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17D-004 (4) BP- 022-1560 540 BRIDGE RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17D-004-001 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-2022-1560 PERMISSION IS HEREBY GRANTED TO: Project# ROOF Contractor: License: Est. Cost: 25660 ERIE CONSTRUCTION 106394 Const.Class: Exp.Date: 05/11/2024 BERCH-HEYMAN ELEANOR K&TIMOTHY P Use Group: Owner: MINER Lot Size (sq.ft.) Zoning: RI/RR Applicant: ERIE CONSTRUCTION Applicant Address Phone: Insurance: 121 F WEST DUDLEYTOWN RD 860-358-9240 WC6-Z51-293745 BLOOMFIELD, CT 06002 ISSUED ON: 12/05/2022 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: V ,2 . i Do Fees Paid: S40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner RECEIVED 1 , DEC 2 20 Co nmotiwealth of Massachusetts W Board of Building Regulations and Standards FOR Mass whusetts State Building Code, 780 CMR MUNICIPALITYUSE DEPT.OF BUILD,NO INSPECTIONS BuiltfttiPtilltitqAriglitiction To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Buildin Permit Number: i(2_).l—(blip. Date Applied: tall� Z.) //: l2 Z-z z2_ Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 3 ,e6r/ � 1.1 a Is this an acc ted 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❑ Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 935.pert of Record;tYczailor _ Mo r_/!'^_ La `% jf OM Name(Print) m City.State,ZIP 6"-y0 i r/ Ci y13-5ri--72os 13erd ,hoet ya.Is c u . �th 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)' Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:• tief Description of Proposed Work': 4—'71 e_.. su.d/e SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ WO 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ 0 Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: $ �� in Check No.69 Y Check Amount: -iv Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License SL) �6t;39y �� /2y aCtd L_. � License Number Expiration Date Name CSL Holder U Al 33 (�(;' List CSL Type(see below) �y No.and Street Type Description mi/Q4 3 e/ S.2 g/ U Unrestricted(Buildings up to 35,000 cu.R.) /J R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Insulation Telephone Email address D Demolition 5.2 Registered Home Impr vement ontractor(HIC) r S 0C /' /,g'�Z J 6I 111111 E e/(_ois�t fox. HIC Registration Nu nber Expiration Date HIC Coma Name or ICI Registrant Name /21 l� �. ,Qr..dfe c,jn i2e� ,`VP-- 3a.ino-uV; . ��c,�C o�e�• I�oKL. No and Streets., Email address !Ai N✓ seVon. 7C—/d b C2603Z TgoS5.9 72vo 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 ❑ 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 application is true and accura to the f my knowledge and understanding. J 0.11 ae,V; 0jr�c. //t$O ZZ Print Owner's or Authorized Agent's a (Electronic e) 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 /-.1', ` Massachusetts �� - I t .4o1'') LI DEPARTMENT OF BUILDING INSPECTIONS i ♦ 212 Main Street • Municipal Building J, c'::, Northampton, MA 01060 ,SNJY 460 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: In Location of Facility: /D btr haivi gj, s0ti7m•c..A.m The debris will be transported by: Name of Hauler: (1 2)u_r7/ c-f 1-4,4-t Signature of Applicant: r Date: 1`//30A�. The Commonwealth of Massachusetts ° _ 1, Department of Industrial Accidents = 1= 1 Congress Street,Suite 100 t,=?�s'mr1F Boston,MA 02114-2017 =F www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leuibly Name(Business/Organization/Individual):Erie Constuction Address: 121 F WEST DUDLEYTOWN RD City/State/Zip:BLOOMFIELD CT 06002 Phone#:8603589240 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.1=1 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.1:1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑✓ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑✓ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Jam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:LOCKTON Policy#or Self-ins.Lic.#:WC6-Z51-293745-022 Expiration Date:04/25/2023 Job Site Address:540 bridge rd City/State/Zip:northampton ma 0'062 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,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify wide, e p' •. ,� of perjury'that the information provided above is true and correct. Signature: Date: Phone#:8603::9240 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I City of Northampton rcc,ir ... ' �` SAS- "5.4 t w Massachusetts � i' t. yy 1 ti, ,r DEPARTMENT OF BUILDING INSPECTIONS F , 212 Main Street • Municipal Building J Northampton, MA 01060 �Sb •. �1�� HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, 4, (insert full legal name), born _ 'insert month, day, year),hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requir ents of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a proje or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeown- s'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 C ' 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R" 1.2: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on whi.h there is,or is intended to be, a one-or two-family dwelling, attached or detached structures accesso to such use and/or farm structures. A person who constructs more than one home in a two-year perio shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent 't I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the i roject or work on my parcel, I am not engaged in construction supervision in connection with any project or ork involving construction, reconstruction, alteration, repair, removal or demolition involving any activity re: lated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project o work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20_. (Signature) Commonwealth of Massachusetts !if s M1it !BfFeH 3.Alil� L'f�7,7,e 1411Boar o��uil i 1� ula[(oris and Standards I'llt 't COnatructlirSupprvlst)r't & 2 Family CSFA-106394 + stpires:05/11/2024 CHADLEY LM p 8935 OAK V L HOLLAND OH 4 VOt.I.�+dil'JJ Commissioner daj catmlbri. Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: CDrporation Registraticni 159905 ERIE CONSTRUCTION MID-WES—. INC. Expiraticr: 06/18/2023 D B-A ERIE METAL ROOFING 3516 GRANITE CIRCLE TOLEDO, OH 43617 Update Address and Return Card. Office of Consuner Affairs &Eusiress Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: Corporator before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 159905 0611E12023 'OOC Washington Street • Suite 710 ERIE CONSTRUCTION MID-WEST. INC. Boston. MA 02118 D BA ERIE META_ ROOFING PATRIC<TROMPETER 351E GRANITE CIRCLE TOLECO. O-i 43517 Not valid without signature Undersec-etarj ERIE home remodeling delivered. April 26, 2022 RE:Permits To whom it may concern: Letter of Authorization Janae Fitzpatrick,office administrator of Erie Construction Mid-West, is authorized to represent myself and/or our company in signing permits. If you have any questions, please contact Nicki,our risk management coordinator at 567-408-2145.Thank you. Sincerely, vorextlogr ti Randy Hamilton President Erie Construction Mid-West • • 3516 Granite Circle Toledo,OH 43617 ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MMiDD/YYYY) t,i...,.----- 4/25/2023 4/22/2022 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 Lockton Companies CONTACT 1185 Avenue of the Americas,Suite 2010 PHONE FAX New York NY 10036E-MAIL° Ext)_------ (A/C.No): 646-572-7300 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:The Cincinnati Insurance Company 10677 INSURED Erie Construction Mid-West,LL(' INSURER B:The First Liberty Insurance Corporation 33588 1500420 3516 Granite Circle INSURER C:Evanston Insurance Company .. 35378 Toledo OH 43617 INSURER D: INSURER E: INSURER F: I COVERAGES 1st CERTIFICATE NUMBER: 18402199 REVISION NUMBER: XXXXXXX 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 ADDL SUBR POLICY EFF POLICY EXP LI ITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY N N EPP0534782 4/25/2022 4/25/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X I OCCUR 1 PREMISES(s occurrence) $ 100,000 MED EXP(Any one person) $ 10 000 PERSONAL&ADV INJURY I $ 1 000 000 _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I $ 2 000 000 _ POLICY JECT J LOC PRODUCTS-COMP/OP AG I $ 2 000 000 - OTHER: $ A AUTOMOBILE LIABILITY N N EBA0534782 4/25/2022 4/25/2023 COMBINED SINGLE LIMIT $ A EBA0612292 4/25/2022 4/25/2023 BODILY i 1,000,000 x ANY AUTO BODILY INJURY(Per person $ XXXXXXX OWNSD ONLY SCHEDULED BODILY INJURY(Per accide $ XXXXXXX AUTOSHIRED NON-OWNED PROPERTY DAMAGE $ XXXXXXX AUTOS ONLY AUTOS ONLY (Per accident) $ XXXXXXX A X UMBRELLA LIAB X OCCUR N N EPP0534782 4/25/2022 4/25/2023 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ $ XXXXXXX B 'WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY YIN N WC6-Z51-293745-022 4/25/2022 4/25/2023 X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ('7 E.L.EACH ACCIDENT $ 1 000 000 I OFFICER/MEMBER EXCLUDED? I I N/A -- '(Mandatory in NH) E.L.DISEASE-EA EMPLO E $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIM $ 1.000,000 C Excess N N MKLVIEUE101063 4/25/2022 4/25/2023 Occ:$5,000,000 Agg:$5,000,000 DESCRIPTION OF OPERATIONS'LOCATIONS VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) CERTIFICATE HOLDER CANCELLATION See Attachment 18402199 I to Your Information ANY OF THE ABOVE DESCRIBED POLICIES Bli CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESLrvi ATIIVE``yy'' IA \ \ ©1988-2015 ACORD CORPORATION. 'A'I rights reserved. Attachment Code:D607603 Master ID: 1500420,Certificate ID: 18402199 l��l LOa(TON'° For Your Information Dear Erie Construction Mid-West, LLC certificate holder: In an effort to meet demand for instant electronic delivery of certificates, Lockton Companies now provides paperless delivery of Certificates of Insurance. Thank you for your patience and willingness to help us lessen our environmental footprint. To fulfill your certificate delivery, we need your email address. Please contact us via one of the methods below with your Holder ID number, email address, and phone number in the evenit we have any questions. Your Holder ID number is 184021 . Email: Eriecertrequests@lockton.com • Toll-free automated phone service: 866-218-4018 If this certificate is no longer needed or valid,please notify us. Thank you, Lockton Companies Lockton Companies 1185 Avenue of the Americas, Suite 2010 New York.NY 10036 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." • An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or he receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia