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11-015 (10) BP-2022-0504 34 RUSTLEWOOD RIDGE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 11-015-001 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-2022-0504 PERMISSIONISHEREBYGRANTED TO: Project# 2022 ROOF Contractor: License: Est. Cost: 12500 MICHAEL SHEA 071107 Const.Class: Exp.Date:04/24/2023 Use Group: Owner: K WHITE MATTHEW W&CHRISTINA Lot Size (sq.ft.) Zoning: WSP Applicant: FLORENCE ROOFING Applicant Address Phone: Insurance: 405 RYAN RD WC2-31S-374455-041 FLORENCE, MA 01062 ISSUED ON:05/10/2022 TO PERFORM THE FOLLO T11NG WORK: STRIP AND RESHINGLE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAIVjfPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: >2 . ,u Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 , . .-. .-•\-., 1 7.7''---- , _.„ The Commonwealth of Massachusetts iffxiy 9 Board of Building Regulations and Standards 202 , ' USE , ,FOR -, - Massachusetts State Building Code, 780 CMR . MUNICIPALITY Building Permit Application To Construct, Repair, Renovate'Or DemOish a Revised Mar 2011 fiv.,:„. ----- " One-or Two-Family Dwelling • ' r>in 4 This Section For Official Use Only ' -- Buildin Permit Number: 4e,...,AI, a50--54 Date Applied: 4--.01r. ) .Z5 ./71&- 5-10-2ozz Building Official(Print Name) Signature Date, SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors 7 Map& Parce Numbers. 34 Rustlewood Ridge IA a Is this an accepted street?yes x no Map Numr Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 1 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: Zone: Outside Flood Zone? Public 0 Private 0 Check if yes!: Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Matthew White Florence,MA. 01062 Name(Print) City,State,ZIP 34 Rustlewood Ridge 413-341-0240 VVhitefamilyshopping©gmail.com 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 la Specify:Roofing Brief Description of Proposed Work2:strip and re-shingle. SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined: CI 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 $ Total All Fees: $ Suppression) Check No.2,( / Check Amount. 0 Cash Amount: 6.Total Project Cost: $12,500.00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES I 5.1 Construction Supervisor License(CSL) CS-071107 4/24/23 C.Philip Andrikidis/d/b/a Florence Roofing License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 405 Ryan Rd. No.and Street Type Description Florence,MA.01062 U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry, RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-262-8007 florenceroofing@gmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 01573 I 8/26/23 C.Philip Andrikidis HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 405 Ryan Rd. florenceroofing@gmail.com No.and Street i Email address Florence,MA.01062 413-262-8007 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 0 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 to act on my behalf,in all matters relative to work authorized by this building permit application. 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 contai ' this ion is true and accurate to the best of my knowledge and understanding. C.Philip Andrikidis 5/6/22 Print Owner'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 Industrial Accidents M si 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gor/dia 11 usiters'('umpensation Insurance Affidavit:Builders/('ontractorsfElectriciansfPlumbers. TO BE FILED WITH"I"HE PERMITTING.AUTHORITY. Applicant Information Please Print lxeibly Name(BosinceaKkEanitationflndividual): C. Philip Andrikidis/d/b/a Florence Roofing Address: 405 Ryan Rd. City/State/Zip: Florence, MA. 01062 Phone#: 413-262-8007 Are yam an a tpliayee!Check the appropriate boa: Type of project(required): 1.07.4 I am a employer with 5 employers(full ardor part-tinge)-• 7. ®New construction 201 am a sok proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'wrap.insurance required" 30 I am a homeowner doing all wink myself_[No workers'comp.insurance required.l i 9. ❑Demolition 4.0 I a a ho own, and will be hiring corara►xors to conduct all work on my property. I will ®Building addition m n ensure that all contractors either have workers'compensation insurance or are sole 1 1.0 Electrical repairs or additions proprietors with no employees- 12_®Plumbing repairs or additions SO tam a general contractor and I have hid the subcontractors listed on the attached%beet. 13 Roof repairs These subcortrxwr.have employees and have workers'wrap.insurance) 6.0 We a a corporation and its officers have exercised right of per M(iL c. ! 14.12 Rip and Re shingle n 152,41(4).and we have no employees.[No workers'comp_insurance require".] *Any applicant thou chats bras.