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24A-138 (3) BP-2023-0968 40 ROE AVE COMMONWEALTH OF M SSACHUSETTS Map:Block:Lot: 24A-138-001 CITY OF NORTHA PTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING P RMIT Permit # BP-2023-0968 PERMISSIO IS HEREBY GRANTED TO: Project# SIDING/ROOF 2023 Contractor: License: Est. Cost: 68000 MATTHEW DERY 064404 Const.Class: Exp.Date: 07/01/202 Use Group: Owner: TRUST ES KUENY TUCKER &MELISSA Lot Size (sq.ft.) Zoning: URA Applicant: MATT EW DERY Applicant Address Phone: Insurance: 408 HOOSAC RD (413)369-4447() WC5-315-375318-042 CONWAY, MA 01341 ISSUED ON: 07/26/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF AND SIDING 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 NOR HAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fees Paid: $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner , rr{ --The Commonwealth of Massachusetts vl ic, l V ri.. + Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code, 780 CMR USE JUL a 34il Per Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling ........ _ i This Section For Official Use Only � uu.�L niN(, ti5P GTfONS n Bu �engft'�t A 3 ?Le $ Date Applied: eu,1J (Zn //7Z -7-Zb-Zoz3 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers qc floe itvc t> M7-ri)i.% jtio- 1.la Is this an accepted street?yes u' 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❑ Zone: Outside Flood Zone? MunicipalOn site disposal system IDCheck if yesg p y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of R ord: RE Li SSA- lcvt'Jy Nc2-rwnwkFT-0P, MA O 1 o Z ?- Name(Print) City,State,ZIP LID Kai: ,k 1I 5" 5.--- plL 13 rh�ISSa ur.,�%/ � 3roto,I , COI"No.and Street Telephone EmailAddress SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building to Owner-Occupied # Repairs(s) re Alteration(s) VI Addition 0 Demolition In Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': S-rQ1•F Er.1 Sr)NC. 2co S illNGt..CS an a T8,''u-C.E W 1-r k..t I)Ct,' A-S?/4/1Li S1-1,NG1C5 -i7ip Eg'�T11-,G. ZLaiN6, i Z C-7L &-C. i"3 T t4 111=1.,) C.C. ` S 1-- a►-. E- 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: o D C'� 1 ❑ Standard City/Town Application Fee 2.Electrical $ 0 Total Project Costa ;Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) IU" Total All Fe� c=� Check No. Check Amount.k‘, 6. Total Project Cost: $ 19%1 0 001 0'0 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS- 0 bt-1 D L o t) L/ kerr „f �^ y r"{ License Number Expiration Date r:� Name of CSL Holder �j �/ List CSL Type(see below) lJ L1 O a �CO SA .k� No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu. ft.) Ci-)wA`f % tA>c 01 SLI I R Restricted 1&2 Family Dwelling City/Town,Stfaate,ZIP M , Masonry RC Roofmg Covering WS Window and Siding ' 1 i i \ SF Solid Fuel Burning Appliances N 13 5 7� S�b g6 �I l F abk , cows I Insulation Telephone mail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 3 6 3 ob 1Z3 i20 7 II�}�' i w a,—Dc(tj HIC Registration Number Expiration Date HIC Com any Name or HIC Registrant Name '° oo 'r, ) \,)\ < i VA) Q 0.v\ . Cows o.and Street Email address k/Town,'State, u wh , tv\A- o,3u ' y 'l3 31.1-1 a 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 Pr No ❑ SECTION 7a: OWNER AUTHORIZATION TO BI COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES NOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize -I}t.✓ , �ji.-.,z y to act on my behalf,tin all matters relative to work authorized by this building permit application. Mcl,1S411- IBC✓.= ,-/ A/ 145e1 07/i /23 Print Owner's Name(Electronic Si e) Date SECTION :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 accurate to the best of my knowledge and understanding. e,7AZ 0 Z 3 er's or Aine)Agent's Nam carom--Signature) Z e NOTES: 1. An Owner who obtains a building permit to do his/her own work,or 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 inf rmation on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor Lice 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" The Common onis'ealth of Massachusetts tit;. !Iimill k 1)e;nrnttc�nt of Industrial Accidents ►� P l Congress Street,Suite l00 i. �_ "M Boston. tl.-f 02114-2017 _►�� iirtl'w.pluss.goi'/dot %l miters'Compensation insurance.11Tidas it: Builders/('ontractors/ElectriciansTlunebers. 10 BE FILED% I I II 111E Pf:N%II 1-111(; Al 1 i1O1(111. Applicant Information Please Print i_egibls Name I Business Oreamiatiun.kiln*dual►:MATrHtEba _.'---1_,__ G...ay _ Address:_90% orskc 1Z-oJr� _..,..-,_. ---- City/State/Zip:Co,w, y h UA . of 3 u 1 Phone#: 4t. 3;4/ clb ft, .. Are yea inesephryre!( heck the appropriate Inks: T.)pe of project(required): I I am a employer,A uh Z employees I full eat ur part-iota).• 7, 0 New construction i I am a sole proprietor or partnership and hate no cmpluyees aurking, for Inc in 8. f Remodeling any capacity.INIr winker+'comp.insurance rtw{uirctl_l lJ z. I am a h ogneowner doing all work myself.(No workas'coop.insurance rekpeirctl.l« 9. i)iuolition 4.0 I an*a hwroeowlet and isill be hiring contractors to cuaduei all work on tin property. I will 10] Building addition ensure that all contractors either has wurkaa compensation insurance or are sole 11.I Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 50 I am a gcrieral contractor and I has hired the sub-contractors listed on the attached sheet !hew sub-contractors hate enlplu%ces and hale worker comp.insurance.- I3� 1 Roof repairs !hew 14. Other 6.0 we are a corporatism and its officer.has c criticised ken ercised then rlu of eptltinl per%Kit.c. — — I t 2.'tit a).and w e hate no employ oes.I No workers'comp.insurance required.I 0 'Any applicant that checks box a I Must also fill out the%►eilon helms showing their workers compensation polies intottnatio n. `ilurrauwn em who submit this atl►rhas it uidicating they are doing all work and then hue outside contractors must stdntut a new atfidat it indicating such. :Contractors that check this hark must attached an additional sheet showing the name of the sub espltraetors and state whether or not those entities has employers. It the suls-corm.etrrs hate employees.*het iriusi pnrstde their workers"comp.pole),nwnhwv. I am an employer that is providing worberr'compensation insurance for my employees. Below is the policy and job site information. Insurance cctntpans. Name: L,3t -1-y 1,),,„, L Policy*or Self-its. Lie. ;-. NC.j - 3 1 S - 51S-3/K— ey2 Expiration Date: 0147.1 Za2, lob Site Address: 40 ;Zc.E AVE .City/State/Zip:44tlkt4,1/rlyr el 4O/t Z I. Attach a copy of the workers'compensation policy declaration page(showilgthe policy number and expiration date). Failure to secure coverage as required under MGL c. 152.§25A is a criminal sidlation punishable bs a tine 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 tine of up to S250.00 a day against the violator.A copy of this statement ittas he tors aided to the Office of Investigations of the DiA for insurance coverage seritication. i do hereby certify under the pains and penalties of perjury that the information provider/above i.true and correct. Surname. 1 -- l).ta_ t l-77 17t Zj Phone:.: L111 379 vs(1:., Official use only. Do not write in this area, to be completed hr citp or!awn efriuL ('its or Town: Permit/License Issuing.tuthorit) (circle one): I. Board of Health 2. Building Department 3.('its:i ossn(jerk 4. Ekctricai Inspector 5. Plumbing inspector 6.Other ('outset Person: Phone#: City of Northampton ,,SHAM.,\ �' Massachusetts �4,{ 'e c11 1 .• • 4 DEPARTMENT OF BUILDING INSPECTIONS ,J z 'Y 212 Main Street • Municipal Building y' CDC f,,.a-,, Northampton, MA 01060 '�st�h, 3�7�,N 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: ALL UkicL‘NtD NO'CZ�tHA,j.n cn. 1 MA_ The debris will be transported by: Name of Hauler: AtkkVEZ S;-'�0c, LPL Signature of Applicant: V Date: 0 1 1 Z1'Z, THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:individual Registration Expiration 163763 06/2312024 MATTHEW J. DERY MATTHEW DERY 408 HOOSAC RD. ri,r,.e1'e'?, ✓ ;e6' CONWAY,MA 01341 Undersecretary Iff Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Const rSwisor CS-064404 pires;07/01/2024 MATTHEW Ji1ER „3 .• 408 HOOSAGRD ,' `- CONWAY Mit 01 `, x tJ:14.0 `'"^^—:-sioncr f?. Bench. Y r WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY .% Liberty Mutual.INSURANCE AR INFORMATION PAGE 175 Berkeley Street Boston,MA 02116 Issued by LM INSURANCE CORPORATION 27 43 Policy Number WC5-31S-375318-042 Issuing Office 016C RENEWAL OF: WC5-31S-375318-041 Issue Date 09-24-22 Account Number 1-375318 Sub Account 0000 1. Insured and Mailing Address MATTHEW DERY DBA BLACK DIAMOND BUILDING RISK ID 000108865 408 HOOSAC ROAD CONWAY,MA 01341 Status 01 — INDIVIDUAL Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 09-27-2022 to 09-27-2023 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 3,268 Premium will be billed ANNUAL Producer 0004-014173 ENCHARTER INSURANCE LLC 25 UNIVERSITY DRIVE AMHERST MA 01002-2217 WC 00 00 01 A © 1987 National Council on Compensation Insurance,lnc. WC 00 00 01 B (CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1 Insured Copy Policy Number CUP2893C }.. :f COMMON POLICY DECLARATIONS RENEWAL OF: - r ,.r CUP2893C NGM INSURANCE COMPANY " + 4601 TOUCHTON ROAD EAST,SUITE 3400,JACKSONVILLE,FL 32245-6000 • em 1. Named Insured and Mailing Address Agent Name and Address '. ATTHEW DERY ENCHARTER INS LLC CL SC 08 HOOSAC RD CONWAY MA 01341-9794 25 UNIVERSITY DRIVE AMHERST, MA 01002 Agent Phone No. (8 6 6) 415-5 3 91 Agent No. 204031 Item 2. Policy Period From: 0 5-3 0-2 0 2 3 To: 0 5-3 0-2 0 2 4 at 12:01 A.M., Standard Time at your mailing address shown above. Item 3. Business Description: CARPENTRY -- RESIDENTIAL -- THREE STORIES OR LESS Form of Business: INDIVIDUAL Item 4. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown, there is no coverage. This premium may be subject to adjustment. Coverage Part(s) Premium S Commercial Property Coverage Part NOT COVERED Commercial General Liability Coverage Part NOT COVERED S Crime and Fidelity Coverage Part NOT COVERED Commercial Inland Marine Coverage Part NOT COVERED Commercial Auto(Business or Truckers)Coverage Part NOT COVERED Commercial Garage Coverage Part NOT COVERED COMMERCIAL UMBRELLA COVERAGE PART $ 650 . 00 Total Policy Premium $ 650 . 00 Item 5. Forms and Endorsements Form(s)and Endorsement(s)made a part of this policy at time of issue: See Schedule of Forms and Endorsements Countersigned: Date: _ By: Authorized Representative THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S),TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART(S),COVERAGE FORM(S)AND FORMS AND ENDORSEMENTS,IF ANY,COMPLETE THE ABOVE NUMBERED POLICY. CO-DEC(07/01) INSURED COPY Policy Number: CUP2893C Renewal Of: CUP2893C ViALa fir COMMERCIAL LIABILITY UMBRELLA DECLARATIONS NGM INSURANCE COMPANY 4601 TOUCHTON ROAD EAST,SUITE 3400,JACKSONVILLE,FL 32245-6000 ?sured and Mailing Address Agent Name and Address = DERY ENCHARTER INS LLC CL SC . -::::SAC RD • a 'AY MA 01341-9794 25 UNIVERSITY DRIVE AMHERST, MA 01002 Agent Phone No. (866) 415-5391 Agent No. 204031 oticyPeriod From: 05-30-2023 To: 05-30-2024 at 12:01 A.M., Standard Time at your mailing address shown above. ""'w IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY,WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. DESCRIPTION OF BUSINESS FORM OF BUSINESS:INDIVIDUAL BUSINESS DESCRIPTION: CARPENTRY -- RESIDENTIAL -- THREE STORIES OR LESS LIMITS OF INSURANCE 8 EACH OCCURRENCE LIMIT (LIABILITY COVERAGE) $ 1, 000 , 000 PERSONAL&ADVERTISING INJURY LIMIT $ 1, 000 , 000 Any one person or organization o AGGREGATE LIMIT(LIABILITY COVERAGE) $ 1, 000, 000 (except with respect to"covered autos") SELF INSURED RETENTION $ 10, 000 Sub-total Premium $ 650 . 00 •//�Yh14Y STATE TAX OR OTHER (if applicable) TOTAL PREMIUM (SUBJECT TO AUDIT) $ 650 . 00 (PAYABLE AT INCEPTION) AUDIT PERIOD (IF APPLICABLE):NOT APPLICABLE ENDORSEMENTS ENDORSEMENTS ATTACHED TO THIS POLICY: SEE SCHEDULE OF FORMS AND ENDORSEMENTS THESE DECLARATIONS,TOGETHERWITH THE COMMON POLICY CONDITIONS AND COVERAGEFORM(S)AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE NUMBERED POLICY. Countersigned: Date: By: Authorized Representative CU DEC 09 00 Copyright, Insurance Services Office, Ir1c., 2000 INSURED COPY Policy Number:cuP2893C Renewal Of: CUP2893C ti �$ COMMERCIAL UMBRELLA SUPPLEMENTAL SCHEDULE OF UNDERLYING INSURANCE MAIN LINE BOP/CONTRACTORS LIABILITY AND MEDICAL EXPENSE $ 1, 000, 000 LIABILITY/MEDICAL AGGREGATE LIMIT $ 2 , 000, 000 PRODUCTS/COMPLETED OPERATIONS AGGREGATE $ 2 , 000, 000 nsurer: MAIN STREET AMERICA ASSURANCE COMPANY ,,,. Policy Number: MPP2893C Policy Period: 05/30/23 - 05/30/24 Type: 0 0 Insurer: o Policy Number: o Policy Period: - S Type: `' Vi.P Insurer: Policy Number: Policy Period: - Type: Insurer: Policy Number: Policy Period: - UM 0041 (04/00) Page 1 of 1 INSURED COPY