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10B-069 (3)
BP-2024-0335 63 WATER ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 10B-069-001 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-2024-0335 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2024 Contractor: License: Est. Cost: 15430 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date: 07/08/2025 Use Group: Owner: M EMERSON GERALD W& BEATRICE Lot Size (sq.ft.) Zoning: URB Applicant: DL WEST ROOFING CONTRACTOR Applicant Address Phone: Insurance: 11 PLYMOUTH AVE AWC4007036390 FLORENCE, MA 01062 ISSUED ON: 03/27/2024 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: Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner The Commonwealth of Massachyisetts;� I.`° n Board of Building Regulations andStandards M,R 2 6 FOR 2024 MUNICIPALITY Massachusetts State Building Code, 780 CMR USE Building Permit Application To Construct, Repair Renovate Cif Demolish_a Revised Mar 2011 One- or Two-Family Dwelling ,/v9 This Section For Official Use Only Building Permit Number:t f 4a q/ "✓6 Date Applied: i‘v,,-$ 7, //i2 .3 27.26zy Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address:: [C2 LOCO-CI— _ 1.2 Assessors Map& Parcel Numbers 1.la Is this an accepted street?yes no C� 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 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 wner' Record: kt o°c .i -may Lc J mil • c10 S3 Name(Print) City,State,ZIP (.e3 feller cS4. 413 ,c8c1— 13 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) 4Ef.A Addition ❑ Demolition ❑ Accessory Bldg. CINumber of Units Other lirSpecify: . &pec Brief Description of Proposed Work2: Re,NAD,_,e_ ,Q,,U t QSet,,cm.id u oe V etr\ VtAat'kv\ .w_ n Ay- 4 �,v.� . o Sic,(A Ck 1(' G�_ V- 03oc � c9 Ski s ' s SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1. Building $ Is- yx, ___1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost; (Item 6)x multiplier x 3. Plumbing $ _ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fee r) Check No. Check Amount: g 0 Cash Amount: 6. Total Project Cost: s 15/43'. — 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �c CpAk4 (J.1,ujk-- License Number Ex iration Date Name of CSL Holder List CSL Type(see below) g[,_ No.and Street Type Description ��xr YV�• bC04 Z U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling y M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Lt3 let 5---7j l( 4:.ttc•.,'4-8 1-5 tQ utkc l\.CSAAA I Insulation Telephone Email address (-3 D Demolition 5.2 Registered Home Improvement Contractor(HIC) L n r 1 s32� 1toz n.C—• lJ`�o�i 1 po�tNtitQl� HIC Registration Number pir ion Date HIC Company Name or HIC Registr ame t l Pt1, -J-L & , 4tw a�sQd,,, 4.Ca/ . No.and Street Email a F P- c Vvviq - O COCCI_ il3 7 •-•--—4-3 t l 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 {f No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMITi I,as Owner of the subject property,hereby authorize •l,r tt- "4-�.4µ �i6alllTrGL� - to act on my behalf,in all matters relative to work authorized by this building permit application. txa -,A^- '31- (-tc_,zi 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 containe ' this p i tion is true and accurate to the best of my knowledge and understanding. ` ite2.-zci Print 9 rner's or Au 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 "' Massachusetts ��0 i._ s,�'-f DEPARTMENT OF BUILDING INSPECTIONS '2' 212 Main Street • Municipal Building a Y, Northampton, MA 01060 s6'"-libN � 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: U4IL R,z.csf,( S 231 6411,tuek4 iei-k GrAtcy he, The debris will be transported by: Name of Hauler: O,L, 0 '4.-d- .iiS 646(Lk - / / Signature of Applicant: y ---7 Date: '5/Zy Z`3t1 17. The Commonwealth of Massachusetts Department of industrial Accidents 1 1 Congress Street,Suite 100 Boston, MA 02114-2017 '.--% • 1.....-T-71 ww1v.mass.goWdia IVi»-kers' Compensation Insurance AlTidas it: BuildersiContractors/Ekctriciansfl'Iumbers. It) III I-1i.i.1)Nk VIA HIE rt:RN1111'(N(;AUTHORIT1 Aimlicant Information Please Print Legibly Name(liusines.s,`Orgaluzationjudividual): 41:).L. 11--.)-)s.-(2t (l..c--a. Address: k,l, (3 V./vt.k.c>.4-4/\ 4.9->t • City/State(Zir ei•Ar.0,,,c.„ Phone#:_(.4.02.) (4S-13( / Are yuu un employee("tuck the;appropriate boa: 'I)pc of project(required): 1.ationi a employer v,WI L. _eno.y,...e.(fa anilior part-time).* 7_ [] New construction 2171 I am a sole propnetur or funnels-hip and have no employetrs working for me irt 8. 0 Remodeling any capacity_[Nu workers'comp.insurance required" 9. E] Demolition 301 ant a homeowner doing all work myself.[No winker.'curry.nicsunence nNuirecti' 10 El Building addition 4.0 i arn a homeowner and wall be hiring contractors to conduct all work orz my property_ I will ensure that all contractors either have workers'compensation insuranix or are sole 11_0 Electrical repain;or additions proprietors with no employees_ i 2.0 Plumbing repairs or additions 3 I ant a wrier:al contractor and I have lured the sub-contractors listed un the altachixt sheet. EtThese sub-contractors Ism c employees and have workers'comp.insurance.: I 3 Roof repairs .4& k I (2 :37 60 We ate a corporation and its officers have exercised their right of eAren 14.gOthet f\f/J..---)ialian per MGL e. 152.§114),arid we have no entployves.[No workers comp.insurance required.] 'Any applioatt that checks box al must also fill out the weciurn below showing their workers'compensation policy information_ 4.lictineownert who submit this affidavit Indicating they are ilotng all work and then hue outside contractors must submit a new affidaY it it:ahem:rig such. tContractorr,that cheek this box must attached an Additional sheet showing the name of the sub-contractors and stair v.heiher or not those entities have employees, It rite 3ub conIrsctura Icroe employees,they must provide their workers'comp.poliey number. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. ,.---, Insurance Company Nan' -, Air A. d„,5. b. _ Policy 4 or Self-ins. Lic. 4:/11PC Leoo-4-eryp3ie)tz7-43 A— Expiration Date: Job Site Address: (.4:6 (...Lscds-er" fy4 City/State/Zip:( ide)'3/ Ott.A. 00,5-3 Attach a copy of the ssorkers'compensation policy.declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MCJL 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 form of a STOP WORK ORDER and a tine 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 verification. I do hereby cert y un,de lit paia%awl un allies of perjury that the in far:nation provided above is true and correct. Signature: 4 - , , Date: 1/11/1.°71 Phone 4:( -14-3) (6c 3(( , Official use only. flu not 'anti'ill tlriN area. la be c ampleteil by city Of town oflicial. ('itv or Town: Permit/License 4 Issuing Authority(circle one): I. Board of Health 2. Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Coniact Person: Phone tit: i ACORO® 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 Travis NAME: KSK INSURANCE AGENCY INC (A/C nlz,Eat): (413)527-7859 •(a/c.NO): _ E-MAIL ADDRESS: travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAICN EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B DANIEL WEST INSURERC: D L WEST ROOFING CONTRACTOR INSURERD: 11 PLYMOUTH AVE INSURERE: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE Li OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ _ OTHER: $ AUTOMOBILE LIABIUTY 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 PER 0TH STATUTE AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNERA OFFICER/MEMBEREXCLUDE/D?ECUTIVE N/A N/A N/A AWC40070363902023A 05/01/2023 05/01/2024 E.L.EACH ACCIDENT $ 100,000 (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.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.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