17C-125 (5) BP-2023-0597
69 NORTH MAPLE ST COMMONWEALTH OF ASSACHUSETTS
Map:Block:Lot:
17C-125-001 CITY OF NORTH MPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNRE STERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUA NTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-0597 PERMISSIO IS HEREBY GRANTED TO:
Project# roof 2023 Contractor: License:
Est. Cost: 17500 DUBAY BROTHE'+ ROOFING INC 100292
Const.Class: Exp.Date: 10/15/20'4
Use Group: Owner: MATI HOFF KIMBERLY&JESSICA R
Lot Size (sq.ft.)
Zoning: URB Applicant: DUBAI BROTHERS ROOFING INC
Applicant Address Phone: Insurance:
36 EDENDALE ST (413)781-2533 UB-1K82045
SPRINGFIELD, MA 01104
ISSUED ON: 05/09/2023
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 NO THAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: (
� I
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissisner
r
4 EMAIL loNf=KV REA - . ` `, .
41Qy The Commonwealth of Massachusettg `B FOR
W Board of Building Regulations and Stands c0
Massachusetts State Building Code, 780 C`1 j' UNICIPALITY
1, / j USE
Building Permit Application To Construct,Repair, Renovate(O,iis i a C Revised Mar 2011
One- or Two-Family Dwelling '---,,:°soT.1O',s
This Section For Official Use Only
Building ermit Number: 6p 0—`✓ 7 Date Applied:
c��►�` n /L 5.9-2023
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Aikjress: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted s eet?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 pone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
14 ni Ale'Af- riah'I 4 le_ I!?R
Name(Print) City,State,ZIP
/
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(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 Other Q Specify: 94,
Brief Description of Proposed Work':
</-7-it
'7,
? d 'ei'✓e ' If nz 4 4Y1-42
KC- l s/, fe'S
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 Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ ,J
Suppression) Total All Fees: $ "/0.00
Check No.1 Ot/ Check Amount: Cash Amount:
6.Total Project Cost: $/7 so a, a- 6 '"Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C 000, Z -js.—ZY
t. � �� License Number Expiration Date
Name of CSL Ho der
List CSL Type(see below)
c�s erg 1 i/L S
No.and Street Type Description
rnio- 0,/ fi U Unrestricted(Buildings up to 35,000 cu.ft.)
Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
7 / ZS�� L SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
�� / I O ' 7// y-zz-zs
/i/ V' HIC Registration Number Expiration Date
HIC Company NNmy or Registrant Name l
S l�aC-re? .�l�c ,5 / t-Lille-dco,S / � Gd1-/`;roe-1 Oe 71"
No.and,St7ej O'/t t 7g1 ZS S, ail address
Cit /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 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 applic •o ' true and accurate to the best of my knowledge and understanding.
P t Owner' or Aik rize nt' me(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"
t The Commonwealth of Massachusetts
I tit Department of Industrial Accidents
t_
=1 1 Congress Street,Suite 100
-;i+% Boston, MA 02114-2017
o;.. www.mass.gor/dia
11 oaken'('ompensation Insurance All-tda♦it:Builders/C omlractorsiElectricians/Plumbnn.
'JO RE FILED s%f111 111E PF:RSIiFI ING4UTHORl'1'1.
Annlicant Information Please Print 1 cribh
Name(Business(h!anitatton hulas tduall: C72(.1&-G /C'.S / .,c-l'< i
Address: gS_-- _-- �d,r o� �'
Y P J`-' /C 1'� Phone#: 7�l-?-c �.5?
Cit fStatel'Zi
Art)..no maple:pee(' ibe appropriate bs: Ty pe of project(required):
1.83 I am a curio►er with / employees(full and or part-tins 1-' 7_ DNc ss construction
:0 lam a sok proprietor or parincnblp and lase no emph,"ees working for me in N. O Remodeling
any capacity_(No'aur►ars'comp.utsuranec requrcall
301 am a hu uwnet Jwng all DOAmsself.1tio worksrs'WSW.msurarre n-ywrssl.]•
9. ❑ Demolition
es
4.0 1 am a hoimusi tier and u ill be bumf:asMittactors to eornJd A u all VID on m.1.pruparts. I VI III
10 0 Budding addition
ensure that all contractors either fuse*workers.compensation insurance or are sole 1 1 a Electrical repairs or additions
prupncturs with nu►uipioyees. 12.0 Plumbing repairs or additions
50 lam a general contractor and I hase hued the sub-cuntracwn lasted on the attached sheet.
These sub-contractors fuse cn>ployecs aid lase%oilers'com p.insu ance. 130 Roof repairs
6.0 N'e an a comuration and its officers base efaarctsed then right of csenllltam &L per N c. 14.0Otht'1
152,yd 1N1.and we Lase DO cmpluyees.[Nu waders'cusp.insurance requital.]
'Any applicant that checks bus al must also fill out the section Muss show any their swains'compensation Palle} information.
liornat/w nen sibs,submit this affalas it uaheatmg tires arc doing all work and then hue outside contractors must submit a rs.si aifalas It mdlcalmg such.
:Contractors that check this lot must attacked an skhtional sheet shu%an the name of the sib-csaur-acturs and state w heihc-r 1M not those entities has..
employees. It the sots-luntracturs fuse employees.dr-y must prosaic their workers'csanp.policy nu nt'er,
i am an employer that is providing worlen•compensation insurance for my employers. Below is the policy and job site
information.
Insurance Company Navin:
Policy »or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/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. ;25A is a criminal s olation punishable by a tine up to S1,500.00
and or 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 violator.A copy of this statement nuy be torssarded to the Office of In%cstigatons of the DIA for insurance
cos crage serif ication.
t do hereby cerli • der e ppins a Ides of perjury•that the information provided abor•e is true and correct.
/ �.
SiLnatun: - Date. � "-�--• L —7
Phone#:
Official use only. Do not write in this area.to be completed by city or town officiaL
('its or Tessa: Permitll.icease#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.('ity/Cown('krk 4.Electrical Inspector S. Plumbing Inspector
. 6.()Kier
Contact Person: Phoned:
A or CERTIFICATE OF LIABILITY INSURANCE DATE02MM/DD/YYYY)
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 CONSTITUE 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(les)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 an endorsement(s).
PRODUCER CONTACT
NAME:
MCCLURE INS AGENCY INC PHONE FAX
PO BOX 339 (A/C.No.Ext.):(413)781-8711 (A/C.No.Ext):
WEST SPRINGFIELD,MA 01090-0339 E-MAIL
ADDRESS:
INSURED INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:ACE AMERICAN INSURANCE COMPANY
DUBAY BROTHERS ROOFING INC
35 EDENDALE ST INSURER B:
SPRINGFIELD,MA 01104 INSURER C:
INSURER D:
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 ADM
OF INSURANCE AD SUER N/ POUCY NUMBER POUCY EFF POUCY EXP LIMITS
LTR INSD VD (MMID MI DIYYYY) (MDDIYYYY)
COMMERCIAL GENERAL LIABB..ITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR DAMAGE TO RENTED
PREMISES(Ea Occurrence) $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY I PROJECT I I LOC PRODUCTS—COMP/OP AGG $
OTHER
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
BODILY INJURY(Per person) $
- OWNED ^ SCHEDULED
_ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident) $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LU1B CLAIMS-MADE
AGGREGATE $
- DED RETENTION
WORKERS COMPENSATION PER OTH
AND EMPLOYERS'LIABILITY Yn+ N/A UB-1K82045-7-23 02/01/2023 02/01/2024 X STATUTE -ER
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? Y
A (Mandatory In NH) E.L.EACH ACCIDENT $100000
If yes,describe under
DESCRIPTION OF OPERATIONS BELOW E.L.DISEASE—EA EMPLOYEE $100000
E.L.DISEASE—POLICY LIMIT $500000
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
CERTIFICATE HOLDER CANCELLATION
DUBAY BROTHERS ROOFING INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
35 EDENDALE ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
SPRINGFIELD,MA 01104 ACCORDANCE WITH THE POLICY PROVISIONS
AUTHORIZED REPRESENTATIVE
®1993-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/3) The Acord name and logo are registered marks of ACORD
�„--.'1 DUBABRO-01 CMASCIADRELU
AC-ORE,- DATE(MWDD/YYYY)
4.----- CERTIFICATE OF LIABILITY INSURANCE 12/20/2022
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 ADDRONAL 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 CONTACTAMC_ _
McClure Insurance Agency,Inc. T FAX
103 Van Deene Ave. (01,1C,,PHONE,Ext:(413)781-8711 ,N,1413)731-8548
West Springfield,MA 01089 aoiRhss: _____
INSURERrs)AFFORDp*O COt1WRAG8, __ NAIO S
INSURER A:Penn-America Insurance Company 32859
INSURED INSURERS: _.. --.-- --.Dubay Brothers Roofing Inc. INSURER c: �__
35 Edendale Street INSURER D:
Springfield,MA 01104 INSURER E: 1 —.—
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONOmON 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 ppp��� POLICY EFF POLICY EXP -
LTR TYPE OF INSURANCE I A(t UB POLICY NUMBER DNIMDDNYYYI IMMIDOryYYTI LIMITS
A X 1 COMMERCULL.GENERALLIABRITY EACH OCCURRENCE3 1,000,000
�._i CLAIMS-MADE DX OCCUR PAC7233432 7/22/2022 712212023 DAMAGE TO RENTED p81 i 100,000
5,000
MED o(PtnnLane oeraanl 1
PERSONAL A ADV INJURY $ 1,000,000
2, 000
GENT_AGGREGATE SIR-LIMIT APPLIES PER t A J.AGGREGATE S_ -- _— 0�,
X 1 POLICY[X 1 ,LOC PRODUCTS-COMP/OP AGG S _—_ 2,000,R O
OTHER_ $
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY (Ea-accidently .1_.____._______
— ANY AUTO I BODILY INJURY(Perpeiman) S__
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY_LP_er-aeddent) S
,' Iq PROPERTY DAMAGE
1_____. AUTOOS ONLY NON-OWNEDED TOOS N Per accident) 5
S
UMBRELLA LIAR _ OCCUR EACH OCCURRENCE ,�_(----
EXCESS UAB .�CLAIMSautADE1 AGGREGATE -S-____ -_
DED 71—_--RETENTIONS $
TH-
AND EMPLOYERS'LIABILITY 1 STATUTE_ Off_. ------1
ANY PROPRIETOR/PARTNER/EXECUTIVE I YIN —1
NIA EL EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? t
(Mandatory in NH) E.L.DISEASE-EAEMPLOYEE S
It y describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS 1 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
Cornerstone House Buying LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
y ACCORDANCE WITH THE POUCY PROVISIONS.
1218 Westfield St
West Springfield,MA 01089 --
AUTHORIZED REPRESENTATIVE
k hr- ..
1
ACORD 25(2016103) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts Home Improvement Contractor Registration
Re 1 stratlon
T _: _ Type: Individual
TIMOTHY DUBAY
35 EDENDALE STREET . ' 1 Registration: 181711
SPRINGFIELD, MA 01104 Expiration: 04/22/2025
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual expiration date. Iffound return to:
Reaistratien Exni__ration Office of Consumer Affairs and Business Regulation
1000 Washington Street -Suite 710
181711 04/22/2025
TIMOTHY DUBAY Boston,MA 02118
TIMOTHY DUBAY
35 EDENDALE STREET
SPRINGFIELD,MA 01104
•
Undersecretary Not valid without signature
Commonwealth of Massachusetts
Division of Occupational Lind Sta e
Board of Building Re ulations and Standards
Constructi� �etySpecialt>> ,
CSSL-100292 i �ires: 1011512024
TIMOTHY J D�IBAY
35 EDENDALE STREET
SPRINGFIELI MA 01104
(� cJlr x_
Commissioner w0s%a
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: VV'-, j4iy!? rrin
The debris will be transported by:
Name of Hauler: ✓ � `ej r•- yc6c,
Signature of Appli Date:
DUBAY BROS. ROOFING INC. CONTRACT
(413) 781-2533
Page No. of Pages
DESCRIPTION OF JOB
ARCHITECT DATE OF PLANS
PROPOSAL SUBMI I I ED TO: —
JOB
ilADDRESS
rr)0 CITY STATE ZIP
j PHONE DATE
'WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR:
i
r,
I
1
r !
t r.
I
/ We hereby propose to furnish material and labor, complete in accordance with above specifications, for the
sum of dollars ($ • I
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 Npte: This proposal may be withdrawn by us if not accepted
insurance. Our workers are fully covered by Worker's Compensation Insurance. within days. J
Acceptance of Proposal -The above prices, specifications and condi-
dons 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