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24B-013
BP-2022-1472 6 DENISE CT COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24B-013-001 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-2022-1472 PERMISSION IS HEREBY GRAN 4 ED TO: Project# ROOF Contractor: License: Est. Cost: 22000 TIM DUBAY 100292 Const.Class: Exp.Date: 10/15/2023 Use Group: Owner: DUNN KATHLEEN E Lot Size (sq.ft.) Zoning: URB Applicant: DUBAY BROTHERS ROOFING INC Applicant Address Phone: Insurance: 35 EDENDALE ST (413)781-2533 UB1K82045722 SPRINGFIELD, MA 01104 ISSUED ON: 11/15/2022 TO PERFORM THE FOLLOWING 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 VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: , r tI • l+t. 4 . . 'I •i. Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner F3ECFIV :... : . i he C mmonwealth of Massachusetts it Boa d of uildmg Regulations and Standards FOR NOV 1 4 j 2022vlas chu etts State Building Code, 780 CMR MUNICIPALITY MUS�'I II uildin Permit A lica 'on To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 DE J OF©UIl.DING INSPECTIONS e-or Two-Family Dwelling __ nRT�OMPTON,N1A 0 iOoU This Section For Official Use Only Building ermit Number:um� L�jig-aD.— /Cf 72. Date Applied: C , .. 42,5 /Z II"0 4-z02z Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Propep Address: 1.2 Assessors Map&Parcel Numbers 6 -Ve4i r 2 Cie ‘.7'13 Oi3 1.la Is this an accepted street?yes no Map Number Parcel Number 13 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'Rf Ford• F io�in� , O!04.a iC"!i�a�Dp �. � u i c e /(/L14 Name(Pri ) City,State,ZIP 5 R v -�.q n7 (413)53 r a35a b e ►n U i r r°S5 el/Act'',I,coo nil No.and Street v Telephone Dail Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 1p Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other- 0 Specify: Brief Description of ProposedWork2: 17rrp reYC., Gr!a/ /`G IG4.4'e f�0O'74 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ — Suppression) Total All Fees: $, 14 ,y,� Check No. i Check Amount: �1 O Cash Amount: 6.Total Project Cost: $ Z'7.�v►/ * '' ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) J P7j7 OC) License Number Expiration Date Name of CSL Holder . `!r List CSL Type(see below) Type Description No.and Street Swwn 1,/ �� `/, U Unrestricted(Buildings up to 35,000 cu.ft.) c((%ii / Restricted 1&2 Family Dwelling City/T ,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 7g/2S?. I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Nam ' r HIC Registrant Na e d g S Fdy� i/e N.d$, re,etx / P G//D/ 7 V 2S'�S-" Email address Citown,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 permit application. Print Owner's Name(Electronic 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 contained in this ap lication is true and accurate to the best of my knowledge and understanding. P Owner's or uthorized ent'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 fotind 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 pore) 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 / o YMgM•Oy, SAS..- - Massachusetts A. s.- ''4e in i '� DEPARTMENT OF BUILDING INSPECTIONS A`.• :je° 212 Main Street • Municipal Building �v`;,, Cs „,,y :," Northampton, MA 01060 �4 jq %. r.. 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: /) /1-cfin (tewcie mei n3 e 47en)/L The debris will be transported by: Name of Hauler: I ` 41 _f4 7 Signature of Applica : _ / Date: I/—'// 2 Z The Commonwealth of:Massachusetts tgi Department of Industrial Accidents n, 1 Congress Street.Suite 100 0 Boston,MA 0211 d-201 T . ...‘0 www.mass.gor/dia 11 uakers'Compensation Insurance Affidas it:BuildersKbntractorsIElectricians Plumhrrs. it)RE:FILED%fill THE 1'1:RN1f1T1NGA11TNO1t11%. Annlicant Information Please Print Lrcihls Name I Husincs,vOrganvatwn Individual): °Z6�j gY�„� � 1 / ` Address: 3 s -r 41/,_ 94- City/State/Zip: V`t aL a o//?7' Phone#: 7 Sr/Z ' 3 - Are sew is anpl yea!Cheek the appropriate hoe: Type of project(required): i tam a employer%tb / cmeployces(full and or part-timct_• g7. New constructtun 2I am a wk pruprrctue ur purtncnhip and base mi employees%oiling fur nee in t. CI Remodeling any capacity-INu%orders'cutup.uwrran►r required.) 9. p Demolition 3n 1 am a humex,tner doing all work myself.(Nu tuners'cusp.insurance moored]' 4.0 I am a bunko*n a %ill be hiring amiraturs w conduct all work un my property. I es ill 10 0 Building addition ernd ensue that all congra'ton either lane wittier;co peruatwm insurance or arc sole 1142 Electrical repairs or additions proprietors Meth nu employees. 1 1_.EI Plumbing repairs or additions 50 I am a general contractor and 1 fuse bared the sub-cuntracturs listed or it che+sheet_ 13 Roof repairs Th,.e subcontractors have employees and Fos a workers'comp.uearaaot.: 6.0 we an:a corporationand offi cers has u.axciscd thou right ut.:Yu:m wn per MtaL c. 14. Od"" 152.11(4).and%c hase nu employees.Ito workers'camp.insurance required_] 'Any applicant that chocks but a must also fill out the section helms slims Mg their wurk.ra eumpcnsauun puller information 'Hunev%nets who submit this atfwLe,t mwlr.ating they arc doing all work and then hire outside contractors mini subnut a ntw atfislas it mrdiaumg suck :Contractors that.heel this box must attached an alihteunal sheet shu%ing the mane of the sub•cuntrrrtura and seat.%Irctbcr or nut thusr ad ies hate .employees. It the sub-contractors base employees.they must paused.their %oaken'comp.policy number. i am an employer that is providing workers'compensation insurance for my employees Below is the policy aid job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: Citr'State.Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,1125A is a criminal violation punishable by a tine up to S1.500.00 and ur one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the s iolatur.A copy of this statement may be forwarded to the Office of Investigations of the DIA fur insurance coverage verification. • I do hereby cc • ode►the pains and penalties of perjury that the Information provided above Is true an)d awed Sienature://JV� °�/j� Date: J / 2_Y-Z Z Ofcial use only. Do not write in this area.to be completed by city or town official City or Town: Permit/License a Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone Si: DUBAY BROS. ROOFING INC. CONTRACT (413) 781-2533 Page No. of Pages DESCRIPTION OF JOB ARCHITECT DATE OF PLANS PROPOSAL SUBMITTED TO: JOB / /, f/ 14 1 ". n ADDRESS CITY STATE ZIP r`// PHONE DA'E !WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR: -.. o / • We hereby propose to furnish material and labor, complete in accordance with above specifications, for the sum of dollars ($ with payment to be made as follows: All material is guaranteed to be as specified.All work is to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from specifications Authorized involving extra costs will be executed upon written orders, and will become an extra Signature charge over and above the estimate.All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary Note: This proposal may be withdrawn by us if not accepted insurance. Our workers are fully covered by Worker's Compensation Insurance. within days. 1 p Acceptance of Proposal -The above prices, specifications and condi- tions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: - Signature DUBABRO-01 CMASCIADRELLI A c RL CERTIFICATE OF LIABILITY INSURANCE DATE(M 9/27/202YYY) 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 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 NAME: McClure Insurance Agency,Inc. A/C,No,Est):(413)781 8711 FAX 413 731.8548 103 Van Deene Ave. ( 1° I( Neh� West Springfield,MA 01089 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL S INSURER A:Penn-America Insurance Company 32859 INSURED INSURER B: Dubay Brothers Roofing Inc. INSURER C:_ 35 Edendale Street INSURER D: Springfield,MA 01104 INSURER E: 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. _ INSR ADDL SUBR POUCY EFF POUCY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDiYYYYI_(MMIDDVYYYYL UNITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PAC7233432 7/22/2022 7/22/2023 DAVIS-Mr E MBEs o °a„ce) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY X 511& LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ AUTOS ONLY SCHEDULEDED UE BODILY INJURY M(Per accident) $ AU ONLY UR AUTO ONLY (Per aaident) GE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE ERANY OFFICER/MEMBER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 DubayBrothers RoofingInc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 35 Edendale Street Springfield,MA 01104 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION.'All rights reserved. The ACORD name and logo are registered marks of ACORD ��® DATE(MM/DD/YYYY) A C CERTIFICATE OF LIABILITY INSURANCE 09/27/2022 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 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 NAME: Cheryl Masciadrelli MCCLURE INSURANCE AGENCY INC (A/C.No,ExD: (413)781-8711 (A/C,No): E-MAIL Che I mCClureins.COm DR ADDDRESS: rY Gay P 0 BOX 339 INSURER(S)AFFORDING COVERAGE NAIC N WEST SPRINGFIELD MA 01090 INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: DUBAY BROTHERS ROOFING INC INSURERC: INSURER D: 35 EDENDALE ST INSURER E: SPRINGFIELD MA 01104 INSURERF: COVERAGES CERTIFICATE NUMBER: 818498 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 SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR JNSQ.WVD POLICY NUMBER JMM/DDIYYYYLJMM/DD/YYYYL LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE OCCUR PREMISES(EaENTED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) _ UMBRELLA LIAB OCCUR EACHOCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- PEATUTEER AND EMPLOYERS'LIABILITY ANA OF ICER/MEMB REXCLUDED ECUTNE N/A N/A N/A 6S62UB1K82045722 02/01/2022 02/01/2023 E.L.EACH ACCIDENT $ 100,000 (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 I 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/. 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. Dubay Brothers Roofing Inc 35 Edendale Street AUTHORIZED REPRESENTATIVE Th Springfield MA 01104 Daniel M.Crowlby,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts ` Division of Occupational Licensure Board of Building Regulations and Standards Construe` pJr4 3!Specialty • CSSL-100292 ,pires: 10/15/2024 TIMOTHY d I1fr1BAY 35 EDENDALE STREET SPRINGFIELBMA 01104i, Commissioner da /•. J"m .F0/2-4.2-407-moeilo-/ ar34-ezeitaLe14- Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual TIMOTHY DUBAY Registration: 181711 35 EDENDALE STREET Expiration: 04/22/2023 SPRINGFIELD,MA 01104 Update Address and Return Card. SCA 1 0 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 181711 04/22/2023 1000 Washington Street -Suite 710 TIMOTHY DUBAY Boston,MA 02118 TIMOTHY DUBAY 35 EDENDALE STREET 1(srr,4'4 fit' SPRINGFIELD,MA 01104 Not valid without signature Undersecretary