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31B-277 (15)
BP-2022-1221 55 STATE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31 B-277-001 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 Permit # BP-2022,1221 PERMISSIONIS HEREBY GRANTE'/ TO: Project# ROOF Contractor: License: Est. Cost: 20000 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date:07/08/2023 Use Group: Owner: COOPER'S DA1 RYLAND OF NTON 1 C Lot Size (sq.ft.) Zoning: CB Applicant: DL WEST ROOFING CONTRACTOR Applicant Address Phone: Insurance: 11 PLYMOUTH AVE AWC4007036390 FLORENCE, MA 01062 ISSUED ON:09/29/2022 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 VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: mill+aAK b . . 1.dL I ' Fees Paid: $140.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner lam) I' , . The Commonwealth of Massa us its I I Board of Building Regulations and S ndaris sEP . ` \C / Massachusetts State Building Code, 80 C R I M ANICI E n ALITY Building Permit Application To Construct, Repair, o $:.`!_ !-coolish a� 'evise Mar 2011 One-or Two-Family Dwelling `oryn IN IN This Section For Official Use Only �-�'' .�'1 n oNS Building Permit Number: /�j- o•d,.).'.1?)-1 Date Applied: `_jallAfik, 1 ,5�1i n BuildingOfficial(Print Name) A L 4/a7/a� Signature Dafe SECTIO N 1: SITE INFORMATION 1.1 Propertys Address:kk �� 1. al,i..sprs Map& Parcel Numbers 77 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 ¢,wne r of Record: K l Csbo 'Meet n 1 uv\A• '-b`{e Name(Print) City,State,ZIP SS S k-e St-re- 6.10),c(e3 cliciSY No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Cl Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other c Specify:tEQl.a� _ Brief Description of Proposed Work': R.ei ip rext. c. 4244t.f& Se LV r54-41 q 4 4 v wu_a -o 9.tdo SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ .20j00G-. .— 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost' (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ -- Suppression) Total All Fees:A� / Check No.1/11(�1 Check Amount. I6b Cash Amount: 6.Total Project Cost: $ Ijo le)06 r' ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CAS(.—tag oor- SVNj�QA �ja License Number AfttiC) t Date Name of CSL Holder la C k` P4 List CSL Type(see below)No.and Street Type Description UC � L e '�• ��e2 R Unrestricted(Buildings up to 35,000 Cu.ft.) —�Gt fP R Restricted 1&2 Family Dwelling City/Town,State,Z M Masonry /AO Roofing Covering WS Window and Siding I SF Solid Fuel Burning Appliances <<3 5--` 3(t CALW1a`4s 7`1V1tkl•c_ I Insulation Telephone Email a'SI ess D Demolition 5.2 Registered Home Improvement Contractor (HIC) t�rb.32� �•L‘ CoMv-r��6/ HIC Registration Number Ekpiration Date HIC Co any Name or HIC HIC R�Name II ` _n \` nn b � a��e• �K1'�� 1'Lin No.and Stre t Email a ress e rom.c.et NAA. �qssez 3)665- 3 \ 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 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 perm' application. C0n Cab 5(-6(1-traZ Print Owner's Name(El ctronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By enterin t my name below, I hereby attest under the pains and penalties of perjury that all of the information contain-i th.: p cation is true and accurate to the best of my knowledge and understanding. — — ii/e/le_es Pri owner's or A thorized 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 r••, -No,' Massachusetts �Y .- �.y A DEPARTMENT OF BUILDING INSPECTIONS �', �;' 212 Main Street • Municipal Building „$' Northampton, MA 01060 SS`�- ��\''�' 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: Q6;(.1 Veciidi..145 1 b1 `�s ( vim• NbC• kfitr\f nAA•6(64 a The debris will be transported by: Name of Hauler: Q-L 0 1ti 14, 34%?K-- Signature of Applicant: Date: 1 r "it- The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston, MA 02114-201 WIV W.In ass.gowdia IS I»kers' (*inn pc risa t ion Insurance„X Hid a%it: lin i I de rs (OntractursiEkrt rici a iisifPlu m h ers.. Ill itt:1:11:121)1.4 I III I BE PERS]IIII NG AtiTtIORITI", Applicant Information Please Print Letlibls . Name 03 usliwN.h Organization=indivniusi): 0- *(•-•` ii--41,44i.v .s&A,tifrizior Address: kk_ fllyvta..441 CLPe. — , City/State/Zip: rboreAA-t-tt (IAA- 6t0 -7.