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38B-213 (5) 18 FAIRVIEW AVE BP-2019-0405 GIs#: COMMONWEALTH OF MASSACHUSETTS ME Block:38B-213 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2019-0405 Proiect# JS-2019-000647 Est.Cost: $23000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: EAST COAST METAL ROOFING 101285 Lot Size(sq. ft.): 4486.68 Owner. FOELSTER MARK Zoning: URB(100)/ Applicant. EAST COAST METAL ROOFING AT: 18 FAI RVI EW AVE Applicant Address: Phone: Insurance: 701 TREASURE ISLAND (508) 341-8339 O Liability WEBSTERMA01570 ISSUED ON:10/2/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/2/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner z Department use only LL S City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit f C\1 ;� 212 Main Street Sewer/Septic Availability ROOM 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans O phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans CC 2Z IL— w Other Specify APPLICA ON TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: 2 T is section to be completed by office /-4�'"v/'tC 1— A L-(, Map 3 � Lot ai 3 Unit "4�a'�+r fU 6 106 G Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORrZED AGENT 2.1 Owner of Record: Mao-k Aot,)it FO ei441/ JS � , All Name(Print) Current Mailing Address: � ` a /s- S.1 3 - S'GC- ���4(.il Citi Telephone Signature 2.2 Authorized Ascent: P� / L eco "?o T�r�.r� rt .Ls&4a PPI Name(Print) Current Mailing Address: 2� C�JS D S' - -7"a Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical HVAC 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number If This Section For Official Use Only Building Permit Number: Date Issued: Signature: Ie-71zh ia Building Commissioner/Inspector of Buildings Date Cf S -e- 4 RU V 7S `� EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) rT i _. �., �. . � i Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R. Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ® YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES,describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 40 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO IV IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors E3 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[p] Other[pJ Brief Descnption of PZroposed Work: S (a ! oc,4 , 1 hs E1-rII ) LZ ti -k—y J 4 L ti_r 4ti ll -e ��/�c% 2u�fi� J 1 Alteration of existing bedroom Yes (l No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes L,�No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stones? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS �AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, t/l G� 5' as Owner of the subject property 'l hereby authorize L'Qj'F C()f_J-f /11-114 / 1i>(yu T) / NL[ to act on my behalf,in all matters relative to work authorized by this buildinyperyKit application. Signature of Owner Date ow— I, 4 Ci L I <J f Q 0 G J f 4U} ' /�-c:L r1 f as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accura e,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name k:��a'Lt 4--� Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: i,C e ( / /U /,,2 P License Number AL- �' �c��, � �. T �Y10>— Q —/( - 2. U Address Expiration Date —,-- Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ 9 2— Company Name Registration Number -7u, Z_jiu«,r Rct 1,-uY4sjO/ -/o /— /9 - 2 (-) Ad ssf Expiration Date Telephone SECTION 10-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...... ❑ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): East Coast Metal Roofing, LLC Address: 701 Treasure Island Rd City/State/Zip:Webster, MA 01570 Phone#:508-333-0106 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working forme in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. E:1 Demolition 3.E]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.❑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.Q Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.El I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]ROOF repairs These sub-contractors have employees and have workers'comp.insurance? 6.❑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. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: /S f('/"vi'le w /4y-e— City/State/Zip:y ), �!(�w„e�... . /f� Ol6(o U Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratio 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 verification. I do hereby certify under the pains an enaIties of perjury that the information provided above is true and correct. Signature: Date: /0 ` — Phone#:508-333-0106 Official use only. Do not write in this area,to be 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#: City of Northampton VL Massachusetts DEPAR4MENT OF BUILDING INSPECTIONS a M 212 Main Street •Municipal Building Q Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: � - Fs i L//-(Iv /4 t'''om (Please print house number and street name) Is to be disposed of at: (Please print name and location of facilit / Or will be disposed of in a dumpster onsite rented or leased from.- (Company rom:(Company Name and Address) Sign f Permi p ner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation — f Registration: 184472 EAST COAST METAL ROOFING,LLC �', Expiration: 01/19/2020 701 TREASURE ISLAND RD n WEBSTER,MA 01570 ,F 4 1 H 4// Update Address and Return Card r, ickq�'Qll Office of consumer Affairs t Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Reaistration Expiration Office of Consumer Affairs and Business Regulation 184472 01/192020 10 Park Plaza-Suite 5170 EAST COAST METAL ROOFING.LLC Boston,MA 02116 PAUL LECHIARA 701 TREASURE ISLAND RD U WEBSTER.MA 01570 Undersecretary Not valid t signature .v. Commonwealth of Massachusetts Orvisson of Proress+onal Licensure Board of Budding Regulations and Standards Con3tructt04D.S1JPWVisor Specialty CSSL 101285 F�iras:OL11QpZp 1411 EDDEWOOp AVE CRANSTON RI A CERTIFICATE OF LIABILITY INSURANCEDA E(MMI20D1 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. H 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(&). PRODUCER CONTACT NAME: Kevin Pkes Platinum Insurance Agency, Inc. PHONE (401)272900 I FAX No; (401)272-5901 1990 Pawtucket Avenue AE-MAILDDRESSo kpires@platinumins.com East Providence, RI 02914 INSUR AFFORDING COVERAGE NAICI Phone (401)272-5900 Fax (401)272-5901 INSURERA: Western Works Insurance Company INSURED INSURER B: RGSW,LLC. INSURER C: 41 Edgewood Avenue INSURER 0: Beacon Mutual Insurance Company INSURER E: Cranston RI 02905 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 CONTRACTOR 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. TSR TYPE OF INSURANCE INSR BR POLICY NUMBER MMMVUDCY EFF POLICY D/EXP LIMA © COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ❑ CLAIMS-MADE © OCCUR MAGE TO RENTED PREMISES Me occurrence) $ 50,000 ❑ MED EXP(Any one person) $ 5,000 A ❑ I NPP8410827 04/05/2018 04/05/2019 PERSONAL BADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2,000,000 POLICY ❑ JJECO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 ❑ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ �OONLY E:] SCHEDULED L AUTOS BODILY INJURY(Per accident) $ ❑ NON-OWNED PROPERTY DAMAGE $ ❑AUTOS ONLY AUTOS ONLY r acdde ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION PER ❑an+ AND EMPLOYERS'LIABILITY Y/N TATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIV EL.EACH ACCIDENT $ 100,000 D OFFICER/MEMBER EXCLUDED? Y N/A 0000076113 03/16/2018 03/16/2019 (Mandatory in NH) EL.DISEASE-EA EMPLOYE $ WOW If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Marlborough THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 140 Main Street Marlborough,MA 01752 AUTHORIZED REPRESENTATIVE J ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03)OF The ACORD name and logo are registered marks of ACORD EASTCOAST East Coast Metal Roofing, LLC. METAL R 0 0 FI H G � 701 Treasure Island Rd,Webster, MA 01570 AATel:844-611-3267' ea stco a st m eta I ro ofi ng,co m REQUIRED PERMITS Registered Home Improvement Contractor MA #184472 Registered Home Improvement Contractor CT #HIC.0644642 Rhode Island Registration #40663 Homeowner Information Name: _ /►�AO.It Fo��S+e�- i` /JN�►� LoSAA Address: �� �AilftyiP.v� Aut City: NO&ILA/10100 A.-MA Zip: 01060 Phone: q)S7 -V3 " l` !Sd, Required Permits: The following building permits are required and will be secured by the contractor as the homeowner's agent and I/We as Owners of the subject property, hereby authorize East Coast Metal Roofing, LLC. to act on my/our behalf,. in all matters relative to work authorized by the building permit application: Owner's Signature Date - �O�Z�A� 0�-k — Owner's Sign ure r Owners who secure their own permits will be excluded from the Guaranty Fund provision of the MGL Chapter 142A This permit notice forms a part of the Purchase and Installation Contract of the same date.