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10-007 (4) 200 AUDUBON RD BP-2021-1032 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 10-007 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-2021-1032 Project# JS-2021-001762 Est.Cost: $16625.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DANIEL WEST 106007 Lot Size(sq.ft.): 34368.84 Owner: JOAN BRANDT Zoning: RR(100)/WSP(100)/ Applicant: DANIEL WEST AT: 200 AUDUBON RD Applicant Address: Phone: Insurance: 11 PLYMOUTH AVE (413) 695-7311 WC FLORENCEMA01062 ISSUED ON:3/22/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRI P & 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. 2 Cgl • 11 . i � Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 3/22/20210:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner , IL, MAR 2 2 2021 The Commonwealth of Massachusetts11. FOR oard of$uilding Regulations and Standards Masstachusetts"State Building Code, 780 CMR MUNICIPALITY U �: ;,, ,.. . USE �r�I�1SPF. TON Buiidin rP_e ut,c pplication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling 2 h or/ This Section For Official Use Only Building P 1/�"it Number: '0 3,>' Date Applied: LVIAJ ` Z:e5 3 2Z-ZOZ( Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property ddre s: 1.2 Assessors Map&Parcel Numbers Zeio l im bCtr1 N-3• ( 0 0 1.1 a Is this an accepted street?yes no Map Nuihber Parc Qi?i ler 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: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 1 Qv1 rCcw LiCeo4S1 lonn . otc c-3 Name(Print) City, State,ZIP 2c ( bi RA. Gi3) Cafe- No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 /Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other Speciffy� +i i-\ate C Brief Description of Proposed Work2: R¢-y I L Q .Q.AS74 GSpIc� qr\ o//�,{Z . VI,\ rn >L Se ql L U AA 1s Ct. ! t 01.---\ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ \(. Lc-ZS, d o 1. Building Permit Fee: $ Indicate how fee is determined: / 0 Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No.0 Check Amount: 44 Cash Amount: 6.Total Project Cost: $ l(Q (-Z5.° 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Ex 'ration Date Name of CSL Holder \,t Pb 7d"-� List CSL Type(see below) No.and Street Type Description ,n,,A U Unrestricted(Buildings up to 35,000 Cu.ft.) �'u t.L.< y v v l . E'(..,7 R Restricted I&2 Family Dwelling City/Town,State,ZIP RC n u r ni dow and Siding /� SF Solid Fuel Burning Appliances 6 3)c S-73 l ( C� 1 8?-[�0 444(1•Cam'` I Insulation Telephone Email address�J D Demolition 5.2 Registered Home Improvement Contractor(HIC) . J2.� ,�� eSt `wr z. ir HIC Registration Number xp' ion Date HIC mpany Nam IIIC Registrant l\ okk�' S4-S QY 0 , C�(M N and S et dteg EtW ' t . ©lb4`7_ CgL3v �-3 t( Email a 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 Issuance of the building permit. Signed Affidavit Attached? Yes No .❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize f-0.L. UE5t ( 6(l,.4 ede= to act on my behalf,in all matters relative to work authorized by this building permit appion. llort Print wner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering name bel her y attest under the pains and penalties of perjury that all of the information contained' is applic o is a and accurate to the best of my knowledge and understanding. Print r s or Autho zed ent's Name(Electronic 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 0•-, I MYr s 4,,5 s, y Massachusetts tw4 x- 'f" a t ( 4 DEPARTMENT OF BUILDING INSPECTIONS y ,� ' - 212 Main Street • Municipal Building yJi; c:b r Northampton, MA 01060 sskh i,‘� 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: U�� ( (tA, Z,39 &S-gtca-(c.)v) Cam. The debris will be transported by: Name of Hauler: 1.L• L. -DC 5 .c) t; 4-��/� Signature of Applicant: /l Date: 3 L Z�Z ( The Commonwealth of Massachusetts ==? r Department of lrtdustrral.lccid tt ',L s 1 Congress Street.Suite 100 ` - " Boston. 4 02114-2017 -,17;t, www.mass.gm./dhl flurkers'Compensation Insurance Affidavit:Bui ders1ConIractorsiElecuiriai FPlumbers` 10 tit ULED tW t t it t tali_PU'ltM11TLSG AI r ilt,11t17 4. Annticant Information Pirate Print L..r:ibk Name i Elusiness lhyaantZilttart:ttttlt%ilitltl.. 4c)0, L. (.5-:C3e-K _.(.1_►C1��C(, `zCJ Addre,!. \ QL.1/`,1.1.1-`___)1,..AA A. City:State Zip` ,(e.. L e1 r . bv�cr Z_ [eht,fife - �` ,L3) C.e4S 73 / %r'Ow tti caspanorr't Meth Ehr appruitrtutr tNla: hype of project trequired). 1 III are[A i"mphiyfY mitt ctt irlf r•,:.t I ail Jailot raatt,tillte E~ 7. 0 NC+F i lcbt uct on 2-0 i am a rail ttnrpnaa or ptininhrp mil bane no tannItaunis**irking firm in 8 0'" Remttdcltng any opacity EMI*Aviles`c1 np.ntturnit'� trcptutial j •,—••��r 10 I met a hollfaxt*lio tiding all Semi motif.itin%%titer tum l aatutuak.'+t int trul_i 1t. !`_1 Ck.tttulitiun _—�`�� I U 0 Bustling addition 4 a I mn a lumanis*n a and ac11 tat luring*muu a�iuc%to kVeidi i all**cork on ran t+nrlet:tts I u,t 11 duality dud all c ittr.attea eidirt!arc wtuirts.z'irtepetrtntave imqatutwt ev otar odic 1 r.I Elk:tt u tti rs'patr,or Additions pn,piar ns w ick no teapktp t 12.t0 Plumbing repots in ;ad+.httvtts aq 1 ain a perIcr 4 C ltramn-a'tat I have hunt the sub%nutlIL1LN timid on Ldm'tIIJJ bLII sheet 130 1 Roof repairs e�MAIM> -t:uah'sutotr ts, �e tad y'sea t lea►t v:utki 'e tram �t p t, +riwt.... L Jj h OW c am a cuepnr>titetm atat tta u$etitnf.tutu iauctiva thew right or Gasnetiruai pet Wit c I 4.s--+othcr 1e_;It*It and sit hint no tv ,lu4cca (Nu wuekera'cuing!instil unixtatlutntif.t 'YE, two i4 ut tt_t,it rlh la bat rI found step fill,tut Ow,ediiin hki a t u•V•ug flan to t.ri�trs`(limp mvIruu iatthcy tnlenuatetat I ier.n ecovncrt A iiii ut it.n.i dub att"td-il it iadIu ...,airy.are dcriut;.u1L.,irk tout thin bird*airs idr saattz..•tar a Inuit,ubitili a dew afratlauit d tinkt-rush I gait/moon.enrol tb[ .1 fibs I'4%li=Lai attar.6ial an 3itbtinn:ii,ihtt"$ahtn.InQ tht mint ill Ilia 'Ya't.c.calrraa:kxr,ant!czar(..11r_hLr fit 41.l th.)t to liter h:.4'. Lugaluarc.. II tii:soh-i_or triett,mr hal unpins cus fit.'),nutai tuir.tile dude Nttrkum'.vine.policy taiurthcr t am an employer that is pros'tiding workers'compensation n insurance for my ensployees. Below is the paltry and job use information. Insurance Company Name; L 2J - A. I. OA. t Policy#or Self-Ms. Lk.#: . C, (Apo -{').3ce3CCb-Ze>eDAkxpenattwn Date: S/ 1 I '�Z t Job sift;Addrrhd: Z D J .. kkc.k, city:sa r.-zip AAA . Ot S Attach a copy of the workers'rompensailea policy drelittratlun page(show the pulley number s�eapiratinn date). Failure tct scout"coverage Xi required under MGL c. 15_ :'SA as a mammal vatil.tutim punishable by it fine up to SI51111.UtI arut or ate-year irnpri onmenL 'tsirll as ctr it penitfties to the limn of a STOP WORK ORDER and a tint of tip to S150,110 a day against the violator. A copy of this statement may h* 1.4rwtu'iled to the Office of rnvcsfsgautliis ot'the DIA for ittsw n cut crake t crilic;tit I do hereby cent t under t ins ad pen of pertttri Char the intorxallon provided d abuse is true and ca d. 5itt:►turt. �e i},ltt Z i ( ID Z / Phone�: C t � • — 7 3 t Official use only. Do ntar write in this area.to her completed by stint or town official City or Town: PermiiiLkense St _---._ ____ [swing Authority lelrcle one): I.Board of Health 2.Building Department 3.['ity Taws Clerk 4.Electrical Inspector 5. Plunthing Inspector h,Other contact Person: Phone#: ACC)11t DATE(MMf00fYYYY) L1�`..�", iJ CERTIFICATE OF LIABILITY INSURANCE 05/13/2020 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 have ADDITIONAL INSURED provisions or 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 CONTACT Adina Edgett NAME: Webber&Grinnett PHONE (413)586-0111 FAX (413)586-6481 INC.No,Exh: (AK,NoI. 8 North King Street ADDRESS: aedgett@webberandgrinneil.com INSURER(S)AFFORDING COVERAGE NAIL I Northampton MA 01060 INSURER A: Penn America/XS Brokers INSURED T�.--�- INSURER B: WCAR-A.I.M.Mutual D L West Roofing Contractor INSURER C: 11 Plymouth Ave INSURER D INSURER E: Florence MA 01062 INSURER F COVERAGES CERTIFICATE NUMBER: EXp 04/21 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. MISR AUDISU6iT POLICYEFF POLX:YEXP LTR TYPE OF INSURANCE INSD WV0 POLICY NUMBER (MM/OD/YYYY) (MMIDD!YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ��OCCUR DAMAGE TO RENTED ---� PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) S 5.000 A PAV0256772 05/01/2020 05/01/2021 PERSONALS ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,PO- 000.000 POLICY JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ _ �~ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ - OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY - AUTOS ONLY (Per accident) S UMBRELLA(JAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S DELI I I RETENTION$ _ S WORKERS COMPENSATION I STATUTE I ERH AND EMPLOYERS'LIABILITY Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE Y NIA AWC40070363902020A 05/01/2020 05/01l2Q21 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? andatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1 (M 00,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ '� DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached I more space is required) 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• O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD