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24A-141 (3)
BP-2023-0891 55 ROE AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24A-141-001 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-2023-0891 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 19760 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date: 07/08/202 Use Group: Owner: W SIE EL ANDREW J&LOIS 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: 07/10/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF 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: ( 3-11 � - Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissi4 ner RECEIVED The Commonwealth of Massachusetts WBoard of Building Regulations and Stands s JUL 1 0 2023 POR Massachusetts State Building Code, 780 C R NUNICIPALITY USE Building Permit Application To Construct, Repair, Rprio _ ec_t ised Mar 2011 One- or Two-Family Dwellin NORTHAMPTON.MA 01060 This Section For Official Use Only Building Permit Number: g n—)-3-9q/ Date Applied: i/ 's—.% /`ice- -7-l0 60 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION perry Ad ess: 1.2 Assessors Map& Parcel Numbers • 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Dist'iit Proposed Use 1 Lot Area(sq h) 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 O�w�ner,''of Record: I >�c4i vti A Name(Print) City,State,ZIP 6S R avc- 6twc8c/ oo? / & • edd No.and Street Telephone essErna' i}r SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply) New Construction ❑ Existing Building 0 Owner-Occupied 0 I Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. ❑ Number of Units Other fir,Specify: Atm., 1 Brief Description of Proposed Work' at 'ALI..? ,se SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials) I. Building $ I e 160 ..-- I. Building Permit F e: $ _Indicate how fee is determined:- 2. Electrical $ �/ ` IDStandard City/To Application Fee / -. - - ❑ Project Costa(Item 6)x multiplier_ x 3. Plumbing $ 2. Total Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ �!I Check No.`3 3 Ch ck Amount: 6. Total Project Cost: $ /�'�G• kip/Pa id in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1 � LULA- �e umber License Vumber E it lion Date Name of CSL Holder 1 1 �, (�� List CSL Type(see below) k(.- No.and Streets Type Description j„,^ � ,n,k ^ ' O CoZ U Unrestricted(Buildings up to 35,000 Cu. ft.) lix LL V vy� R Restricted I&2 Family Dwelling City/Town,State,DP M Masonr y CC Roofing Covering vV Window and Siding 4 471'., /!" SF Solid Fuel Burning Appliances tc 43(( a /0,1gIceS1 j.(9n/1 I Insulation Telephone _ Email dress D Demolition , 5.2 Registered- Home �I�mprooevement/Contractor ,(HIC) ''}$3Z 1 041-• Vim ``�eA c `y'�/�44.thr HI�Registration Number E irat n.Date HIC Company Name or HIC Registra*Name tk Pilld a , 181-S4: n ill C9wt No.a�n�d�S,,,Att� �,y�� b(Q4 " _) f5 131( Email a ess �?y�pylLQ �'7r, iZIJ City/Town, State,ZIP _ Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE A FIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitt d 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 r ,k,. ( 9WJ1W� -- to act on my behalf, in all matters relative to work authorized by this building permit application. �e� I� �d/7s 3 Prm Owner's Name�Ele nic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By enteri my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contain n this lic ion is true and accurate to the best of my knowledge and understanding. _ 1/10Z-3 Print wner's Aut 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,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 r �� Massachusetts ;1..", '% DEPARTMENT OF BUILDING INSPECTIONS `, f 212 Main Street • Municipal Building ', T1 15,' Northampton, MA 01060 sf'NlY 3''\-\;' CONSTRUCTION DEBRIS AFFIDAVIT (FOR AIL I)EMOI.ITION 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: V&A/V/0-( ReS-f (e-Vrt, 2-31 644t4"c avn (\A, The debris will be transported by: Name of Hauler: `.1,.,. 40i Coc Signature of Applicant: Date: 7 $ ZDZ3 46. P-7-1 The Commonwealth of Massachusetts r- • Depurtm ell( of industrial Accidents _ ,„„„, I COttut.e.s Street Suite 100 0-• Boston, MA 02114-2017 wommoss.gor1/4 leo kers' ('iniensation Insurance Affidavit:BuildersAuntractorvElectricins/Plumbers I(4 BF. Fit.El) It 11 TIFIF. PERMIT! At. . AilillicRitt Information Please Print Leeibbi Name 13usule:•.s Orgaraf...inon In Jul : 708 C_Cirjete.