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24C-019 (22) BP-2022-1053 286 PROSPECT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24C-019-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT U NG Permit # BP-2022-1053 PERMISSIONIS HEREBY GRANTED TO: Project# ROOF Contractor: License: Est. Cost: 49500 MMC SPECIALTY ROOFING INC 76497 Const.Class: Exp.Date:06/07/2023 HAMPSHIRE REGIONAL YOUNG MEN'S Use Group: Owner: CHRISTIAN ASSOCIATION Lot Size (sq.ft.) Zoning: URA/URB Applicant: MMC SPECIALTY ROOFING INC Applicant Address Phone: Insurance: 176 PINEVALE ST (413)642-3842 AWC4007030594 INDIAN ORCHARD, MA 01 151 ISSUED ON:08/25/2022 TO PERFORM THE FOLLOWING WORK: STRIP AND RE-SHINGLE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of PIumbing 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: I ; I 52 3-- I . Fees Paid: $346.50 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner R ECEI V -� -_ _i 1 AUG 2 5 2022 i,,, 'he Commonwealth of Massachusetts 0, Office of Public Safety and Inspections -r.of euitOinu;iris' PECTIONS Massachusetts State Building Code(780 CMR) • n _�nOprFiA".4nT(�n; �1A01 �rmit.Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: ?2.-•10 S.1 Date Applied: Building Official: SECTION 1:LOCATION 254 [a:-QSp ci- st 4.)e(41„c—r-i-cAn v lcD C) Nc w.f :r-r Re3,o.-c.l YitkC.A No.and Street Ci trn. O`a Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building 2F Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 01 Specify: (ZOO C: Are building plans and/or construction documents being supplied as part of this permit applicatt'on? Yes 0 No git Is an Independent Structural Engineering Peer Review r uired? Yes 0 No ?' Brief Description of Proposed Work: I xc r eXcS.4i COcA-';tea �. ...gk� _)11 Jve �. - _ �s�� 060 Vf . a,.�ri "TPO - 4 S Lp--a-v,.-- L.,...);�,‘ Z.0 �c�cc c— l�ac-1-1,....- SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) E Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) 'M(C) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-ID R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA CI IBD IIA 0 IIBI] I IIIA 0 IIIB ❑ IV 0 VA 0 VBD SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information Sewage Disposal: Trench Permit Debris Removal: A trench will not be Licensed Disposal Site 0 Public❑ Check if outside Flood Zone 0 Indicate municipal 0 required 0 or trench or specify: Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes❑ or No❑ Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner N c.,,r, YM44 2819 Perfect- sk /-,kx ,M o i 06 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: ct) Ij-55Y' 7036 - - Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: M MI C 5 s..t'0.`i RC� 06. P; v � p0• Sic :+ T..�►�,r, rei...cd AM (Di t S Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor M NBC-- 5 fc��1 -i (2.4noz, 1-7.) Company Name ; CS — Li Name of Person Responsible for Construction License No. and Type if Applicable act 1t � k4; \ R 2 gam;�,�.��d� „,,,4 otic, o Street Address City/Town State Zip 413-t`iz 3542_ - - Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ L 1 cco (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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. 41444- i,JL)e Pc-b A.- Ma e -64i1 12 3/z Please print and sign name Title Telephone No. Date 299' kti Re . , jt riAnwir'k AAA Oi CD 77 1Sac1te.).co Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: . 11 8-25-ZOZ Z Name Date The Commonwealth of Massachusetts _ = Department of Industrial Accidents ,Tv Office of Investigations __; ;__; 600 Washington Street Boston, MA 02111 „7" .1s17 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /I AItL Spec ' (z60 , 3 Loc . Address: 76 �-t— City/State/Zip: „ 0,-- .,,,,i)AAA 01 t 51 Phone #: 3- c,ka _ 3 44 2 Are you an employer? Check the appropriate box: Type of project(required): 1.IN I am a employer with l 2.. 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. + 7 n Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.1] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.at Roof repairs insurance required.] t 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. 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: A I !p V\ ,MLitt',-1 Tr1 czw�� Policy# or Self-ins.Lic.#: Akk+ 40O •7C3C ;'Li 2022A Expiration Date:_ 6/7 j Job Site Address: 2i5.(o City/State/Zip. Nc c'tk-w..entOtt;.r Nl' Oi C 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 hereb cer d the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 2 `' Phone#: '12_ - 3 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#: City of Northampton `�tiiartir, . . Sf. `" '; Massachusetts ��S'. y. . ,:, �� DEPARTMENT OF BUILDING INSPECTIONS ?`. \�rp � tit ' 212 Main Street • Municipal Building yJ� �a' l Northampton, MA 01060 jsk;'3,j�'\�� 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: U1Ibc-r,--k^o-vv-) j /�A - The debris will be transported by: Name of Hauler: Acccr 1.-.- --c4e. c 5/2-0022._ Signature of Applicant: �- Date: L. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constry41 1Bi pprvisor i CS-076497 - xitpires:06/07/2023 CLIFTON FROST 89 MARSH HILL RD BRIMFIELD M j 01010 Commissioner Cla, K. BiEkm r..� ‘ U �"1 MMCSPEC-01 KAYLA AcoRO° CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) `� 7/12/2022 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(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 Kayla Marie Drinkwine NAME: Phillips Insurance Agency,Inc. PHONE 97 Center Street (Arc,No,Ext):(413)594-5984 I FAX (A/C,Nol:(413)592-8499 Chicopee,MA 01013 ADDRESS:kayla@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC/ INSURER A:The Cincinnati Insurance Companies INSURED INSURER B:Arbella Protection Insurance Company MMC Specialty Roofing Inc INSURER C:National Union Fire Ins Co. 19445 50 Valley View Drive INSURER D:A.I.M.Mutual Insurance Company Westfield,MA 01085 INSURER E:Liberty Mutual Insurance Co 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. RIM TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP UNITS LTR, INSD VNDIMMIDD/YYYYI (MMIDO/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CSU0147019 2/21/2022 2/21/2023 DDAMAGETO eo rrence) E 100,000 MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY x spa LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY (Ea accMBINEDiden SINGLE LIMIT t) 3 1,000,000 X ANY AUTO 1020117984 6/7/2022 6/7/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS yy E pBODILY INJURY(Per accident) $ AUR OS ONLY AUTOS ONLDY (-'er accident)D AMAGE $ . $ C X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 3 5,000,000 EXCESS(AB CLAIMS-MADE BE 018233585 6/7/2022 6/7/2023 AGGREGATE $ 5,000,000 DED RETENTION$ $ D WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY AWC-400-7030594-2022A 6/7/2022 6/7/2023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ __ FICERIMEMBEREXCLUDED? N NIA Mandatory In NH) E.L.DISEASE-EA EMPLOYEE, 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ E Worker's Compensatio WC5-33S-B21N4R-012 1/24/2022 1/24/2023 State of CT 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD