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17C-067 (3)
BP-2023-0727 151 CHESTNUT ST COMMONWEALTH OF M SSACHUSETTS Map:Block:Lot: 17C-067-001 CITY OF NORTHA PTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-0727 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 13490 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date: 07/08/2023 Use Group: Owner: K. BR NNAN, EMILY Lot Size (sq.ft.) Zoning: URA Applicant: DL WE T ROOFING CONTRACTOR Applicant Address Phone: insurance: 11 PLYMOUTH AVE AWC4007036390 FLORENCE, MA 01062 ISSUED ON: 06/05/2023 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: !jv 3-1.1 w • Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner / ,, ! The Commonwealth of Massacltfsett U� .S ��fY=.FOR W Board of Building Regulations and Stand dt�}s Massachusetts State Building Code, 780 C�eG� (9° ? M ICIPALITY yq�lp�� U Building Permit Application To Construct,Repair, Renovate a evise Mar 2011 One-or Two-Family Dwelling •4,1, o �r- , This Section For Official Use Only Buildingpermit Number:�jb� ).7. - �7 D e Applied: 0-1 i t,J 72-x- / L- 5-2o23 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property 1.2 Assessors Map & Parcel Numbers 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 OWNERSH P' 2. Owner'of Record: wv,\ C6CIMe_Q1 . t�1�2 Name(Print City,State,ZIP 15 t C I,,c.51-J S+. �:tl).)311 -3D 2 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) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Allier 0 Specify: r ARINJ r(44=c,ite Brief Description of Proposed Work?: () Q. ( (IQ., o l\ kc(1 t..) G (...., b Lh ...4-c,A °LS et -.1k):-K_ r2 • SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) _ 1. Building $ r2) `1,c0 ,s 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost3 (Item 6)x multiplier_ x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ 401 6(3 C eck No.jyl0 Check Amount: 641) Cash Amount: 6.Total Project Cost: $ ,'�1t'i�Q e--- i Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVI ES 5.1 Construction Supervisor License(CSL) _ Apo 1 eB 17-7)23 License Num r Exp atio Date Name of CSL Holder List CSL Type(see below) R No.and Stare"t Type Description lam(ev�X I b(�4 Z— U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,EIP ,M � Masonry I ii�� Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 14rb (.g6C-?"--j l dyy`l8�-s4,6401'1, cam I Insulation Telephone Email ad ss D Demolition 5.2 Registered Home Hoome�Improvement Contractor(HIC) .� Li CA 2 "V � HIC egistration Number pir lionDi HIC Company Name or HIC Registrant Name tk (tlw�� - c cL1s�cv__.cst• N nd treet Wv ' 6�� /- 3)L �3!' Email a ess ity/Town,St te,ZIP �fl 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 1 — --, 6,G1,W(Gd ✓ to act on my behalf, in all matters relative to work authorized by this building p- i .pplication. riroda, 944,44, 4/31 taro Print Owne 's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering y name below, I hereby attest under the pains and penalties of perjury that all of the information containe this a c ion is true and accurate to the best of my knowledge and understanding. Prin ner's o Au orized 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,finish-d 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 7, i‘ Massachusetts - ' , * 4 ! ' ,• DEPARTMENT OF BUILDING INSPECTIONS % *.` ' K. 212 Main Street • Municipal Building -+, ,ti^a', Northampton, MA 01060 SSN ht''' ` 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: Valli ' 4- ..9 v14,5Z43424 644 k 121J• -T The debris will be transported by: Name of Hauler: k- (.. l�-xz. - (\51:)c- Ct.V` (NAr C1-zpv-- Signature of Applicant: Date: 0Aot3 .. "'%,. The Commonwealth of Alassachusetts Department of Industrial Accidents nor ler-"....• .=•..i. igt.a. aiiaai ii111110 .t„ I Congress Street, Suite 100 lb ,to Boston. MA 02114-2017 '...... _ www.mass.goWdia 11 i»kers'Compensation Insurance Affidavit:Buiklers/ContractorstElectriciansiPlumhers. TO RE FILED WITH THE PERMITTING ACTI1(MRITI. Applicant Information Please Print 1..egihtv Name tRusineas,Organmationandistichtal): O. . . Address: U. ("1 City/State:Zip roAte, NI. OtOct—4_ Phone#(11..-5) 1fi5---1 ? Li yaw an employ cr?("heck the apiaruprinte hot: I ..,pe of project(required): 1.231 ---ii a,aupkr:ox'Anti .,Z,„„, employees(full and'or part-tortek• i 7. 0 New construction LCD i ant a sole proprietor or partnerdup and have no employees working for me in 8. a Remodeling litty capacity(NU workers'comp.1.11Nertelee required.1 9. El Demolition ;..0 I ant a h nosnI doing all work myself.INo workers'comp.irourance required.r I 0 0 Building addition 4.0 1 arn a homoussiter and tit ill he hiring contractors to conduct all work on my property. ensure that all Centracturs either have suTerm conipenstation Insurance or are sole : 1 Eirj Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5 1 ant a general ntractor and I lime hired the sub-euretractors listed on the arlitiehett Itteet 131:j Roof repairs 'hest sub-contractors have einployees and have workers'comp.insurance; 14.00ther 6.0 We are a t..sylp..,ration and its officcns have remised then right of exams:Mat per MU.c. I 152.t 114 I.dmi`,-,c have no etinployees.(No workers'slings. 111Stelittt:4.7 Itttitteed.1 *Any applicant that cheeks bock-di must also fill out the section below show mg these*utter,'tottapetuation put icy thfonnaltaxt t Homeowners who submit this allidasit indicating they are doing all work and 1.,....61ti hue outside conunietors 1111.1%t$tsbnut a new affidavit indicating such. teontractors that check this boa must attached an additional sheet show ing the name of the mat-centIntckzn and Alai:On hotter in not those entities haw plosee, It Is,:sub csintractors hats CittplOyCeN.lik."!, MU-.I no,*ikik:their workers'comp.policy marils.3 1 am an employer that is providing leaders'compensation insurance for my employees. Below is the policy and Job site infOrmiltion. Ae*--", AA Insurance Company Name: 14---4-.I '1 i 1/1kt-3k/c( IA') 60 -• ____ Policy It or Self-ins. Lie.#: 11-444.11264-03(e-51pza-z_-5/is- Expiration Date: Job Site Address: ‘S t da.c..7. •(-1‘.1...xi- Sk . City/StateiZip: 4v0.4A.g. 0(14 • 0(C:3(.4 7_ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOE_ c. 152. §25A is a criminal violation punishable by a fine up to S1,500.00 ,in&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 d.r. iigairist the violator. A copy of this statement may be forwarded to the Otriee of ink,..,ligations of the DIA for insurance n.:0% r.tuc venti,ati I do hereby cert. ander I pi ns and penalties of perjury that the information pro killed obov.is true and correct. .--;,1!...7nattlics Date: 0 ecre 3 1 ::, .. (ft4-3) iecS- 3 /1 Official use only. Do not write in this area,to be completed by city or town official ('it or Town: PermitiLicense a Issuing Authorip!,(circle one): I. Board of Health 2. Building Department 3.Cityrrown(lerk 4.Electrical Inspector 5. Pio inbiot Inspector t, other contact Person: Phone 4: ......._ ....._.......- ACoRL CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `•--'� 05/19/2023 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: Travis Sias KSK INSURANCE AGENCY INC PHONE FAx (A/C,No,Eat): (413)527-7859 - (A/c,No): E-MAIL ADDRESS: travissias@ksk-insurance.COm 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAICa EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSUREDINSURER B: DANIEL WEST INSURERC: D L WEST ROOFING CONTRACTOR INSURER D: 11 PLYMOUTH AVE INSURER E: FLORENCE MA 01062 INSURERF: COVERAGES CERTIFICATE NUMBER: 893862 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ _ N/A PERSONAL 8 ADV INJURY $ _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ECOT- 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 UAB OCCUR EACH OCCURRENCE $ __ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER _ AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER!EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? WA N/A N/A AWC40070363902023A 05/01/2023 05/01/2024 - -- (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 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.govilwd/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 BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Daniel West 11 Plymouth Ave AUTHORIZED REPRESENTATIVE Florence MA 01062 Daniel M.Cro�4vley,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