24C-019 (24) BP-2023-1701
286 PROSPECT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24C-019-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-1701 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2023 Contractor: License:
Est. Cost: 27200 MMC SPECIALTY ROOFING INC
Const.Class: Exp.Date:
HAMPSHIRE REGIONAL YOUNG MENS
Use Group: Owner: CHRISTIAN ASSOCIATION
Lot Size (sq.ft.)
Zoning: URA/URB Applicant: MMC SPECIALTY ROOFING INC
Applicant Address Phone: Insurance:
176 PINEVALE ST (413)642-3842 AWC4007030594
INDIAN ORCHARD, MA 01151
ISSUED ON: 12/06/2023
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:
eltaL i).(11/$
Fees Paid: $196.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
BP-2023-1701
286 PROSPECT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24C-019-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-1701 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2023 Contractor: License:
Est. Cost: 27200 MMC SPECIALTY ROOFING INC
Const.Class: Exp.Date:
HAMPSHIRE REGIONAL YOUNG MEN'S
Use Group: Owner: CHRISTIAN ASSOCIATION
Lot Size (sq.ft.)
Zoning: URA/URB Applicant: MMC SPECIALTY ROOFING INC
Applicant Address Phone: Insurance:
176 PINEVALE ST (413)642-3842 AWC4007030594
INDIAN ORCHARD, MA 01151
ISSUED ON: 12/06/2023
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:
tojtoi,,L,9 *iv
Fees Paid: $196.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
eN,rc. f
The Commonwealth of Mass ch s -s 0��
�`►1` Office of Public Safety and Inspections, n,o9r
Massachusetts State Building Code(780 CMR)
�.. ..
Building Permit Application for any Building other than a One-or Two�'�Incmpi2'y, elli
(This Section For Official Use Only) '�o, N� /
Building Permit Numberi, 3- )7C I Date Applied: Building Official:
SECTION 1:LOCATION
186 11 s p slot AkrAL.ae►y+t, to a `(M C A
No.and Street City/Town Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below
Existing Building®' Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other I3rSpecify: VRc c4 -
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No a-
Is an Independent Structural Engineering Peer Review required? Yes 0 No fj-
Brief Description of Proposed Work I r0-r 0C'e &r "'a rOat 't' avick l h s'U(
'net.) Pd isoc `xa.v.vra4- A-pr, F Tifk vka.-t-►o444 a-' r1a .-J .Q o Teo
t c>r•* stic-Ve.✓✓1 { s-V �ec C r,JQ lr{'TA v.T�1
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): _ _ Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.) (,SOO
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1 0 S-2❑ U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV 0 VA VB 0
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site 0
Public 0 Check if outside Flood Zone❑ Indicate municipal 0
A trench will not be Po
Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
,iiv", \r— Via CA -26'6 Pc-os +- s} .-4-,0.v,--0-o G l 0(o
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
- - 413- 36ti_6227
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
NW�C_ s fJ ;c`I �twr, 6, Pin��cSi
11 �� ;K•• oc�� ? �- Clcc t
Name j J t7 Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
A4 Ak C- S pe c T-ok J RoC')'F in
Company Name
( - PCc5*- C.S � O7( 7
Name of Person Responsible for Construction License No. and Type if Applicable
'9 Mack, 1-�`,�\ R S��>��';�1 c 010 )o
Street Address City/Town State Zip
LM �YZ- ( Z - - �os� i0(73 I, CC)t
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Construction Cost x here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 2 -, 200 (contact municipality)and write check number here 12 S 0
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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.
u ye 1 i -262 - '7 i 3 a (Y20-,
Please print and sign name Title �J Telephone No. Date
Z.LIct 12crec iw i C�Z Am- O/07) vv1a{ c.r u�.t f S 4:2 p 1
Street Address City/Town State Zip Email Address
it ' a3Municipal Inspector to fill out this section upon application approval: i d�11\i. U a
Name Da e
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Re ulations and Standards
Consto ervisor
CS-076497 w • ires: 06/07/2025
CLIFTON FROST
89 MARSH HILL RD
BRIMFIELD?OA, 01010
•t��I.i,t'dil�,l
Commissioner '� p
City of Northampton
• ,i•�`
Massachusetts
e- x' DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •• Municipal Building y0 'a.
' �, Northampton, MA 01060 sse ��OC
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: ,,�;1b a /MA-
The debris will be transported by:
Name of Hauler: W�
Signature of Applicant: • Date: 1-112 7 Z 3
Y
The Commonwealth of Massachusetts
V;MEMO
--6, Department of Industrial Accidents
°F111] 1 Congress Street,Suite 100
_'eld= Boston,MA 02114-2017
= www mass.gov/dia
•_t Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information n l Please Print Legibly
Name (Business/Organization/Individual): /A/vA C— �J' -1 `may f '}�i V1�
Address: \7 Pine-u„`e �-c-
City/State/Zip:Tom. ;e.,Y1 Orcl,,-r4) AAA(O i t 5ii Phone#: t-{l3 •— 6 4{Z - 3 84(a..
Are you an employer?Check the appropriate box! Type of project(required):
1.®I am a employer with 12- employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
10[]Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.2FZoof repairs
These sub-contractors have employees and have workers'comp.insurances
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ii M
Insurance Company Name: A i /4U24-x.)4L\ ---rA{,U{'G,Vt<:-... .. ,_
Policy#or Self-ins.Lic.#: AWC — Li(r) -TO bS9Y-Zc2 lExpiration Date: 6/7/zy
Job Site Address: 2 4 perf ''. -- S sew City/State/Zip:J JC - s,pirc,il MA 10 I0(,0
Attach a copy of the workers' compen ation 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 fine 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 fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verific
I do hereby rtify u d he p i and penalties of perjury that the information provided above is true and correct.
Signature: Date:1/ ---- l VZ-7/2-2-
Q _ -- -
Phone#: `�ti3- 6`I2 - ? -(2-.-
Official use only. Do not write in this area,to he completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
..-----"1 MMCSPEC-01 NICOLES
A`..---Ro CERTIFICATE OF LIABILITY INSURANCE OATE(MM/DD,YYYY)
6a/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 POUCIES
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 Ileu of such endorsement(s).
PRODUCER COryt1TACT Nicole Sarafin
_NAME,
Phillips Insurance Agency,Inc. PHONE _ FAX
97 Center Street (A/C.Nrr,EA:(413)594-8984 Iac,No):(413)592-8499 '
Chicopee,MA 01013 nP•I'd,1Atll ss:nleole@phillipsinsurance.com
INSURER(S)AFFORDING COVERAGE NAIC Y
INSURER A:The Cincinnati insurance Companies
INSURED INSURER B:Arbella Protection Insurance Company
MMC Specialty Roofing Inc INSURER C:National Union Fire Ins Co. 19445
50 Valley View Drive INSURER D:A.I.M.Mutual Insurance Company 33758
Westfield,MA 01085 INSURERS:Liberty Mutual Insurance Co _
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 POLICY EFF POLICY EXP
LTRINBD,.WVQ POUCY NUMBER IMMDD/YYYYI IMM/DD/YYYYI UNITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS4IADE X OCCUR CSU0147019 6/7/2023 6/7/2024 PREMISES Ea eccunsni t $ 300,000
MED EXP(Am one eon) S 5,000 moon)
--- - PERSONALS AOV INJURY _ $ 1,000,000
GEML AGGREGATE PLIMIT APPLIESPER: GENERAL AGGREGATE $ 2,000,000
X POLICY n Tar, 1 ,LOG PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER
B AUTOMOBILE LIABILITY COMBINEDSINGLE LIMIT ;
1,000,000
X ANY AUTO 10201179/14 8/7/2023 8/7/2024 BODILY INJURY(Per person) $
OWNEDppT��� ONLY --SCHEDULEDAUT BODILY� INJURYD (Per accident1 S
RU7i5s ONLY AUTOS ONLY (Perm na t)A S
S
C X UMBRELLA LIAa X OCCUR EACH OCCURRENCE $ 5,000,000
EXCESS LIAR CLAIMS-MADE TBD 6 7/2023 6/7/2024 AGGREGATE f 5,000,000
DEO j 1 RETENTION$ $
D WORKERS COMPENSATION X PERTUTE I ER
OlY4-
AND EMPLOYERS'LIABILITY STA
AWC-400-7030594-2023A 6/7/2023 6/7/2024 E.L.EACH ACCIDENT 3 _
A Y PROP F(MaOHI UOED7ECUME [---NiN I A 1,000,000
ands o NH} `^ 1,000,000
If yes,describe under I EL DISEASE-EA EMPLOYEE $
DESCRIPTION OF OPERATIONSbelow EL DISEASE-POLICY LIMIT $ 1,000,000
E lWorker's Compensatio WC5-33S-B21N4R-013 1/24/2023 i 1/24/2024 State of CT 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace ie require
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
i AUTHORIZED REPRESENTATIVE
I
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