA No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building d Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Descri Lion of Proposed W rk2: moA., 0\6 C6c 5\Ai49 _S And. ►tS-111 .W R5choli- Sh,"'9 Lear On , SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 9,00O, 00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fe $ lib Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ I 1 Qo.t.b() ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) O b 1 G` 1 11 a la(4 3 )Q-fQ M1 Q.<<(e( License Number Expiration Date Name of CSL Holder Rr 1 ti �O\nk (^MA rl 1 List CSL Type(see below) 1, No. (and Streete V l� Type Description 50J` v 1 j\(.k MA- 01077 U Unrestricted(Buildings up to 35,000 cu.ft.) l R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding y � �( / 1 SF Solid Fuel Burning Appliances 11^J- bDra7 0O ,'- 1 (.o15�(ULT1 eque iIY1Qll. I Insulation Telephone Email address (,OM D Demolition 5.2 Registeredis Home Improvement Contractor(HIC) ICl c 5t.., 1 l(Ola ,( . `�V t0() l' ' HIC Registration Number Expiration Date HIC Nam e me or HIC ' - , :it Name ►a Yo t- (AN sec Ctitc"sWu(4;0 Lodi aai .0el No.and 5treett Email address 5b w u,k, M4 0107 7 413 b-1,7to City/Town,State,ZIP Telephone SECTION 6: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 Issuannce of the building permit. Signed Affidavit Attached? Yes L/ No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize T/t 12 r`6 04 h to act on my behalf,in all matters relative to work authorized by this building permit cation. (gnM1,e � �f/ 3 - '7' Print Owner's Name(Electronic igiature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. \ Q7hi/'It /-44ger! Print Owner's or Authorized Ageless NaSElectronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton ~? Massachusetts �?S ;r DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building /• Northampton, MA 01060 &I,,v CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: Nor �q oTv� , • The debris will be transported by: Name of Hauler: A-PA\A ( 4 - \fJk gnq Signature of Applicant: D RO01ate: The Commonwealth of ilassuchusetts I.__ i=!f Department of Industrial Accidents = FIll'_ A I Congress Street.Suite 100 tPit= Boston. MA 02114-2017 ~''. www.mass.gor/dia 11 ureters'Compensation insurance AtTidacit:Builder.+('untractursfEkctriciansiPlumhers. Fl)BF:FILET)V.Fflt 1 BE I'ERAII Ii lM: ti I HORITY. Applicant Information Please Print l.reihl♦ Name 113usttnx.()rramratbon matt+[dual): .�`nn\b ?.,00Gifk9 U-(, Address: 1a`i g0if11_ 6(ove_ Q,A, ._ City/State/Zip: 501/41 k\414 j41 MA 0\073 Phase#: 43 -bib-a7ID Ara •e�byeri('irrlt the appropriate bat: f pe of project(required): L laatnaaraploycr with l tottt+knee.Chill andur pat-timcl.' 7. D Ne, Wtlltructiptr 2 t l am a]ok proprietor or rmin-r+tnp and huge no cn;altn cc>.aa,rkrna ter roe m 3. a Remodeling v air!,capacity.[No rimier,'comp.utauranai required" 9. ❑Demolition 3D I am a home,wtkr doing all work tnysclf.(Nis sot kaa,'comp.insurance requited.] 4.0 I am a Ia licm hr and w Al Ire luring ctgdrasiorm to conduct all woik on tin propioty.I wit 10 Q Building addition croup:that all corgractt,either lull wdtker. ormiRrt>alatt immune-car are role I la Electrical repairs or additions proprietors is.nth no unplotice.. 12.0 tanking repairs or additions 5.0 t ant a ircncial contractor and 1 lime hired the sub-amtrackn.lint.•ors the:lambed Ant13 V Roof repairs thtrc sub-contractors hair employees and Terse worker.'comp.tae.urancc. a--�14. O rr� [J' the1 IllAatl ttil,w 6.0 s c an a collimation and its officers hat c exercised then night of ao:m[ m per IdIiL e. 1 152.ti ll41.and we have tn.employees.[No is oilers'comp.insurance re �tyuutd.1 vt5 PIA }hrt k 510 j 'An*applicant that cheeks km al roust at at till out the section Mon shostrip that worker>' .ompernatiun policy information. m Iknnetornert%ho submit this attudti it unrleaina they arc dump all work and then hire v ,talc caattca:L rsnod submit it a sat artists,.II indicative wadi. :Compactors that sled,thu bur must attached an additional.Meet slams the the n:une of the sut ctattracto,rs and ibile whether or nut those erliiieehove etui•1.t:,ce.. If tine sub-r nk:x:1 as lease cnttli4ea.trey must yr..nide their MQtlorn-tunp.imltey nunilsr. l am an employer that is providing worAers'compensation insurance for my employees. Below is the police and job site in formation. n ltt.Ltt:utrd:l.tlnpany Name: T Y, Dk\VQ' 1(15J�oS Ct. (45t'1Cy 1 INC _. Ptrlie -:or Salt-ins.Lic_iil: w a (-531Sb5lb°IOIo Expintion Date: `d) a7101034 lob Site Address: ),O n Y,;4 fl o Ak Lk. city zap: AIbCkAft gm itrl,Alli 01060 Attach a copy of the workers'compensation policy deck adaa page(skindag tie policy suember and eapiratios dote). Failure to secure coverage as required under MiGL c. 152,§25A is a criminal violatiion punishable by a tine up to S I.500.00 and or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to S250.00 a day against the t iolatur.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance co%cragc♦critication. l du hereby certify an er the pond 1 • !tier of perjury that the information provided above is lane and correct Signature: 2 • Date: 31�/aoaa.I Phonert: �L,11 i 6-,Z7 '66 Official use only_ Do not write in this area,to be completed by city or lawn official ('it) or'town: Perinitil.icense P Issuing:luthurity (circle one): I.Huard of Ilealth 2.Building Department 3.('it'll own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ('autaet Person: Phone#: Client#: 19846 JRBRO ACORD. CERTIFICATE OF LIABILITY INSURANCE os/2 DATE(MMIDD/YVYY) M/DDNY 8/2020 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 NAME: Kathy T.P. Daley Insurance Agcy,Inc PHONE 413 788-0971 FAX 413 739-2645 (A/C,No,Ext): (NC,No): 1381 Westfield St. E-MAIL ADDRESS: een kathldaley@p y t dale insurance.com P.O. Box 1150 INSURER(S)AFFORDING COVERAGE NAIC# West Springfield, MA 01090 INSURER A Atlantic Casualty INSURED INSURER B:Liberty Mutual JRB Roofing, LLC INSURER C: 124 Point Grove Road INSURER D: Southwick, MA 01077 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) UMITS A GENERAL LIABILITY L185000909 08/27/2020 08/27/2021 EACH q�OECCCpURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREEaErrrence) $50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 X PD Ded:1,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY JEa LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ _ B WORKERS COMPENSATION WC531S625169010 08/27/2020 08/27/2021 X TO YLIMIT oTH- AND EMPLOYERS'LIABILITY _ TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? y N/A(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) General Certificate Workers Comp Information:Proprietors/Partners/Executive Officers/Members Excluded:Jeremy Becker, Manager CERTIFICATE HOLDER CANCELLATION Charles T. Laveck BuildingSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 25 Davis Street ACCORDANCE WITH THE POLICY PROVISIONS. Easthampton, MA 01027 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S155017/M155016 KJD