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35-115 (11) BP-► 022-1132 14 DREWSEN DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-115-001 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-2022-1132 PERMISSION'S HEREBY GRANTE I TO: Project# ROOF Contractor: License: Est. Cost: 12886 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date:07/08/2023 Use Group: Owner: WARE ROSEMARY Lot Size (sq.ft.) Zoning: WSP Applicant: DL WEST ROOFING CONTRACTOR Apalicant Address Phone: Insurance: 11 PLYMOUTH AVE FLORENCE, MA 01062 ISSUED ON:09/12/2022 TO PERFORM THE FOLLO WING WORK: STRIP AND RE-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: 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 VIOL, TION OF ANY OF ITS RULES AND REGULATIONS. Signature: I e, • b >2 . TADIT Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner sryo'�9o0 �dsN N��Wb 444,0 The Commonwealth of Massachus•tts Jy°iN „I° o Board of Building Regulations and S .ndar,s0� ` MU�C IOP LITY \ Massachusetts State Building Code, 80 C alas U• Building Permit Application To Construct, Repair, Reno': e .' ish a ' vise, Mar 2011 One- or Two-Family Dwelling �\ J This Section For Official Use Only V / Building Permit Number: 6P',Rai -I) 3?, to A lied: \� 41110 y0 942- OZ2 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers I`l 0 Sew Or. 1.1a Is this an accepted street?yes_ no__ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: -_ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ow,�,gqer'_�of Record: t.Yw'i S W e_ ecncoArA, tl - (2(,fl ce Z Name(Print) City,State,ZIP 1 ki arc—Se-JA C)_r. — - ctAk 68$"1-S28 civcsmLoctie 81 0 I.Kok,. 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 Specify: (nn(y,. Brief Description of Proposed W ,�urk'. tey� Q�cv . ex(SFt�✓t 4 ha-tk `o& avt.eA a��fL ge,pk4(4 3.«$le . SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ t J ,. 1. Building Permit Fee: $ Indicate how fee is determined: 1 $ � ❑ Standard City/Town Application Fee 2. Electrical $ — 0 Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:A Check No.VXV Check Amount: _Cash Amount: 6.Total Project Cost: $ `21$ • 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) A ..�,, C GSS — f°4 os7 18/20z3 I4%& lJl.L. cat' License Number Extion Date Name of CSL Holder l P Q • List CSL Type(see below) No.and Strebt Type Description ` � IAA , OIZ U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP ` R Restricted 1&2 Family Dwelling M Masonry Roofing Covering S Window and Siding 4SF Solid Fuel Burning Appliances O —431 Alizc4 /sig,spa(.(i' owl I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contract r(HIC) �g 32�- t.(0,1292/�'L' `)""-5' ` i\s �� r HIC Registration Number atin Date HIC Company Nam 'r HIC Re str�nt Name llxttn4_.0)vt ! ��wB1S0� I Cbw No. c l e , i ©r 7 A ry '4-3 I r Email a ss City/Town, State,ZIP l Telephone t ` 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 .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 e\--)ayeA t._93<esif to act on my behalf,in all matters relative to work authorized by this building permit application. CIA-65 brig_ V iteru- Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By enterin y name below, I hereby attest under the pains and penalties of perjury that all of the information containe i this is on is true and accurate to the best of my knowledge and understanding. 1/1/147V--- Print ner'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" _ City of Northampton Oa H M 7 p c Massachusetts � �.. '' ;e "c' * r r DEPARTMENT OF BUILDING INSPECTIONS y ,x,- °} ' , � 212 Main Street • Municipal Building :�� .,b~_' 4e Northampton, MA 01060 'st-yti, 1;-,ti\''' 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: 04,11 RCS-le-U.tk- 231 f . &, V1pc--4-kral kt4r\) VIA4. OlcCeD The debris will be transported by: Name of Hauler: c--).L L9-0...e2A-- il. 'v3 &1 etc Signature of Applicant: M Date: i'1/117V— / The Commonwealth of Massachusetts 7•__•( Department of Industrial.-leeidents I Congress Street Suite 100 Boston. MA 02114-201 7 ww;I:mass.govidia Workers'Compensation Insurance Affid A%it:Builders/Contract orstEkciricians/Plumbers. -11)BE FILED 1511 It I 111:. PERMI'll'IN(;At 111012E11. Applicant Information Please Print 1.