11C-063 (3) BP 2022-1222
75 ARCH ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
II C-063-001 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-2022-1222 PERMISSION'S HEREBY GRANTE'I TO:
Project# roof Contractor: License:
Est.Cost: 19870 DL WEST ROOFING CONTRACTOR 106007
Const.Class: Exp.Date:07/08/2023
Use Group: Owner: SWEENEY FRANCIS J & LINDA M T' USTEES
Lot Size (sq.ft.)
Zoning: URA Applicant: DL WEST ROOFING CONTRACTOR
Applicant Address Phone: Insurance:
11 PLYMOUTH AVE AWC4007036390
FLORENCE, MA 01062
ISSUED ON:09/27/2022
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: I-louse # 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:
. (NT
Fees Paid: $40.00
212Main Street, Phone(413)587-I240,Fax:(413)587-1272
Office of the Building Commissioner
- ,...;t:.------q---__
rT
The Commonwealth of Massachu tts Sep ,``:
Board of Building Regulations and S anda ds FO
it Massachusetts State Building Code, 80 No F� ���� M NIC ILITY
SE
Building Permit Application To Construct, Repair, Renova evise Mar 2011
One- or Two-Family Dwelling oN�qo •iON
�, s
This Section For Official Use Only
Building ermit Number: e:V2"4)..a Lf d).a Date Applied:
i am.,4Z- ___ i Z 9-Z7-2oZZ
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: / 1.2 Astes�o�s Map& Parcel Nurie e
e.
1.la Is this an accepted street?yes 0C" 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❑ Zone: _ Outside Flood Zone'? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
U-v .2ACtf (4 it 5 of -j UeRAA NSA• a tD 5 3
Name(Print) City,State,ZIP/
` At Stref4- 6-t(a)st 8--4,ZV8
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Additi 0
Demolition 0 Accessory Bldg. 0 Number of Units Ober 0 Specify: NAtI..A
Brief Description of Proposed Work': 16 ' -,--22 i., - 4441, a ! .J, •O a „La l h (k
144 �Sp((ck ro6c4' u Cs s in. --A. - `-- c k( • kt ,k
a< feu-(ci- sAA'✓ast . - -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ It aO t 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ �/ — 0 Standard City/Town Application Fee
---- 0 Total Project Cost; (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ / Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ tct S10,-- ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ( .5 L_to mz-9 $ 22=Z3
�AK\4 "" " License Number Ex ration Date
Name of CSL Holder C
List CSL Type(see below)
Pkimts, 4 cusx_,
No..and Slreet
Type Description
•„ ,t .ot�2 Unrestricted(Buildings up to 35,000 cu.ft.)
gat/Mt/LC-El \VVt R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
(R) Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
At))c. --43 l t 0.0-0`' ,5-0((uid/.6"&"` I Insulation
Telephone Email addres D Demolition
5.2 Registered Home Improvement Contractor
(HIC)
L- u. -. '"!'WUL` C�'euT�' a-,r HIC R�3?o Number Exp ation Date
HIC Company Name or HIC Registrant'Name
No. tet Email address
canu/ fbCeZ 60)6643U 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 ��. L)3tZ mpgl cvt,t,
to act on my behalf,in all matters relative to work authorized by this building permi?application.
q 71 'f_bZZ
Print Owner's Name(Electron c 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
containe this a pli tion is true and accurate to the best of my knowledge and understanding.
Prin 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
Massachusetts <,
I ' DEPARTMENT OF BUILDING INSPECTIONS ' �1 *;
212 Main Street • Municipal Building L &".
Northampton, MA 01060 sp��_ 1��v'�
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: Ut1- _l Lc&c Z3 - &S A'- v�`
(,l„n, ,� , . Uj 7,42 b
The debris will be transported by:
Name of Hauler: C- C CO-cc(/' 6�µ-, a . .%e.uc-
Signature of Applicant: /jo'"-----' Date: 4 '
„ The Commonwealth of Massachusetts
- Department of Industrial Accidents
I Congress Street, Suite 100
*I k Boston. MA 02114-2017
www.mass.goWdia
44A,r7., W
V1in-kers't'ompensation Insurance Affidavit:BuitdersiContritctors/ElectriciansiPlumbers.
'1'0 RE FILED WITH TI-IE PERMOTING AUTHORITY.
Applicant Information Please Print Leeiblv
I •
Name i tiusin, ,Organization I ndinridinal'i: C)-‘„;
Address:_tA Yktmirop.1-1A 4A01.-.
City/State;Zip:„P7,(7.0./W., 1,44.,„ 0M,Ce.2_ Phone #: • 6.1-3)
Asti yOu as eittpluer?t thintk the a ppropriata b*.t: Type of project(required):
1.211-am a employ et.With k eriaployees I,fun arittor part-time i+ 7. 0 New cOristructiOn
20 I ant a wile propnetor or parthership and hate 10.1 employees working for mt in 8, 0 Remodeling,
any capacity No w often'conp.mahatma requinal.j
9. 0 Demolition
301 am a homoawnm titans all work inymlf.[No woakm%”emir.imonnux.mituitAxl.)'
