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24C-170 (4) BP-2022-0767 67 FRANKLIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24C-170-001 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-2022-0767 PERMISSIONIS HEREBY GRANTED TO: Project# SKYLIGHT Contractor: License: Est. Cost: 1900 THOMAS ROBERTS 100333 Const.Class: Exp.Date:07/03/2022 Use Group: Owner: TAYLOR-WALDMAN KETAY SARAH &AARON Lot Size (sq.ft.) Zoning: URB Applicant: ROBERTS ROOFS CO INC Applicant Address Phone: Insurance: P O BOX 1312 (413)283-4395 2008W6216 BONDSVILLE, MA 01009 ISSUED ON:06/28/2022 TO PERFORM THE FOLLOWING WORK: REPLACE SKYLIGHT 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 NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: ''/ Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 • Office of the Buildine Commissioner DocuSign Envelope ID:EB579983-5137-4FA6-9805-02964E25DE67 � / vE-D The Commonwealth of Massachusetts i .. Board of Building Regulations and Strand F Massachusetts State Building Code, 780.CMI ,27il(m-nrrvc M ICI ALITY „..`44mnTon rnJgpEc rro+vs UE Building Permit Application To Construct, Repair, Renovate Or ADem '''07 URevised ar 2011 One-or Two-Family Dwelling This Section For Official Use Only Buildin Permit Number:4,s g P- 2� —7 4 7 //Date Applied: lSEV/0 C / (,` 28 Zdz2 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numb us,,, 67 Franklin Street cA Y c. I g70 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' 2.1 Owner'of Record: Sarah Ketay Northampton,MA 01060 Name(Print) City, State,ZIP 67 Franklin Street (631)241-3177 sarah.ketay©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 0 Specify: Brief Description of Proposed Work': Remove&replace skylight SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑ 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: $ it o Check Nol t 5 I Check Amount: Cash Amount: 6.Total Project Cost: $1,900.00 ❑ Paid in Full 0 Outstanding Balance Due: DocuSign Envelope ID:EB579983-5137-4FA6-9805-02964E25DE67 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 100333 7/3/24 Thomas R Roberts,Jr License Number Expiration Date Name of CSL Holder List CSL Type(see below) RC 400 Franklin Street No.and Street Type Description Belchertown,MA 01007 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry P. 1�//�� RC Roofing Covering Y• WS Window and Siding SF Solid Fuel Burning Appliances 413-283-4395 info@robertsroofsinc.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 128264 3/16/23 Roberts Roofs Co.,Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name PO Box 1312 info@robertsroofsinc.com No.and Street Email address Bondsville,MA 01009 413-283-4395 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 to 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 Roberts Roofs Co.,Inc. to act ons.my behalf,in all matters relative to work authorized by this building permit application. ocu ign by: Sa„ 6/23/2022 `'rinPT9 �NM a(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. P' wner's r Authorized Agen 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" DocuSign Envelope ID:EB579983-5137-4FA6-9805-02964E25DE67 City of Northampton HAMp' Massachusetts a? :. 'e ilitDEPARTNT OF BUILDINGINSPECTIONSa• ,je° \ , 212 Main Street • Municipal Building y{.. c� j° _ Northampton, MA 01060 �sb%jy • 1'�0 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: _ Re -Ervefli U cy- NA The debris will be transported by: Name of Hauler: R010erkS (Z001-s Cc.>. ; ii- c' . Signature of Applicant: • ---� Date: 61)-3/?)- r The Commonwealth of Massachusetts Department of Industrial Accidents =Lam= Office of Investigations 600 Washington Street -=1I�= Boston, MA 02111 ''�-.:.• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Roberts Roofs Co., Inc. Address: PO Box 1312 City/State/Zip: Bondsville, MA 01009 Phone #: 413-283-4395 Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 2 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are 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 information. Insurance Company Name: Farm Family Casualty Insurance Company Policy#or Self-ins. Lic.#: 2008W6216 Expiration Date: 4/17/2023 Job Site Address:67 Franklin Street City/State/Zip:Northampton, MA 01060 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: f,I.13'.9--- Phone#: 13-283-4395 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ,4 CERTIFICATE OF LIABILITY INSURANCE 04%b( 7; 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 POUCIES 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 Ce°KrACT Sean Rooney Sean Patrick Rooney,Sr.dba PH NI10 E:tt: 413-887-8817 uvc.�). 877-771-6087 Rooney Insurance Services E-MAIL D(DRESS: sean.rooney©fam)-family.com 2341 Boston Rd. INSURERS)AFFORDING COVERAGE RAC# Wilbraham MA 01095 INSURER A Farm Family Casualty Insurance Company 13803 INSURED INSURER B: ROBERT'S ROOFS INC INSURERC: 40 Franklin St INSURER D, Belchertown MA 01007 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 ADM SUER POLICY EFF POUCY ESP LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER (MAYDD/YYYY► (MWDD/YYYY) LAMM X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f 2,000,000 DAMAGE TO R CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $ A X BOP _ X X 2007X0329 04/17/22 04/17/23 MED EXP(Any one person) s5,000 PERSONAL SADV INJURY $1.000,000 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s4,000,000 X POLICY JEO Li LOC PRODUCTS-COMP/OP AGG $4"000 000 OTHER $ AUTOMOBILE L ABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO _ BODILY INJURY(Per person) f A X ALL OWNED SCHEDULED X 2001C4685 04/24/22 04/24/23 BODILY INJURY(Per accident) $ _ AUTOS _ AUTOS X ED PROPERTY DAMAGE $ HIRED AUTOS X AUTOS AUTOS (Per accident) S UMBRELLA LIAR _ OCCUR EACH OCCURRENCE S EXCESS LIAR_ CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION /\ STATUTE ER AND EMPLOYERS'LIABILITY A 'ANY PROPRIETOR/PARTNER/EXECUTNE Y/N N/A X 2008W6216 04/17/22 04/17/23 E.L EACH ACCIDENTOFFICER/ME $500,000 (Mandatory In NH)ER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000 ff es,debe under DESCRIIPTITION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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 Sean Patrick Rooney,Sr. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014(01) The ACORD name and logo are registered marks of ACORD VDivision of Professional Licensure Board of Building Regulations and Standards ConstructConstructieoNSW4iVispr Specialty CSSL-100333 cpires: 07/03/2022 THOMAS R ROBERTS, JR •" 400 FRANKLIN STREET BELCHERTOWN MA 01007 ♦ `�,, n Commissioner dr.LA K. Y`&uji i Construction Supervisor Specialty Restricted to: CSSL-RF - Roofing Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call (617) 727-3200 or visit www.mass.gov/dpl Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation ROBERTS ROOFS CO. INC. Registration: p 128264 Expiration: 03/16/2023 PO BOX 1312 BONDSVILLE,MA 01009 Update Address and Return Card. SCA 1 C., 20M-O5/17 .//r (riiui/rfiivii//�r/. ,4.41,76/iar//.I Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 128264 03/16/2023 1000 Washington Street -Suite 710 ROBERTS ROOFS CO. INC. Boston,MA 02118 THOMAS R.ROBERTS JR Any /2. 1)„,..4.30 400 FRANKLIN ST � �i mGf�iaLc V BELCHERTOWN,MA 01007 Undersecretary Not valid without signature