-egibl% Name I Ru csOranwlhH I nd 0,id HAI rk„. (ebr\loicealibe- Address: ux—Aftc4. City/State/Zi pc(rctimll VW. OiP(Ce_ Phone# 31 13 Are all employ er? larek the appropriate NA: pe of project(required): 1.4t ara a erripts,cr'with (fun arinfor parmi IOC I 7_ (J New constraction 20 I am a MAC proprietor or piatnership and have mi employee orking for me an K. a Remodeling Any capacity. [No workers'comp.insurance required.) 9. EI Demolition 10I am a liorriorywner doing all work myself.[No workers'curry immunise required] 10 Q Building addition 4.Cj ani a hormowner and will he hiring oontractora to conduct all work on my properry,„ 1 will mom:that all contractors either 11118A: akiracorripensation insurance or are sole I IC Electrical repairs or additions proprietors with no rnriployees. 12.0 Plumbing repairs or addition, I am a general contractor anti I have hired the Aktb-ctxratuctors listed on the attached such. 13. Roofrepairs hest witi-eindrictors base emokiyees and have workers'comp.rusurance.z 14..n Other 60 We an:a corporation and itsofficers have ekiicised their right of exemption per kW&c. 15.2,4114).and we haw no employees.[No workers comp.Insurance trquire.c.i.1 *Any applicant that cheeks brat n I most a6o fill out the section helow showing their workers'compensation pulley niformatrorL Homeowners who submit this affidavit indicating they are domp all work and then hut outside conlmetors must submit a new artida4,ii tContractors that cheek this hos must attiwbred an Additional sheet show ing the name of the sahcontructors and state whether in not those err titich employees. If die soh-cirOtraitots IsarernsIo its.they must prier ilk'tiwir workers'comp 1.74.,he:, 1 am an employer that is providing workers"eompensuiion insurance for my employees. Below is the policy an job site information. Insurance Company Name: Ai ri\ Policy#or Self-ms. Lie. #:AUK. +61 CrY.4-3'107622-,X Expiration Date: '7C? 3 Job Site Address: teA Cpc?..s.t_T-){5\ 1. CityStateiZip c-C 1:5(0(e Attach a copy of the workers'compensation policy declaration page(showing the policy number and. phi Ion date). Failure to secure coverage as reunited under MGL c. 152, §25A is a criminal violation punishable by a tine tip to Si,500.00 and one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to 5250.00 a day against the iolator. A copy of this statement may be forwarded to the()Bice of Investigations of the DIA fórinsuraitce I(hi hereby ee under he piii A and penalties of perjury that tha J+r/ trnru!ron proeided ht.; e is true and cornett Si tuic. / i)ate, q 17Z-7-- Phone#: 3 s- 3 II Official use only. Do not write in this area.to be completed hi city or town official Cit or To n: Per rilitlicense Issuing Author it teircle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ,ACo D CERTIFICATE OF LIABILITY INSURANCE LDATE)MM(DD""YY) 06/03/2022 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: Travis Sias KSK INSURANCE AGENCY INC PHONE Ext; (413)527-7859 FAX _IA/C,No8 E-MAIL. ADDRESS: travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAIC EASTHAMPTON MA 01027 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B DANIEL WEST INSURERC: D L WEST ROOFING CONTRACTOR INSURER D: 11 PLYMOUTH AVE INSURER E: FLORENCE MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: 781048 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 RESP 'CT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT Tb ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR EFF POLICY EXP LTR TYPE OF INSURANCE INSQWVD POLICY NUMBER 1MM/DY/YYYY) (MM DD//YYYYl LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) , $ MED EXP(Any one person) $ • N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 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) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per.accident) UMBRELLA GAB OCCUR EACH OCCURRENCE $ EXCESS GAB CLAIMS-MADE N/A AGGREGATE _ $ DED RETENTION$ $ WORKERS COMPENSATION - PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A AWC40070363902022A 05/01/2022 05/01/2023 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/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.rnass.gov/Iwd/workers-compensation/investigations/. 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 ACCORDANCE WITH THE POLICY PROVISIONS. Matt Murphy Construction 329 Southampton Road AUTHORIZED REPRESENTATIVE westhampton MA 01027 1 Daniel M.Crovwley, 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