25A-039 79 CROSBY ST BP-2020-0467
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A-039 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categ-ory: ROOF BUILDING PERMIT
Permit# BP-2020-0467
Proiect# JS-2020-000794
Est.Cost: $11500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O:const.Class: Contractor: License:
Use Group: CHRIS GORSALVES 106104
Lot Size(sg. ft.): 12850.20 Owner. GRAY CAROL J
Zoning: URB(100)/ Applicant: CHRIS GORSALVES
AT. 79 CROSBY ST
Applicant Address: Phone: Insurance:
219 NAUBUC AVE 860 48-3459 WC
EAST HARTFORDCT06118 ISSUED ON.1011112019 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 DiDartment Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smok : Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature:
FeeType: Date Paid: Amount:
Building 10/11/2019 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
VJJU(--1
Department use only
City of Northampton --us" ermi
Building Department ��j� rive vvay Permit
212 Main Street', Sewer/Se tic A ilability
�.,.
Room 100 V �l� el Avail bility
Northampton, MA 010.60 ��'' Two Sets o Stru ural Plans
phone 413-587-1240 Fax 413-587-1272 PIaU s_
OtHmrpgcify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOi/ E�R DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 8
1.1 Property Address: This section to be completed by office
Map J Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2- PROPEP.TY OWNERSHIP/AUTHORIZED AGENT
2.1 wner of Record:
L�u L)li (-- -16 i�t-6Sb4 Jf IV D/�14 vn ✓��7✓1 �y4 o/D
Na
mnt) Current Mailing Address:
7 - - /a7S
A
Telephone 4/3217
Signature
2.2 Authorized Agent:
Name(P Current Mailing Address:
�vo - 3cfScj'
Sign Cyte Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building �t - (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 = 0 + 2 + 3 +4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: tiJ I I D 119
YO
Building Commissioner/Inspector of Buildings Date
C a rN Y (Y1 �� S�'rr 4 �� C C C ry)
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable?
New House Addition Replacement Windows Alteration(s) Roofing
Or Doors ID
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Sidi rig ftp]—Athe
Brief Description of Proposed
Work: iSrl LACE r,11S' uAz Rod- COV1LK1u 4
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes 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 stories?
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 .
I. 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
f as Owner of the subject
property /
hereby authorize /'� t l I �ltiY► �ri f [�CIQ�
to c on my beha , i afters relative to work authorized by this building permit application.
/O .7
Si Pure of Owner Date
I, S 71-4 �60 5 4 /J ifS i I rl!4 6wner�/A horized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print
C
Sign u Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Constructio u ervisor: Not Applicable ❑
Name of License Holder:
_ License Number
Addr s Expiration Date
Si atu Telephone h�
9. Re is ered Home Improvement tractor: Not Applicable ❑
I I ��✓�'4�r�l � G r��✓y��d Y'�
Company Name l Registration Number
2- s-s-
Address
Expiration Date
O✓► �/ d Telephone
//7/Z
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...... ❑
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS 7
212 Main Street *Municipal Building , ✓►
' . ,P°•,,a
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:
— �2 11 6,5h
(Please print house num r and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
"(4< `l'4-
(Company
lam(Company Name and Address)
Signature of Permit Applicant or Owner 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.
..� . .z ..........j. ....--
Massachusetts �,,�'�
w }�
DEPART14ENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Buildings.
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must beregistered
Type of Work: (Q.o�7— Est. Cost: & �J
Address of Work: bS
Date of Permit Application: Lb�I Cf
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A,SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
f U ? � I��. Lv r�cH S�i�GY-�a✓� � �/ � �L�
Date Contractor Name HIC Registration No. 1
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
'71�e
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
t Type: LLC
i „• Registration: 181994
MILLSTREAM CONSTRUCTION, LLC a, " Expiration: 05/17/2021
219 NAUBUC AVE. {
EAST HARTFORD, CT 06118 /
I ir!
Update Address and Return Card.
