Loading...
12C-113 (2) 78 RICK DR BP-2021-1244 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C- 113 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-2021-1244 Project# JS-2021-002068 Est.Cost: $8000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: A & J HOME IMPROVEMENT INC 101017 Lot Size(sq. ft.): 10018.80 Owner: GLENN ROBERT A Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: A & J HOME IMPROVEMENT INC AT: 78 RICK DR Applicant Address: Phone: Insurance: 60 WASHINGTON AVE (413) 467-1500f W(' SOUTH HADLEYMA01075 ISSUED ON:4/28/2021 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. Certificate of Occupancy Signature: I. . V yg - D� YQ FeeType: Date Paid: Amount: Building 4/28/202I0:00:00 $40.1)0) 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner JfJ 4fiob The Commonwealth of Massachusetts' �r c-.,6, .:.OR Board of Building Regulations and Standar' SST�G �0 le c9/ CIPALITY Massachusetts State Building Code, 780 CM �,rO;iti? . USE Building Permit Application To Construct,Repair,Renovate Or � evised�tar 2011 One-or Two-Family Dwelling °'so/otit /� This Section For Official Use Only Building Permit Number:20'' JJ 4$ Date Applied: if j N, , Building Official(Print Name) Signature i I . Dat SECTION 1: SITE INFORMATION 1.1 Property ekdrels: 1.2 Asse�gr>Map&Parcel Numbe i I 1.1 a Is this an accepted street?yes no 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: PROPERTY OWNERSHIP' 2.lkOrynert�of R&Iek P1 f hh �—1 Dlrrvrc'� "AICC Name(Print) City,State,ZIP V l cc,k Or, 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)4 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Pro os d Work': l O wwv-e LJ n)d r Lt S 7a,G(, et,/ /ac.vr, s tt SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ c?-wo D D 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All F $,(s: I (� 4 Check No.6) heck Amount. " Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 6554-1 t 7 l/l/42a 2/ 4/14 vw 3 � l;2e yr License Number Expiration Date Name of CSL Holder v� ,, ' tom_ "-tie- No. List CSL Type(see below) C e zatyS -f k Type Description SO aly (/`R�ii /�/ Uj Q U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances k3)05---/.24 O I Insulation elephone Email address D Demolition 5.2 Registered Home Im rovement Contractor(HIC) 35397 6y3/2.021 k/ �. 1/i' �_ HIC Registration Number ir Date jLe C Cuomnany Name1or HIC Re ttrant Name d4r/Us ^%�- �/C— an tree ,`� Email address ( OiO2 Mt?)�E—Lli( City/Town,State,Z P 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 APPLIE/S FOR BUILDING PERMIT , I,as Owner of the subject property,hereby authorize _---Q4Yv1� ytJvCN�Pif'® C to act on my behalf,in all matters relative to work authorized by this building permit a plication. Print Owner's Name(Electronic Signature) 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. ki,114 4PLf 14 4L! /Zd�-1 Prier's or Authorized Agent'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" The Commonwealth of Massachusetts .Department of IndustrialAccidents 1 Congress Street,Suite 100 .Boston,MA 02114-2017 4;0 www.mass.govidia We keys'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers. TO REELED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name (Business/Organization/Individual): A t l 1-6-cw_ 1 trivn.uili'overyi Address: (90 1.02tssiAt a}0„+1 City/State/Zip:4 3Y )41\-01g75 Phone#: 1fl3 (167 -15Ob Are you an employer?Check the appropria ox: Type of project(required): 1.EgI am a employer with 5 employees(full and/or part-time).* 7. Q New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 40 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q 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.i—(Plumbing repairs or.additions 5E1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 13.❑Roof repairs These sub-contractors have employees and have workers'camp.insurance? 6.0Wears a corporation and its officers have exercised their right of exemption per MI,a. 14'D Offer 152,§1(4),and we have no employees.NO workers'camp.insurance required.] °Any applicantthat cheeks box#1 must also flI out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they ate 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rnformatforu �, �A. 1 ,�J �C7 Insurance Company Name: �}-} ---- Policy#or Self ins.Lic.#: WC, 531S L 1 t� /,5 ©1 b Expiration Date: S ' 1 -ID a I Job Site Address: 7 c5--" lL p,,, City/State/Zip:/ 4,_,C'r,i s 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 oivil penalties in the form of a STOP WORK ORDER and a fine ofup 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 eeertify der pains and pen f perjury that the information provided above is true and correct Signature: L�C ���c / � '�---- Date: 1-2/1A//2"2/ Phone#: Ci(9 - l 5 Z 0 OffPc*Erl 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.BuildivagDepartment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton I`4 �Massachusetts �4t.• 1 c'c� id I • 14 DEPARTMENT OF BUILDING INSPECTIONS a. 4. +• a t . 212 Main Street • Municipal Building vb. �e Northampton, MA 01060 ''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: CacS,1/4 4‘ j/tic,.e-. Sf t I/ k r ("`lip The debris will be transported by: Name of Hauler: )cc.L,,Ay-C._ Signature of Applicant: : 17/2-� 0-( Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons.ruciorlSupervisor Specialty CSSL-101017 Expires: 11/16/2021 ANDREW J DEREN 60 WASHINGTON AVENUE SOUTH HADLEY MA 01076 Commissioner tac4.42%,/+"-'4--- Ce • 0/gWJ Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 135399 ANDREW J DEREN Expiration: 03/31/2022 60 WASHINGTON AVE. SO.HADLEY,MA 01075 Update Address and Return Card. SCA 1 i't 20M-05/17 r/A( �nritrrror?rnerr///r/ /41JJrreAt,Je/6 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE: Individual before the expiration date. If found return to: Registration Exoiration Office of Consumer Affairs and Business Regulation 135399 03/31/2022 1000 Washington Street -Suite 710 ANDREW J DEREN Boston,MA 02118 ANDREW J.DEREN 60 WASHINGTON AVE. .JCL! '°4 Not valid without signature SO.HADLEY,MA 01075 Undersecretary ACORD @ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `.� 05/08/2020 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(les)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 Marion Lentes,Ext 105 NAME: Foley Insurance Group Inc. PHONE (413)214-7474 FAX (413)214-7447 rat),Eat): (A/C,No): 37 Elm Street mlentes@foleyinsurancegroup.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# West Springfield MA 01089-2703 INSURER A: Atlantic Casualty Ins.Co. INSURED INSURER B: NGM Insurance Co. 14788 A&J Home Improvements Inc. INSURER C; 60 Washington Ave INSURER❑: INSURER E: South Hadley MA 01075 INSURERF; COVERAGES CERTIFICATE NUMBER: CL205813194 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 INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE S 1,000,000 DAMAGE 10 RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) S 100,000 MED EXP(Any one person) $ 5,000 A L1850007042 04/22/2020 04/22/2021 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 2,000,000 X POLICY PET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S g OWNED v SCHEDULED M1P7408E 11/24/2019 11/24/2020 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) C BI $ 20,000 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE 5 DED RETENTION S S WORKERS COMPENSATION PER 0TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) The certificate holder named below is included as an additional insured for General Liability coverage for ongoing operations on a primary&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. A separate A Certificate of Insurance for Workers Compensation coverage will be sent to the certificate holder directly from the insurance carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN For Permitting Purposes ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE y ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD l' ACORO© DATE(MM/DD/YYtIY) J CERTIFICATE OF LIABILITY INSURANCE TE(NM/OD20 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: Lynne Methot • FOLEY INSURANCE GROUP (AC NE•Ext): (413)214-7474 FAC,No1: MAIL Imethot fole Insurance rou corn ADDRESS: � Y 9 P� 37 ELM ST INSURER(S)AFFORDING COVERAGE NAIC# 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: 532092 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 TYPE OF INSURANCE I'bDL SUER POLICY EFF POLICY EXP LIMITS LTR IINSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREMISES(E Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ • GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY PE° LOC PRODUCTS-COMP/OP AGO $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO • BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) 4 $ UMBRELLA LIAR OCCUR I EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE• $ DED RETENTION$ $ WORKERS COMPENSATION / PER AND EMPLOYERS'LIABILITY A ^ STATUTE ERH A OFFICER/MEMBEREXCLUDED?ECUTIVE N/A N/A N/A WC531S621875010 05/11/2020 05/11/2021 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under • DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS 1 LOCATIONS)VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If 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.govflwd/workers-compensation/investigations/. 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 1401 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD