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10B-063 (2)
BP-2023-1596 23 WATER ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 10B-063-001 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-2023-1596 PERMISSION IS HEREBY GRANTED TO: Project# 2023 ROOF Contractor: License: Est. Cost: 14220 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date: 07/08/2025 WELCH THOMAS F& DORIS M&ESTHER Use Group: Owner: WALKER Lot Size (sq.ft.) Zoning: URB Applicant: DL WEST ROOFING CONTRACTOR Applicant Address Phone: Insurance: 11 PLYMOUTH AVE AWC4007036390 FLORENCE, MA 01062 ISSUED ON: 11/15/2023 TO PERFORM THE FOLLOWING WORK: STRIP&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: • • . Tit • f Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner The Commonwealth of Massachusetts ,, Board of Building Regulations and Standards FOR iii Massachusetts State Building Code, 780 CMR MUNICIPALITY USE ' Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 r One- or Two-Family Dwelling This Section For Official Use Only Building Permit Number: P 7C2.3--15'-el 6 Date Applied: 4,0J7Z„ /// _ /i-iH-Z0 Z3 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 2--5 t_,.r,laf 2f CO 13 - 063- bc ' 1 1.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ldRr3 . t332- gyre_ 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 El Private 0 Zone: _ _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 ner'o Rec d: -vvV\ ��ac t-fin k-A-CokS 1 w . C 1b53 Name(Print) City,State,ZIP 23 t er" '34--. ,2053 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction 0 Existing Building 0 fOwner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 ( Number of Units I Other .B Specify: 11t1. Q.Accf Brief Description of Proposed Work': - lir- LtlX6te1 K ct tA, a-50 INb ' c..S `�, 'bc i SL2cr C.�e�ni} 1rc.. e&.se 6A - 5(a . SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only jLabor and Materials) 1. Building $ i 4i 27p , I. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ CIStandard City/Town 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: $ (1O'6 Check No.1371 Check Amount:4 4-0°` Cash Amount: 6. Total Project Cost: S /9i 22c". ' 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) (s5L— el e License Number Ex ira' on Date Name of CSL Holder List CSL Type(see below)L�(�'v� �� R No.and Street Type Description � �� d � � U Unrestricted(Buildings up to 35,000 cu.ft.) /_vrState( t AA R Restricted I&2 Family Dwelling City/Town,l Masonry C Roofing Covering WS Window and Siding J, ' SF Solid Fuel Burning Appliances 63)W 1-3/( !�Iw'1*S� ut(•(A I Insulation Telephone Email-address D Demolition 5.2 Registered Home Improvement Contractor(HIC) P C 114((ri �r HIC Registration �z R Number Expir tion Date HIC Company Name or HIC Registrant Name �l P( �.cz>volt eci.�t cal(, Ste ;i t (' No. d reet Email adiiress City/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 C").(._, Qvt C ‘kAkat- to act on my behalf, in all matters relative to work authorized by this building petnrif application. 10W\ \CJA (l(et(U'53 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 application is true and accurate to the best of my knowledge and understanding. r,L)J•L‘CA ViKteJ723 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 0�<N A M f.yO,� Massachusetts �{ c ` h 5. ,r4 �_ DEPARTMENT OF BUILDING INSPECTIONS +r { , 212 Main Street • Municipal Building Jr bti � Northampton, MA 01060 �s`NyYi�'� 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: \2-9-(1 ' P cL c 23Lt � ram. I -i4 1(c.A otivAi, ®td The debris will be transported by: Name of Hauler: 0 ,L1�-Li- Signature of Applicant: �-- Date: `t 1ti(1-c-D-1-3 .... ..\ The Commotm,ealth of Afassachasetts Department of Industrial Accidents i 11.= ; I Congress Street. Suite 100 Boston, MA 02114-2017 •#...—"17,,,,' .:,,,,,,. • -1' www.mass.goridia VI or-kers'('ompensation Insurance Affidavit: Buiklersi('ontractorstElectricianx/Plumbers. TO RE FILEI)%SITU'IRE PERMITIIM;At:TIIORITV. Applicant Information Please Print Legibly Name(htusinesa,OrganizationAndividual): Address: ttL se ou_73,4,4 0.....e._•i -- , City/State/Zip: VIM- CD(9,Ce7__ Phone #: 61.:... .) & .c-- 1-3 t 1 t Sri. !,nu itit imptover?t'tirek the appropriate Lir,: i Type of project(required): .. sol pioy cc sii t b k. employees Oa ainSor pari-urnet• ;._114-.3rit a ' 1 7. 0 New construction .....0 I am a mile proprietor or partnership and have nu CtlIployi..es working for me in K. 0 Remodeling :my capacity.[Nu workers comp.insurance required" 9. Ej Demolition 10 I am a horpotworcr doing all work myself.[No workers'comp insonone morn-111 t ll 0 CI Building addition I am a hormvstv tier and tt ill he hiring i.x.mtracturs to L-cinduct all work cm my property. I will alMill:that all contractors either have Yk.orkers*compensation in.surance or an sole 1143 Electrical repairs or additions proprietor ia ith no employees. 12.0 Plumbing repairs or additions 5C3 I am a general contractor and I have hired the sub-contractors listed on the attached sheet_ I 32Roof reit Thexe sub-contractor.hate employees and have workers'einem.insunince.:: 14.20ther (20erf 6.0 Vie are a corporation and its officers have excrtised their right of ex.emption per kiGL c. 152,1114i,and we have no employees.[No workers'comp.insurance required.] An applicant that checks but al must also till out the section below show ing their workers'compensation policy information. •Homeowners who submit this affidavit intheatmg the, MC 4.10,Ing all Nutt and then hue outside contractors must submit a new affidavit indicating such. ;Contractors that check this hot must attached an additional sheet slimt mg the name of the suh-coutradors and>tate whither UT not those otistics have employee,. If the sub-contractors hate erreloyets ilik-y must provide their workers°comp,polte:, nuirik:r I am an employer that is providing workers'compensation insurance/or my employees. Below is the polity and job site information. Insurance Company Name: AI lkit N...)6Li.. .......g Co . policy#or Self-iris. Lic.#: ALL2C-1-6,e-,----ib-Y-€3./,e)14="23 4 Expiration Date: 5i 1 --e z,z cf Job Site Address: 31. CitylStateiZip: 5tittAL C6±3 ,5"3 Attach a copy of the workers'conipensation policy declaration page(showing the policy number and xpiration date). Failure to secure coverage as required under MOE c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Ogee of investigations of the DIA for insurance Cuteral...:e verification. I do herehr cer f,um r le s and penalties ofperjury that the information provided abo-iv is true and correct. , Signature: Dal.: Phone#: ‘9 &gc- 4--5 t( Official use only. Do nab write in this areo,.to be completed by city or town official. City or Town: Perm i CLicense# Issuing Authority (circle one): I. Board of Health 2. Building Department 3.Cityfrown Clerk 4.Ekctrical Inspector 5. Plumbing Inspector 6.Other ('ontact Person: Phone#: . .._ Ago 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 INC,N o Est); (413)527-7859 ac,No): ADDRESS: travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAIC# EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: DANIEL WEST INSURER C: 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 TYPE OF INSURANCE IANSD DDL S W UBR POLICY EFF POLICY EXP LTR VD POLICY NUMBER (MMIDD/YYYY) (MM DDIYYYY) LIMITS LT COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ __ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ AWNED 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 RETENTION$ $ WORKERS COMPENSATION X STATUTE 0TH- AND EMPLOYERS'LIABILITYER Y/N ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICERIMEMBEREXCLUDED? NIA NIA 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 I 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.govAwd/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