17C-299 (6) BP-2021-2013
131 CHESTNUT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-299-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2013 PERMISSIONISHEREBYGRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 13830 DANIEL WEST 106007
Const.Class: Exp.Date:07/08/2023
Use Group: Owner: SASS JONATHAN R& CHRISTINE S
Lot Size (sq.ft.)
Zoning: URB Applicant: DANIEL WEST
Applicant Address Phone: Insurance:
11 PLYMOUTH AVE (413)695-731 1
FLORENCE, MA 01062
ISSUED ON:10/12/2021
TO PERFORM THE FOLLOWING WORK:
NEW 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.
Signature:
i
el ' I
•' �
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
VED
The Commonwealth of Massachusetts
I. ° a Board of Building Regulations and Standards OCT FOR
))� Massachusetts State BuildingCode, 780 CM' SMa yCIP• LITY
%� US
Building Permit Application To Construct, Repair, Renovat; Or 13ttrrit I : Revised M'r 20
One- or Two-Family Dwelling INOArH4gf"' tl;4prc oo�s
��jj.,,�� This Section For Official Use Only
Building ermit Nuay5
ber: e7P -1�'2 013 Da A lied:
C iiIU 4'..-7 V-IZ-ZOZI
Building Official(Print Name) Signature ,Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Number la
i3 Iry .P
1 City IA . 11C, .
1.la 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'
2.1,01 caner'of Record:
Name(Print) City,State,ZIP C
1'31 C- s S, 613%'8g--88S 7-- ---
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' (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 pecify: NP-2 R, c cf
Brief Description of Proposed Work': ' t & '- € iscon qS ((x0c,(/- cd. In
We.,, c_c c._, .- ivy 5 _____3_4_,____ e_c=fr Ci r-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ `'5, *p ,.- 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2. Electrical $
--- 0 Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees
Check No.tri Check Amount Cash Amount:.
6.Total Project Cost: $ 1 -3 f330. I 0 Paid in Full 0 Outstanding Balance Due: __
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
r YkieA (.1_— License Number Ex era on Date
Name of CSL Holder (�
List CSL Type(see below) .
P ( rw>� cue- .
No.and Street Type Description
rj__„_. t n A/� Unrestricted(Buildings up to 35,000 Cu.ft.)
lG��� / Y�`�' R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonr
y
egj Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
41-Wet-9,51:3(1 4:4{7` 84-0,cn ( .(e1 l Insulation
elephone Email addre D Demolition
5.2 Registered Home Improvement Contractor( IC)
%J 4 Fb 'e % C r HIC Registration Number xpira'on Date
HIC Company Name or HIC Registrant /ame
\ P(L c�(-L,et OR • dlltel-6�--� ; 1_ Cow
No. St et Email a dk
t te.- vA • 0( 2 Et_njc.2%-=terCity/Town,State, IPTelephone
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 612K No 0
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 'D•L. 104 RPQ4ic C�,iti{ (`
to act on my behalf, in all matters relative to work authorized by this building p t application.
SCai I b/6/zap
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.
gtLx), (\tA (pis( tat
Print Owner's or Authorized Agent's Name(Electronic Signature) w 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
PYH Y
S�5 ..•• SAC
'?•" Massachusetts ��„, x_ '<<
s
DEPARTMENT OF BUILDING INSPECTIONS ;.
212 Main Street •• Municipal Building J`, `D
» : s Northampton, MA 01060 'rsYti; 3;:je
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: 2-3`1 E ( (t�l•
VI,txp(d�( • b\Dkc2
The debris will be transported by:
Name of Hauler: �. (.. ems, Kcc-a. � 44e,r
d 01'i
Signature of Applicant: Date: l f'
. .., - ,
The Commonwealth oplassuchusetts
? --.
Department of Industrial Accidents
i Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.goWdia
.. . -
1),i»kers t'mope tENA lion Insurance A ffida%it: Bo ildersl.iintrActorvElectriciansillumbers.
ID RE VII.EB‘Vrt it i Bt. l'ERk111114‘; k I. I 1101411.N.
Anniticaill Information Please Print Leriblv
Name 4 ausiness;OrganizationAndivuluah:. fk. .. k,..„_s). ( 4:73
Addrt'ss', .__ •
Lk _glitAkbok-fn co-x—
city/stateizip: v1/0. (.51-5>A7_(trei- Phone 4.: 6(-3)(e3 I I
( _
%re'Cal an t'lltp[41:k CFI'thlthrk Lh 11 p II uoitria4c box: '1),pe of project(required).
;Al am a employer with ..-- crisployeett Chill waxer.part-tinici," 7.. CI Nets constructuan
..„D I in a vale pmprietor or parincistim and haw nu employees workout toi rive in 8. 0 Remodeling
i apaCli). No workers'comp,insuramc %Nu:Mall
9. n Demolition
.,D I am a lionwsiw sum doing all work.myself.[No*initial.'comp.invorance required.)"
10 0 Building addition
4.EI I am a lionw,.-ownin and will he hum g oxintratiors to conduct all w irk on to isroperty. 1 will
ensure that all t:Ontra.tors either haw winters'estuntemaison msuranee or are sole ; 11.1:1 Electrical repairs or additions
propnetors w ith no employees
• i 2.0 Plumbing repairs or additions
1 I am a gt-neral contractor and I base hired the soh-contractors listed on the anaeried sheet,
110 Roof repairs
These sub-contractors haw employees and base vomiters'comp.insurance.» .„..„
• 14. Other P--0Cd
0 i We are a corporation and its officers hate exercised then right of exemption per MU c
152,§1141.and we hate no tinployees.(No+4.orkers'comp. insurance requited.]
'Any applicant that eliteirs box al mast also till out the rieentin below show in g their workers'compensation pokey information,
t Homeowners who submit this atrittam intheating they are doing all work and then hire outside contractors anat submit a new atlidas it indicating such
:Contractors that eheek this.box must attached an additional sheet skit/wing the name of the suissemitracturs and,state w hether or not those entities base
employ ecs II the sub-contractois haw employees,they must prep icle Men 'A ork LTS:comp.policy min iher
1 am on etnph0yer that is providing workers'compensation insurance fOr my employees. Below A the policy and job site
information.
Insurance Company Nairie:_AIA_
• • .1A4g....21W.... S-_...Z.P.' —
Policy#or Self-ins. Lie.#: 410-/C tk.P01-45_3(e3Otina-ta t Ar Expiration Date: 1
Job Site Address: V31 LIAL.44,4 ,.(-- City/State'Zip: ,...--1, , mi. ,,, ,,-,
.....
Attach a copy of the oorkers'compensation policy declaration page Eshossing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a tine up to SE.500.00
and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.00 a
da.. . .:ainst the violvitor. A copy or chi!, -.r.i i eii I.:nt may be forwarded to the Office of InvcAigations of the DIA for insurance
,.•. ,,,,:.p..,.: ,•entik.--ar.i..n.
1 do hereby cern ',under h pa. S and pivi allies ofperjury that the information provided above is true and correct.
Sinattire: Dan: 10/67(-0-t- i
Phone#: j Criq'`'S---- . - /1
Official use only.. Do not write in(16 illeil, to be completed by city or town official
City or Town: Perinitilietnse#
Issuing Authority(Circle tme):
I. Board of Health 2. Building Department 3.t'it (Fins ii t lerk 4.Electrical Inspector 5. Plumbing Inspector
ii.Other
Contact Person: Phone 4:
-----
~'CR+Jf can tYaltOO YYYY)
CERTIFICATE OF LIABILITY INSURANCE 05/13/2021
THI$ CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
BERT►F(CATE CES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
REPRE 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 certlflcate holder is an ADDITIONAL INSURED, the pollcy(les)must be endorsed, If SUBROGATION IS WAIVED,subject to
the certificate
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 Ilse of such endorsement(s).
PRODUCER "" --- — - COMA T
'N� Travis Sias
PAX
KSK INSURANCE AGENCY INC ;InNE (413)527-7859 AEC-Nes:
EaaAILES$: Uavlssies jksk-Insurance com
ADOR 203 NORTHAMPTON ST INSURER,SE AFFORDIMQ COVERAGE NAIL e
EASTHAMPTON 33758
MA 41027 t INSURERA; AIM MUTUAL INS CO
INSURED
i INSURER a: -...
DANIEL WEST INSURERC:
D L WEST ROOFING CONTRACTOR INSURER 0: _ ____
11 PLYMOUTH AVE RtSURER e
FLORENCE MA 41062 INSURER F:_
COVERAGES ��_ CERTIFICATE NUMBER: 655152 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD I
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO HICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HE W
REIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR 'ADDLMASK POLICY EFF POLICY EXP _ USSR'S
LTR TYPE OF INSURANCE ..--D ND POLICY NUMBER EMM10GrYYYYL�bWP. A
ma
COMMERCIAL GENERALLIABIUTY EACH OCCURRENCE S _ ._..,. „m...._..---
WAG, O R.:nfTEC
. CLAIMS-MADE n OCCUR PREMISES rEa occumnul ..5 _
MED EXP(Any one 5 1I ) I S
N/A PERSONAL&ADV INJURY S .__
GE N'L AGGREGATE LIMIT APPLIES PER: - I I GENERAL AGGREGATE •S
POLICY !Eli I LOC _COMP/OP
5
•OTHER. --- ) - _..._.___._ U COM91NEO SiN L'Y IT S
AUTOMOBILE LIABILITY IEEecddenl;
I BODILY INJURY(Per person) S � - ���.....
i ANY AUTO I ,
1 ALL OWNED SCHEDULED N/A PROPERTY DAMAGE BODILY INJURY(Per acddeni) 5
AUTOS NON-OWNED ! i :Per accideru: �', __-
HIRED AUTOS AUTOS I
I I 5
UMBRELLALIAB OCCUR EACH OCCURRENCE S
I EXCESS LIAR CLAIMS-MADE' N/A AGGREGATE ,S
DEO RETENTIONS J, s
u
WORKERS COMPENSATION PET!—... OTH•
!AND EMPLOYERS'LIABILITY X STATUTE EIt
YIN EL.EACH ACCIDENT s 100,000
'ANYFROPREETOWPA CLUOEEXECUTIVE
A OFF10EFVMEMaEREXCLUDED9 IN1A/'WA WA AWC40070383902021A 05/01/2021 0510112022
(Mandatory In NHI E.L.DISEASE•EA EMPLOYEE S 100,000 _
D desurheN OF OPERATIONS below un�r I E.L.DISEASE•POLICY LIMIT S 500,000
DESCRIPTIO
I
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES IACORO 101,Additional Remarks Schedute,may be attached If more space Is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 46 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 certiEcala 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 i
certificate of insurance). The status of this coverage can oe monitored dolly by accessing the Proof of Coverage-Coverage Verification Search tool at
WNW-MOSS,govAiwdMrorkers-compensa tlan/investigations/.
i
Sole proprietor has not elected coverage.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
11
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Matt Murphy Construction ACCORDANCE WITH THE POLICY PROVISIONS.
329 Southampton Road
AUTHORIZED REPRESENTATIVE
Westhampton MA 01027 `—•g`"t
Daniel M.Croww)ey,CPCU,Vice President—Residual Market—WCRIBMA
0 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
I ACORD 2bjtu1cow/