100 Building addition
4.0 lam a horwoownm and will be htmly.,,.)ontration,to conduct all work on my promrty. I will
atame that all otmtractora eithiy hare workers"compensation inialtanee or are sole
IIO Electrical repans or additions
proprietor's.with no employees.
: I 2.0 Plumbu .i repairs or additions
-.1 I am a imamal contmeter seal I lathe hired the sttheontnietins listed on the attached sheet
130 Roof repairs
° These sith-connactors have empkryeea and have workers'eomp.instininee.
1 4.n Other
.0 Sli'e are a corporation and its otikers has e exercised then righi of exemption per WI e.
152,)it,ti.,and we hate no ploves.[No worker,'comp.insurance legume&I
An applicant that clua:La boa a I mum also rill out the hicemon below show ins.their w LAMM,:WHIpt:Ths'Alon policy intornaatton,
'lionnaiwrsens who submit this artiaava mita:atm they are doing all work and then hue outside eunitaerstrs must'Anna a new atlidaw it Indic-Wig sixhi..
ICuritracton:that cheek this bitta must attached an arlditional sheet Show in the name of the$.1M-contrwtorN Alla state 0.holler rat nor those ottatic,hate
employecs. It the sub-eolaractees have employees.they must pros ide their workets'oomp,whey number.
I am On employer that is providing workers'compensation insurance fir my employees. Below is the policy tun!job site
informuthon.
(-1
Insurance Company Name: -I-.IN'1- I.) • 0)
—
Policy 4 or Sell-ins. Lie. #.: WC 4P0 .343 0-1-C Expiration Date: 6(1 ttcYZ
Job Site Address: 1-5 ArtA rsi City,-State'Zip: •• . r,I 3
Attach a copy of the workers compenution policy declaration page(showing the polio number a d expir tion date).
Failure to secure coverage as required under MCA, c. 152, §25A is a criminal violation punishable by a line up to t.L5OOMO
and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up th S250.t,K)a
d..iy against the violator. A copy of tins stiielnent may be forwarded to the Office of Investigations of the DIA 10: insurance
,:e%cruic VerifiCat ion.
I do hereby cern under i e in. one!pen al ties of-perjury that the infOrmation provided about:is true and correct
Sipatine: t•• Dale: I t(e" 10-22
Phone v: c(-1,(3) 66,5--1-3/t
Official use only.. Do not write in this area.to he completed by city or town Vidal
City or Town: Permit/License#
.....
Issuing Authority, (circle one):
I. Board of Health 2.Building Department 3.City rl'UN%ii Clerk 4.Electrical Inspector 5. Plumbing 111%otrim-
&Other
Contact Person: Phone 4:
.. .... .........____....
AccP® DATE(MMIDD VVYV)
Le......"---' 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 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 T
NAME: faVIS Sias '
KSK INSURANCE AGENCY INC H PHONE Exq; (413)527-7859 FAX ;
E-MAIL
ADDRESS: travissias alksk-insurance.com
203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAIC fl
EASTHAMPTON MA 01027 INSURER A: AIM MUTUAL INS CO 33758
. ,
INSURED • INSURER B:
DANIEL WEST INSURER C:
D L WEST ROOFING CONTRACTOR INSURER P.
11 PLYMOUTH AVE INSURER E:
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 TYPE OF INSURANCE ADOL SUER POLICY NUMBER POLICY EFF POLICY EXP LIM TS
LTR INSD.WVD (MMIOO/YYYY1 ,(MMIDD/YYYYI _
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
‘ DAMAGE TO RENTED
l CLAIMS•MADE OCCUR PREMISES(Ea occurrence) ' $
MED EXP(Any one person) ' $
. N/A PERSONAL&ADV INJURY $
GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $
1
OTHER: $
- _
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Eaa accident) r.
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $
AUTOS . AUTOS
NON-OWNED PROPERTY DAMAGE ' $
HIRED AUTOS AUTOS
(Per accident)
$
UMBRELLA LIAR f OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED f 1 RETENTION$ _ H
$
WORKERS COMPENSATION X I STATUTE I I ER
AND EMPLOYERS'LIABILITY
ANYPROPRIETORfPARTNERJEXECUTIVE Y/N 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 EMPLOYE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 500,000 ___._—
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 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.mass.gov/Iwd/workers-compensation/investigations/.
Sole proprietor has not elected coverage. i
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Matt Murphy Construction ACCORDANCE WITH THE POLICY PROVISIONS.
329 Southampton Road
AUTHORIZED REPRESENTATIVE
westhamptonf MA 01027 Daniel M.Crow)ey,CPCU,Vice President--Residual Market-WCRIBMA
(c)1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) --The ACORD name and logo are registered marks of ACORD