- Phone Are!foe ita employer?Cheek the Appropriate oasi Type of project(required): 1.Zifila a employer with,. _. , .,,,,employees tintt and part-tinki." 7_ 0 NW kii' nstruction 20 I am a sole proprietor or partnership and have nu empliyyees working for me in 8. 0 Remodeling any capacity [No workers'comp.insurance reguired.1 , 9. D Demolition 10 I AM a IlAnnootkilet doing all work myself.[NO workers'conc.innAnnina:rOgnintill.]' 100 Building addition 4.0 I am a homeownet and AA ill be hiring oontrakturs EO conduct all work on my preperty. I will mum that all contractors either ha‘c worker%-compensation insurance or are sole 110 Electrical repairs or addition!, proprietors w ith no employees. i 2.0 Plumbing repairs or additiorb ,.0 I am a general contniCtOr and I Irene hired the mh-contractors listed on the attached sheet. I 31:1 Roof repairs Thee SOLA-COntractoni have employees and hose workers comp.insurame.; 14.,El Other 6.0 We are a comeration and its offneers ha ve exercised then nein of exemption per MU c. 152.§1 I 41..and we 11.1AV no aratployoca.[No IACatenc'emir.insurance requined.1 'Any applicant that checks boa 41 mum also till out the section below shuts inF their workers'compensation policy UtiiMitlail4M1 'HOIDODWISCr who submit this affidavit indicanne they are doing all work and then hue outside contractors must submit a new allidak,it indicating such. ;Contractors that cheek this hot must attached an additional sheet showing the name of the sub-cinitractors and state whether or not those eon e,base employee, if the sub-contractors lime employeCh.1110.1 ISIUNI proaid c then workers'comp.poky number. I am an employer that is providing ovoriers'compensation insurance for my employees. Below is the policy an I job.ite information. Insurance Company Name: A-I • (AA, 0(31144 Sio:,_ Co . _ Policy#or Self-ins.Lie.#: AnC.. q..P59-05‘"34LOI.1:52-1—,4- Expiration Date: 6 i (Ittit-5 Job Site Address: SS . lect< ..Sk' ' CityStateZip:V\341.64064/4, OAA- I's knkc) I Attach a copy of the NA orke rs• compensation polio declaration page(slim.%ing the policy number and expiration date). Failure to secure co‘e rage as requned under MCA_ c. I S2. §25A is a criminal tolation punishable by a tine up to S1.500_00 andior one-year imprisonment.as well as civil penalties in the form°fa STOP WORK ORDER and a tine of up to S250.00 a day against the violator. A copy of this statement may he tor ...irk.icd to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ee t.y lit ler the kt ins one,penaltieA of perjury that the information provided abol'eiN true and correct Sli.mature: - Date: 1./7 /1-15t1" Phone#: Li ) (.fic---43/( Official use only. Do not write in this area.to be completed by city or town official ( it% or lost n: Permit/License 4 issuing Autliorit) (circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing I ector 6. Other Contact Person: Phone 4: ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) L.....---- I 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 PH/CN o E,,t1, (413)527-7859 FAX — E-MAIL __(A/C,No).: ADDRESS: traviSsias@ksk-insurance.com 203 NORTHAMPTON ST _ INSURER(S)AFFORDING COVERAGE NAIL k EASTHAM1. PTON 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 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 ADDL SUER LTR TYPE OF INSURANCE POLICY EFF POLICY EXP INSD NIVD POLICY NUMBER (MMIDDIYYVY) (MMIDDIYYYY) LIM TS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY I I JECOT I I 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) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE I $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE I{ $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER 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 $ 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 tfle 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.gov/Iwd/workers-compensation/investigationst 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 I westhampton MA 01027 ( Daniel M.Crowjey,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