SCA 1 i5 20M-05/17
J�e �arrzr�zaizcaetz�l'�a�✓�/�a�Jac�u�elG1
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
181994 05/17/2021 1000 Washington Street -Suite 710
MILLSTREAM CONSTRUCTION,LLC Boston,MA 021,18
CHRISTOPHER GONSALV
255 W ILLIAMS ST E ,.` n/ ' �/,c��(CG.���L•
GLASTONBURY,CT i760 Undersecretary Not valid without signature
t Massachusetts Department of Public Safety
Board of Building Regulations and Standard-E
License: CSSL-106104
Construction Supervisor Specialty
CHRISTOPHER GONSALVES
219 NAUBUC AVENUE
EAST HARTFORD CT Q6-118
/7
Expiration:
Commissioner 08/02/2020
Millstream Construction LLC
Roofing Agreement 219 Naubuc Ave.
East Hartford CT 06118
P: 860.748.3459
This Agreement is made on 09/23/2019 between Millstream
Construction ("seller")and
Name:("Buyer") Carol Gray
Address. 79 Crosby Street, Northampton, Massachusetts 01060
Phone. (413)297-1075 Email Address: carolgray_2000@yahoo.com
Seller agrees to sell,and buy agrees to buy.all those matenals and labor listed below and otherwise necessary to install the products
listed in this agreement as set forth in the following specifications and in accordance with the terms and conditions below and on the
subsequent pages of this agreement.
All products listed in this agreement are covered by Manufacturers Warranty.a copy of which can be provided upon
request.
Roofing Agreement
• Protect Home and landscaping with roof to ground tarps
• Remove existing shingle roof down to roof deck
• Inspect sheathing for rotted,damaged wood or un-nailable surface.Any rotted.damaged or un-nailable wood to
be replaced at cost of$60 per sheet or billed at S65 per hour plus materials. (Up to 5 Sheets of CDX included at
no charge)
• Install ice and water shield(Entire deck surface)
• Install new edge metal to roof perimeter White
• Install new Owens Corning Synthetic Underlayment to roof deck as necessary
Install new iso board with screws and platesiwashers
Install new.060 EPDM rubber membrane reinforced with seam and cover tape on all joints and seams
• Install new Flashing and vent boots as necessary
• Install new Owens Corning starter plus shingle to roof perimeter
• Install new lifetime Owens Corning Duration Series Architectural Shingles( 6 nails per shingle) �•�.�o�
• Install new Owens Corning Ventsure Ridge vent as necessary
• Install new Owens Corning matching hip and ridge caps(4 nails per cap)
• Roof to be left water tight and site cleaned each day
• Clean up and removal of all job related materials
• Magnet to be used as part of clean up
• Lifetime Manufacturer Warranty( 50 years non pro-rated) includes lifetime replacement labor(20 year
manufactures warranty on EPDM flat roofing )including all permits and dumpster fees.
Please Note:The estimated start and completion date provide an estimated time window for your project to begin.Typical
roof projects last from 1-3 business days from the actual start date.In some cases.the actual start date of your project may
fall outside of this time range due to unforeseen or uncontrollable circumstances.
Estimated Start Date. 1.5 weeks Estimated Completion date:1 day
Total cash purchase price$ 11,500 excluding financing and related charges, if any,to
be paid by buyer to any third party lender if buyer chooses to obtain financing)
Payment to be as follows:
Initial Deposit: $ 5750
Final payment upon completion of entire project: $ 5750
BUYER ACKNOWLEDGES RECEIPT OF AN EXECUTED COPY OF THIS AGREEMENT
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
y�r www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Apnlicant Information Please Print Le ibly
Name (Business/Organization/Individual): t Qr1 y U / ►�
� L
Address: P
City/State/Zip: C%0613 Phone#: �OI> 7
Are you an employer?Checkk appropriate box: Type of project(required):
1.Zi am a employer with employees(full and/or part-time).* 7. ❑ New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.[:J I am a homeowner doing all work myself[No workers'comp.insurance required.]i
10 Building addition
4.❑1 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.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5 Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.2ROof 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#I 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-_6(c-i k/t,,ty ill t;
Policy#or Self-ins.Lic. #: 6 N U Lo L 0 10 Expiration Date:
Job Site Address: L 0 O 6 x.37 ' City/State/Zip:
Attach a copy of the workers'compensa ion 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 verification.
L do hereby cpKinderthepains and penalties of perjury that the in1ornnrtion provided above is tr a and correct.
G'
Si anature Q Date: 7
Phone#: O
Official use onlp. 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#:
Aft%
ACO CERTIFICATE OF LIABILITY INSURANCE DATE,
12)04, DrYYYI)
Aartol a
THIS CERTIFICATE IS ISSUED ASA 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. T'MS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS} AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: It the esrdfiats holder is an ADDITIONAL INSURED,the policy(se)must have ADDITIONAL INSURED provisions or be endorsed.
If SUIBROGATION IS WAIVED,subject to the terms and conditions of the poiicy,certain policies may require an endorsement A eLtlierw t an
this oertifltats does not confer rights to the certificate holder in lieu of such endorsemengs).
N�oT
Melissa Quinn
7240
Sumner&Sumner. Inc AC Ex, 860?423--33) N : (860)
757 MMn Street E-MAILmquinn@sumnerandsumner.com
P.O.BOX 187 INSURER(S)AFFORDING COVERAGE El
Willimantic CT 06226 INSURER A Evanston Ins.Co.
WSURED INSURER B: NGM Insulance Company
Millstream Construction, LLC INSURER C: 3erkleyNet
219 Na'ubuc Avenue INSURER D:
INSURER E
Harttorc CT 06118 INSURER F:
COVERAGES CERTIFICATE NUMBER: 18119 REVIBION Nwaaft:
'HIS IS TTO CERTFY THA:7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICAi c NCTWT'^iSTANDING ANY REQUIREMENT.T ERM OR CONDITION OF ANY CONTRACT OP.OT HER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
ADDL F1 POLICY EFF POLICY EXP LNMI'tg
LTA TYPE OF INSURANCE I POLICY NUNBEA MMIpO�YYY YY
Z7CLANLV,MADE
NERAL LIABILITY EACH OOCJRRENCE- GE 70 RENTED S 1.000.000
OCCUR PREMtSES!Ea 3=Mrce? $ 100.000
MED EXP(Arty one Dersm) S `x000
A 3EU0191 121OS2018 ,?/092019 PERSoNALaADvIwURY $ 1.000.000
GENERAL AGGREGATES 2000.000
GREGATE LMT APPLIES PER2Op0,000PPZ- F7 Lx PRODUCTS-COMPIoP AGG fLICY �JECT S
tER COMBINED SINGLE UMrT f 1.000.000
AUTOMOBILE UASILITY Ea ac5deat
GODLY INJURY(Per wr=) S
ANY AU'D
B � $GHEDULu�J BT2296Q 11!092018 11/092019 BODILY IWURY(Per soMetD S
AUTOS ONLY AUTOS PROPERTY DAMAGE $
HIRED Al1rOS ONLY U OSo Y Uninsured motorist S 1.000.000
UMBRELLA UA8 EACH OCCURRETJCE.... f 3.000.000
OCCUR
A E�CESe UAB EZXS3W2000 12)C92C,8 ! ,2'0:20,9 AGGRE-XII s
CLAIMS-MADE
5
� DED FETENTION 5
oQq OT>•+
WOKKEPW COMPENBATFON STA EP
i AND 11PL0YEM'LIA8fLrTY Y/N I c.L:ArN ACCIDENT f 500.000
C IANYPROPR�'ORIPAM7QREXECL7tvE fl IN/A BNUWCC,45355 ,2/09/20,6 ,?/09/20,9
OFFICEIVNIEMBER EXCLUDED EL DISEASE-EA EMPLOYEE S x.000
H Yes.describeunder EI_DISEASE-POLICY UMR S 500'000
DESCRIPTION OF OPERATIONS below
i I �
I
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Addmcna!Remake Scnedula may be attacmd I*more apeoe is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLKNfS BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED IN
Proof of Insurance ACCORDANCE WITH THE POLICY PROVI&ONS.
AUTHOR®REPRESENTATIVE �- - q ,� �,• I^ /
D 1988-2015 ACORD CORPORATION. All riahta reserved,
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