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16D-011 (4)
BP-2023-1483 2 GREELEY AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 16D-011-001 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-2023-1483 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 19160 DANIEL WEST 106007 Const.Class: Exp.Date: 07/08/2025 Use Group: Owner: DAVID JOHNEDIS Lot Size (sq.ft.) Zoning: URB Applicant: DANIEL WEST Applicant Address Phone: Insurance: 11 PLYMOUTH AVE (413)695-7311 FLORENCE, MA 01062 ISSUED ON: 10/23/2023 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: I(` . ,r • >2CS-s°1 • Ii Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner R The Commonwealth of Massachusetts rI': Board of Building Regulations and Stand rds Massachusetts State Building Code, 780 MR OCT MU IPA TY O 2/i� SE Building Permit Application To Construct,Repair,Re ova coolish a C4evis d M 2011 One- or Two-Family Dwelling -.. o�i Ah�ibliv hNc This tion For Official Use Only oN.A.44-CTrn °'�so N� Building P it Number: °jn"j'�j � � Date Applied: ' / 1:// 2, Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers t Cor-4.2.4y . 1.1a 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 ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ic_ CAI-,(Cdk )o4uaPc--V5 c(rxvKtti %A_ � e 4Z Name(Print) City,State,ZIP 2 Crr—e.tci c 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 tier 0 Specify: ht_r• Q&c Q- BriefDescription of Propos d Work': QouvibL., eYr`.hkS cNIL,aILA- rerrize C.taa tn.n(--c.,.L( C.(o SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ / I,4-0 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost' (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ ,r Suppression) Total All Fee. 1�► sjj Check No. Ili Check Amount: lto Cash Amount: 6.Total Project Cost: $ Ci/NO. 0 Paid in Full 0 Outstanding Balance Due: • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ' cLitvi.eA l e_ . i . .- Xee 4— a �Z5 License Number Exp ration Date Name of CSL Holder p �n n�-{��'w'\ktkCv List CSL Type(see below) l�C No.and Street J Vim" Type Description ��OI( I A QWIZ U Unrestricted(Buildings up to 35,000 Cu.ft.) V�/� R Restricted 1&2 Family Dwelling City/Town,State, Masonry At) Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 64)i& ". 31( 60l(�`- 4Q1S1 L L6i I Insulation Telephone Email a ess D Demolition 5.2 Registered Home Improvement Contractor(HIC) 4 3Zq- _at- Lk__ -(' Q-L. 1i.a&stt- (l Lv- HIC Registration Number Expirat i on Date HIC Company Name or HIC Registrant Name V.l F' gult,IA, &LLE . cG ` 4-cos ...“.Cam• No.jwid Strbet Emai address City/Town, Staee,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 ge--- 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 A1,C -i— to act on my behalf,in all matters relative to work authorized by this building permit application. ( 0.(--,OCkStA(QA es:A.C. tOI el(Z.5:)-(_* Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering m name below, I hereby attest under the pains and penalties of perjury that all of the information contained' is a io is true and accurate to the best of my knowledge and understanding. bC) /f/trY Z-5 Print ner's or uthorized Agent's Name(Electronic Signature) D 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 F „-" Massachusettsu?lkis4's _ e'trs I sA 4 '- l**'l-' 't ej DEPARTMENT OF BUILDING INSPECTIONS , 212 Main Street • Municipal Building Jti Cb ri,:, r Northampton, MA 01060 srk 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: kl&L f (-61-1S I The debris will be transported by: Name of Hauler: K-(; lso-� RsboI2u Signature of Applicant: / 1"1""-- Date: !o CL '1-crz3 • .' . , . t 1111111. The (-onnnonwealth of Massachusetts H 1....-7, -, '....ii..,1 „..--:,e :-.- __, g Dep ar tint nt of Industrial,4ecidents E. 1 Congress Street, Suite 100 Bast on. MA 02114-2017 ;„\--:----/e www.ntass.gorldia Workers'Compensation Insurance Affidavit:Builders/ContractorsiElectricians/Plumbers. TO BE FILED WITH'111E PERMITTING AUTHORIIV, Applicant Information Please Print Legibls Name tilusiniess;OrgantiatiottIndividual I: 0-L, Address: ‘Adek -tr, 44..Q.... , . City/State/Zip: Rocei-tte tpAA . 604 7 Phone#: 64-5.) CAS--1-3( I Art you an employee Check the appropriate bat: Type of project(required): 1.0$111 a employer with I employees tfull and'or part-nowt* 7. 0 New construction 20 i am a sole proprietor or partnership and have no employees working for rue in K. 0 Remodeling any captor), No workers'comp.insurance required.) 9. 0 Demolition 30 I ant a homoirones doing all work myself.[No werrktas'comp inounnice reepuria.1.) i 0 flBuilding addition 40 I ant a homeowner and w ill be hiring contractors to eunduct all work on my property. I will trittrum that all contractors either base workers'exiamensanon insurance or are sole I I 0 Electrical repairs or additions proprietors.ss ith no inriployces, I 2..0 Plumbing repairs or additions sin I am a general contractor and I have banal the sub-contractors listed on the anached sheet These sub-corstractors hs's,a emplinmes an d has e wor I 3.[Atoof repairs kers'comp. trINUninee." 14,abth el t\„0„,...) Pfki\0 C3 ff."- 60 We are a corporation and its tinkers hat e exercised their right of exemption per Merl c. 152,§1{4).,and we base no etraplo)ves.[No stork 'comp.insurance required.] *Any applicant that checks box al must also till our the section below showing their workerra.compensation pokey ortCr:nation. +Hoarreowners who submit that affidavit indicauriu they are doing alt work and then hire outside etworactors mu u submit a new affidax it indicating such. :Cormactors that check this box must attached an,additional sheet showing the name of the suh-contractors and state whether or not those oodles hate employees If the sub-eornmetOrs base employees,they mum prom ide their workers'ornrip,wiity number, lam an employer that is providing workers'compensation insurance for nay employees. Below is the policy and fob site information. Insurance Company Name. • A-1--itA Policy#or Self-ins. Lie. 4: AL.i.- C-I-t33 to 7 es--z 7i4-- Expiration Date: Job Site Addres Z fr--e-e-14 (21,,-3 - City/State/Zip: 6(6c Z-. Attach a copy of the workers'cionipensation 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 tine up to S1,500.00 and or one-year imprisonment,as well as civil penalties in the fonn of a STOP WORK ORDER and a line of up to S250.00 a dns„ against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cot erdide verification. I do hereby cert' unde 1 this and penalties of perjury that the Information provided above is true and correct Signature: - Date: /15//etz)7-5 Phone rt: -23) 69 S—/3 / Official use only. Do loot write in this tirea.to be cm mphleil Ity city or town official City or Town: Permit/License 4 Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.Cit±o[lots it(jerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone 4: • AC RO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `...►i 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 sac No Ext); (413)527-7859 (Arc, E-MAIL ADDRESS: traviSSlas@ksk-Insurance.COm 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAIC# EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED - INSURERS: DANIEL WEST INSURERC: D L WEST ROOFING CONTRACTOR INSURERD: 11 PLYMOUTH AVE INSURER E: FLORENCE MA 01062 INSURER F: 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&ADV INJURY $ GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY PRO- JECT 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 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 EMPLOYEEp $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I 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-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.Cro I y,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