&? Address: P vs.k_DcIvr+\ City State Zip: etorevv-E) IA e7loceZ Phone (kr3) L 3 t rr tit.] JIJ rI1Jpt1Pr?t heck the aprimprinie hint Thpe of project lrequired) 141 arn Jcnipktyer with 1,- employees(lull ariii or part-turiet* 7. NeAs. cOnstructIon 20I am a sole gropnetat or partricrsittp and ha.t c nu einpLoyets orkthy tor the in g. 0 Retliodding any L.:ANL:Ay (No*miters 1.31S u rano: rcq uared) 9 CI Demolition 10I am a 110-MICONSICT Joins all&writ myself. [No workers'comp aristirantv required y io EJ Building addition 4. I alai a humeon run and*tall iseLnrmolintractors to corriduct all+a ink on my prowny. will ensure that all einitratiors citlicr has,:winters"iOilven.alion insurance or an:sole • 110 Electrical repairs or addition, propnetars%LA nu employ CO, I 2-0 Plumbing rcpairs or addition. am a general coma actor and I have hared the sub-contractor,listed on the attached sheet I 3._M Roof repairs Tficse sub,euntmetorsba employees and Inas e*utters'cop.unurancer, • I 4. AL? K>all 6.0 wc are a corixtratatin and its officers inn c exercised du right of exemption pet c. 151..§1141.and wiluive no employees.iNo oricri t.-omp.insurance required.] An appiicant that chtx:ksbu I must also fill out the section below shrew int!thear orkt.'n compensation policy information. klomix,wmers who stktriti kith attifiavat indica-my.the arc doing all work and then bite,KIENilie Corelradoo tnu, ,.ubnut a new affidat it Indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sul,contractos and.stau v.honer m not those taniaties lune employees If di:sub-contractor, eirailtnees.they must pros itIc their li,uricers'comp.rtiii,.:y• I am on f.mployer that is providing workers compensation insurance for nit employees. Below is the policy and job site itriOrmation. lusurdrice Company Name: II-, J, 1A044.4, 43.4AS, - Policy#or Self-ins. Lie. 141-7( 1-61(=>30343 2oz3 A- Expiration Date: S te3;Z(.1 , Job Site Add]css: tf-ity.',State Zip:vv,,,,Artutlif, AA • c)(0,-(1/4--, Attach a cops of the storkers'compensation pollen declaration page ishosviag the polic,v number and xpirition date). Failure to secure coverage as required under MU_ c. 152, 25A is a criminal violation punishable by a tine up to S1,500„00 and:or orie-year imprisonment,as well as civil penalties in die form old STOP 4.,`ORK ORDER and a fine of up to S250.4.*a day against the violator. A copy of this statement may be forwarded to the OfficC of Investigations of the DIA for insurance er,o4eerihcatiort. I do hereby ce h.UI e 1k pains antis 1^thies of periiity that the information prorrilea nhor i. true and correct, Signature: Date. - J Phone Ce13--- '3 t • Official use only. Do not write in this area. lain ompleted by city or town officiot ity or Irises: Permit/License 4 Issuing Authitrits icir(.'le one): I. Board of livalth 2. Building Department 3.('it'. 4.01.11 lerk 4. Electrical Inspector 5. Plumbing Inspector. 6. ()their ( on I act Person: Phone 4: AC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 05/19/20?3 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 (A//c°.No.Ext): (413)527-7859 FAX (A/C. E-MAIL ADDRESS: travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAICN EASTHAMPTON MA 01027 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: DANIEL WEST INSURERC: D L WEST ROOFING CONTRACTOR INSURERD: 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 Y PAID CLAIMS. INSR I SUBR POLICY E EXP (MM/DD (MM/DDI/DD/YYYYI LTR TYPE OF INSURANCE NSD WVD POLICY NUMBER LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ _ N/A PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET LOC PRODUCTS-COMP/OP AGG $ _ OTHER: $ AUTOMOBILE UABIUTY 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 EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION X I PERTUTE I I OT ERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? �N/A 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.govllwd/workers-compensation/investigations/. 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 Daniel West ACCORDANCE WITH THE POLICY PROVISIONS. 11 Plymouth Ave AUTHORIZED REPRESENTATIVE Florence MA 01062 Daniel M. Crowley, 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