#1 mutt also bent the section below sbowirg their workers compensative Live policy idlommlion. t lisnneowvsers who submit this affidavit indicating Okay ant doi s all tardt and then hire outside oinuractrns guru admits saw affidavit hallos mak :t'unt actors that check this boa mutt attached as addition!limo glow+g 11ae aarne of the ntd.conerretnrs manias windier ay raft draw nftila ins employees. lithe sub-o.unracturs have ens luy ea.they mast provide their rvaicera ialcap.policy number.. I am an employer that is providing workers'compensation ixsartrAce for my employes. Below Is the policy and job site Information. Insurance Company Name: Liberty Mutual Fire Insurance Company Policy#or Self-ins.Lie.#: WC2-31S-374455-052 Expiration Date: 1/25/23 Job Site Address: 34 Rustlewood Ridge City/State/Zip: Florence, MA. 01062 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 certl nder th Les and penaltlrs of pMury that the information provided above is but and correct Signature: /2 Date: 5/6/22 Phone#: 413-262-8007 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): I.Board of Ilealth 2.Building Department 3.('ity'llown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton C ij 0,,...... sic Massachusetts 4.+ 'te t' c • DEPARTMENT OF BUILDING INSPECTIONS �3 je°y^ 212 Main Street • Municipal Building jt,. a' , Northampton, MA 01060 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: Valley Recycling Location of Facility: The debris will be transported by: Name of Hauler: Florence Roofing `?---j Signature of Applicant: Date: 5/6/22 AC RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/06/2022 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 CONTACT NAME: Susan Fleury KING & CUSHMAN INC PHONE /c No.Ext): (413)584-5610 FAX C,No); E-MAILSS: sfleury@kingcushman.com P 0 BOX 447 INSURER(S)AFFORDING COVERAGE NAIL# NORTHAMPTON MA 01061 INSURERA: LIBERTY MUTUAL FIRE INS CO 23035 INSURED INSURER B: C PHILIP ANDRIKIDIS INSURERC: DBA FLORENCE ROOFING INSURER D: 405 RYAN RD INSURER E: FLORENCE MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: 771921 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 ABDL TYPE OF INSURANCE 3UBR POUCY EFF POLICY EXPMI LIMITS LTR INSR WVD POLICY NUMBER (MDD/YYYY) (MMIDD/YYYn COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE OCCUR PREMISES(EaENTED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO L i LOC PRODUCTS-COMP/OP AGG $ PRO- JECT --- OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ER PER H AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNERJEXECUTIVE Y/N EL EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A WC231S374455052 01/25/2022 01/25/2023 - (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I 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.govilwd/workers-compensationtinvestigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton North Building Insp ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01062 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Ace CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/06/2022 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 NAME: Susan Fleury CIC CISR CPIA King&Cushman Inc. PHONE (413)584-5610 _ PAX (413)584-9322 A-MA A/C No,Eat): (A/C,NO): P.O.Box 447 IL sfleury@kingcushman.com ADDRESS; 176 King Street INSURER(S)AFFORDING COVERAGE NAIC It Northampton MA 01061 INSURER A: Hudson Specialty Ins Co INSURED INSURER B: National Union Fire Ins Co C Philip Andrikidis,DBA:Florence Rooting INSURER C: _ 405 Ryan Rd. INSURER D: INSURER E: Florence MA 01062 INSURERF: COVERAGES CERTIFICATE NUMBER: CL225604772 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 VVITH 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 ADOLSUBR- POLICY EFF POLICY EXP MI LIMITS INSD WVD POLICY NUMBER (MMIDDIYYYY) (MDD/YYYY) X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) S 5,000 A HBD100015188 02/13/2022 02/13/2023 PERSONAL BADVINJURY $ 1,000,000 GEMLAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO-JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 - OTHER S t 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 S AUTOS ONLY AUTOS ONLY (Per accident) X UMBRELLA LIAB OCCUR EACH OCCURRENCE S 5,000,000 B EXCESS LIAB CLAIMS-MADE BE021372491 09/06/2021 09/06/2022 AGGREGATE $ DED I 1 RETENTION$ S WORKERS COMPENSATION �T PER I I OTH- AND EMPLOYERS'LIABILITY Y/N I STATUTE f ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under �. DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Location:34 Rustlewood Ridge,Florence,MA 01062. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Northampton Department of Building Inspections ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St AUTHORIZED REPRESENTATIVE Northampton MA 01062 1 / - t fy kl.l.�- ! ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD