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18D-012 (2) BP-2022-1192 46 PINE BROOK CURVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 18D-012-001 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-2022-1192 PERMISSION IS HEREBY GRANTED TO: Project# ROOF Contractor: License: Est. Cost: 13395 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date:07/08/2023 Use Group: Owner: BEAUREGARD KATHLEEN A Lot Size (sq.ft.) Zoning: URB Applicant: DL WEST ROOFING CONTRACTOR Applicant Address Phone: Insurance: 11 PLYMOUTH AVE FLORENCE, MA 01062 ISSUED ON:09/23/2022 TO PERFORM THE FOLLOWING WORK: STRIP AND RE-SHINGLE 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: it TAIT Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner ' 1%.% The Commonwealth of Massach "setts /1/ W Board of Building Regulations anOtan rds sFA OR Massachusetts State Building Code, 78 R <2/ NIC ALITY �rnF �aa E Building Permit Application To Construct, Repair, Reno':• 'Qr molls evis“ Mar2011 qM 4i�� One- or Two-Family Dwelling ro„/'vsn This Section For Official Use Only �1 o ctioN Building Permit Number: 8A" a a /-10�- Date Ap lied: °u S ii...) as // CI'22-Zig2 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1Prip�errty Address1.2 Assessors Map& Parcel Numbers 1 CC,o K (Prug. 1.1 a Is this an accepted street?yes 04_ 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: Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 AccessoryBldg. 0 Number of Units Other S eci W '' 1,.�_—� r p � Brief Description of Proposed Work': k`,Q.1Ma9Q 1IN Q&.. .r-Q- SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ `"7SI�G ',�— 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: $ liq� Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 2C1�'� `�1 • ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ►A( Licenssee Number Exp ati Date Name of CSL Holder List CSL Type(see below) f'kC No.and Stree Type Description .c r..vi, p n � Unrestricted(Buildings up to 35,000 Cu.ft.) �e 1,^v 1 ( cel_ R Restricted l&2 Family Dwelling City/Town,State,ZIP( Masonry Roofing Covering WS Window and Siding cI ',_` Q SF Solid Fuel Burning Appliances 61.j CAS-1'3(� alAP.)` 6 5T r<ti •(¢f►, I Insulation Telephone Email ad e D Demolition 5.2 Registered Home Improvement�� Contractor� _ (HIC) '�S3.,Z1 `(i �,/ bk. I�x'�l&C �+� �` HIC Registration Number E pira ton Datel HIC Ccompa�bnylName,o�HIS 4�stra4►t Name k, l- nd St et et d-RA. • c(co g' 40 S a t' "13Cs( Q MR. d(O(.!'Z (�- 3_)/ s 3� ` dress City/Town,Stdlte,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 .' 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 t L Csq(kk.Lfor to act on my behalf, in all matters relative to work authorized by this building permit application. r-QOA -C CQ ,t 9F-tofr-ozz-- Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering y name below, 1 hereby attest under the pains and penalties of perjury that all of the information containe this ic 'on is true and accurate to the best of my knowledge and understanding. ifec Print ner's or uthorized Agents 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. I42A. Other important information on the HIC Program can be fot,nd 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 i Massachusetts �� :_ DEPARTMENT OF BUILDING INSPECTIONS -. PP x. 212 Main Street • Municipal Building v1 ,...? ' Northampton, MA 01060 s:r Ilit t1�1� 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: ik t t-S 131 Cetb j / 1A OM- a(6cZ The debris will be transported by: Name of Hauler: %-(-• c t" ,h vt3 aCll5k- Signature of Applicant: Date: 7 elicit-- The Commonwealth of..,Wassachusetts Deportment of Industrial Accidents ---14--- I Congress Street, Suite 100 1L3 :,.--,v Boston, MA 021141-201 7 -;3 4 ,0 E.m ass.govidia 1%4.11 kers'Compensation Insurance A Hula s it: BuildersiContractorsfElectricians/Plumbers. 1'0 HE FILE0 IA I 1 it i 111 PERMIT1ING At rtIORITA. .lonlicant Information Please Print 1,..eeihh, Name t aukinessilksanmat ton I ndivntlual): 00.11/414 ,,,....1.9.1 — _ Address: V\V-VtOtis6 -kii_ 0--2.0 - City/State/Zip: •CLIDezpve.A7. po. bcp.(<2, Phone . — Ate you an employ cr.?t"htek tio•apprupriak law Type of project(required): I.0 I am a employ LT IA ith employees flail anytor part-rink.1.* 7. 0 Nekk eorwructim :20 I am a lit:prOpilektr Or part&IL-pailp and bait..au employees working for me in I 8. 0 Remodeling airs capacity. [Nu workiera comp.minimum required.] 9. 0 Demolition k..0 I am a hommiwner doing all work myik-If..[No workers"comp.wouranoe matured.)' i 0 ci Budding addition 40 I am a fiumeowina and will be hiring mnitractues to conduct all work 4311 my property. 1 will ensure that all eingrucium either It workers"cornpensamin insurance or WV SA: I I 0 Electrical repairs or additions propmetrini v,ith no employees.. / . I 1.0 Plumbing repairs or additions 0 I am a general contractor and I IVO`L'hired dm a.utuoiintractori.hated on die attached shim. I 30 Roof repairs These lb-Clitaractors ha e employeea and base workers" orip.mainarice.: ; I 4_ROthei N.44-7 kOcCf 0.0 We am a corporation and im offiveni have exemiscd then right of exemption per MU c. 152414i.and we have no L-mployees.[No workers'comp.insurance sequivettj 'Any applicatm that chocks box.01 moat also till out Lire Seetifini NAM'SkILY%trig then workers'wmpernation poi my t Ill,;(1:litElOCI, ' tkillatV*Ver%Who submit this affidavit indicating they arts doing ad work and than hire outside commetaira must Nhbutit a rte*affkias,it indnatuag such. IContractors that ote.,...i this box mum attacbod an additional sheet show mg die name of the sull.-cotitructorN anct sate whether ilt nut thkne titti An*IOW CtrIplOyemnr, if the hilb-iAglinfaCVN!lake employees.they must prod c their workers"mwrip.policy number . _ . 1 am on employer that is providing ovoriers°compensation insurance fin-my employees. Below is the policy and job site information. Insurance Company Name: Ac---- 'S-.V\IVi \Mt,it..-44 IAK-S• Ce). — Policy '4 or Self-ins. Lic. 41 PC..1490q--0340,3,2,022-4 Expiration Date: S I 1-07-3 Job Site Address: 9,6 Lie. psi, Orb044 C3XVe 1 City'State'Zip: 6.0(Stil•e-2,), INV( •CAC)(e0 Attach a copy of the n rkers' compensation polky declaration page(showing the policy number an expiration date). Failure to secure coverage as required under MCA_ e. 152, §25A is a CrtinInal siolation punishable by a line up to SI,500.00 artd`or one-year imprisonment,as well as civil penalties in the form old STOP WORK ORDER and a fine of up to S250.00 a day apinq the violator. A copy of this statement ina be forwarded to the Office of Investigations of the DIA for insurance CI Ilk at in. I do hereby cer ,ttnde I e 1 tins and pe..otalties of perjury that the in fOrmation provided a ove ..s true anti correct . IC tatt *nature: 1).0z. et Phone#: C 3)ttg 5----4 3 1 ( Official use only. Do not write in this area,to be completed by city or limit official City or"1"0'4%ft: Permit/License 4 Issuing Authority (circle one): I. Board of Health 2. Building Department 3.City:"Iiissn Clerk 4.Electrical Inspector 5. Plumbing Inspector 6,Other Contact Person: Phone#: 1 IPPPP Ac�® DATE(MMIDDIYYYY) � . CERTIFICATE OF LIABILITY INSURANCE 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 poltcy(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 Travis Sias NAME: KSK INSURANCE AGENCY INC P�/"�N Eztl; (413)527-7859 lac,NO E-MAIL travissias@ksk-insurance.com ADDRESSL Q 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE — NAMN EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: • , DANIEL WEST INSURER C: , D L WEST ROOFING CONTRACTOR INSURER D: 11 PLYMOUTH AVE INSURER E: I FLORENCE MA 01062 INSURERF: - 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 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 AObL SUER POLICY EFF POLICY EXP LIMITS L.TR TYPE OF INSURANCE JNSD•WV➢ POLICY NUMBER LM/DDTYYYYI IM IY MIDDYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMACLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ • N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO I JECT I LOC PRODUCTS-COMPIOP 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 S NON-OWNED PROPERTY DAMAGE $ _ HIRED AUTOS AUTOS -(Per.accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION • X STATUTE ERA AND EMPLOYERS'LIABILITY Y/N 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, S 100,000 11 yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 r N/A DESCRIPTION OF OPERATIONS I 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 t'le 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.gov4wd/workers-compensationfinvestigations/. 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 $E DELIVERED IN Matt Murphy Construction ACCORDANCE WITH THE POLICY PROVISIONS. 329 Southampton Road AUTHORIZED REPRESENTATIVE Westhampton MA 01027 Daniel M.CroW)ey,CPCU.Vice President--Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD