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35-197 (2)
1160 BURTS PIT RD BP-2021-1142 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35- 197 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-2021-1142 Project# JS-2021-001916 Est.Cost:$6500.00 Fee:$80.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: THOMAS MORIN 112460 Lot Size(sq. ft.): 10977.12 Owner: PEASE RONALD Zoning: Applicant: THOMAS MORIN AT: 1160 BURTS PIT RD Applicant Address: Phone: Insurance: 162 PANDLETON AVE (413) 230-8076 Vv'(' CH ICOPEEMA01020 ISSUED ON:4/7/2021 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 NO;'TH PTO UP 44' 0 IOLATION OF ANY OF ITS RULES AND REGULATIONS. V • 1 • 1 Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 4/7/20210:00:00 $80.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner FRECEIVED \ APR — 72021 1 , The Commonwealth of assachusettsa ';-;.0,1Board of Building Regulatipnsiaod< pEcTioNs FOR Massachusetts State Building Code 5� O`1� °106e— MUNICIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building ermit Number: 6P"�/r ii'/ - Date Applied: EUNJ / 00,5 ��i/� 7 202) Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.11i6,0 ` D rt ddress:E I �l 1.2 Ass Map& Parcel Numbers 7c, C4-S 1.1a Is this an accepted street?yes no Map Number Parcel N//umber 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❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 0Aner1 of Record: i n p cse floc- H.Plese ‘ftlH O!o(o Name(Print) City,State,ZIP //60 &(4.3 e A-gck y/3/671'3'M cvY �0I-0 P r4o I,c.0,� 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) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 44 Specify: R.6a Brief Description of Proposed Work': 'R GxvQ U + {Ze 0<<e R o4+ SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item (Labor and Materials) Official Use Only 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fehheh O Check No. ' 1 Check Amount: 6.Total Project Cost: $ Cp s--00, c2, 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Cons ction Supervisor License(CSL) m CS-- 1► L14v 7 ).). t140m,S .rnoC License Number Expiration Date Name of CSL Holder 1 ��e AA i \ � List CSL Type(see below) No.and Street �(, Type Description CSC C-Of e ,n 61 6-c) U Unrestricted(Buildings up to 35,000 cu.ft.) Y'I R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(MC) S✓ G 0� V 16(\h L/i1P 1' //Gy m `,)��+� e�(c'H 1 HIC Registration Number Exp ation Date Comp Na or C Regi Name G �- � � � IAlley raeRk5c.wA c s�Iz�. t�+n, I �- N and S Email address t41aiOa. 0 1113 ,13610)C, 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 76►'11.cj ►l (`th to act on my behalf,in all matters relative to work authorized by this building permit application. PCW-1-14C1 FeAze- ..)-/ Print Owner's Name(Electronic Signature) to 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 a lication is true and accurate to the best of my knowledge and understanding. 7/6 I Print Owner's or Authorized Agent's Name(Electronic Signature) to 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" The Commonwealth of Massachusetts * 9 Department of Industrial Accidents ��?i 1 Congress Street,Suite 100 Boston, MA 02114-2017 �yy www.mass.got/dta 11 utkers'Compensation Insurance Afdai it:Builders/C'ontractors/Electricians/Plumbers. TO BE FILED N i lie THE PER%11'ITING A141101tfT1'. Annlicant Information Pease Print Legibly Name(Husincss Organization Individual): C(Gcf ( Address: � ) sued(2-''f1'1 A- / City/State/Zip:aCttz fhb o/O 0 Phone#: //3 3o-.5d , Are you as empiuyer'Cheek the appropriate hot: Type of project(required): 1.0 1 am a crnpk s cr w ith employees(full and or part-time 1-' 7. 0 New construction 1 am a sok proprietor or purtnrrstup and hair no employees working futon is K. (J Remodeling any capacity-[Nu workers'comp.insurance required.) 30 I am a homeowner doing all work myself.(No workers'comp.insurance nquirrr!_)' 9. ❑ Demolition ne 4.0 I am a hunxouner and cc ill be hiring eontractura con duct nduct all wutk on my property. 1 w ill l0 0 Building addition cnsurc that all contracture either hair Noreen'cilcipC-nsatuer insurance or are sole I I fJ Electrical repairs or additions proprietors w ith no rmpluyrce. 12.0 Plumbing repairs or additions 50 I am a general contractor and 1 Iav a hued the sob.euntractun listed on the attached sheet_ 13 f-1J 1 Roof repairs These sub-contractors-contractorshuie employees and Iva%/aurkrrs'comp.insurance.: 6.0 We arc a eorpoeaiiun and its officers ha%c exaciscd their right of exemption per MGL c. I4. Other 152,t llil,and we haze no employees.[No workers'comp.insurance required) 'Any applicant that chaels box a1 must also till out the section below show ing their Nutters'compensation policy ullurmation. 1 i Iliirmxu ie wners who submit d affulaiit indicating they are doing all work and then hire outside caxitractors must submit a new atfi*1 it indicating such. :Contractors that cheek this box must attached an additional sheet show ins;the name of the sub-contractors and state w hatter in not those entities ha<e employees_ If the sub-contractors have employees.they must pro%ide their .icarters'Bump.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.Lie.#: Expiration Date: Job Site Address: City/State.Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and etpiratlon date). Failure to secure coverage as required under MGL c. 152.§25A is a criminal violation punishable by a fine 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 fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance Overage verification. 1 do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: 1:1/ J-1 Phone#: L//3 - . 3 0 -7c7.6 Official use only. Do not write in this area,to be completed by city or town official ('its or Town: Permit?License# Issuing:tuthority (circle one): 1. Board of Health 2. Building Department 3.C'ityrfo►sn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton _ '''',;1"AP7i: ..( ''' ,� Massachusetts �,,(2S �._ c'e` NU �a `d 1I t , t r DEPARTMENT OF BUILDING INSPECTIONS y ` \ 7 �r'+ "' 212 Main Street • Municipal Building J, a c Northampton, MA 01060 'Pst%h; :3,Dx'�`� 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: I611/. ce c-I (...I The debris will be transported by: Name of Hauler: U s U+ 1i4 u ic� 4- Qec.v C l Signature of Applicant: F v Date: el&/4 ____.........,N CTHOMEE-01 ARODRIGUES AFRO CERTIFICATE OF LIABILITY INSURANCE DA3/29/202TE D21) 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 f such endorsement(s). ,CONTACT PRODUCER NAME__ Mirante Agency LLC PHONE 20.3 �8-9676 FAX �3 778-9902 272 Main Street Ste 1 ,E-MAIL No,Eat):(- ) (Arc Noy( A Danbury,CT 06810 ADDRESS: INSURERS)AFFORDING COVERAGE NAIC• INSURER A:NORTHFIELD INSURANCE COMPANY INSURED INSURER 8:The Hartford 22357 _ CT HOME EVOLUTION LLC INSURERC: 63 BELLEVEU STUD: Waterbury,CT 06704 INSURER E: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD yYYO POLICY NUMBER (MMIDD/YYY'O (MMIDD/YYYYI, LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 1 CLAIMS-MADE X OCCUR WS418745 3/23/2021 3/23/2022 PACs ,D„�) $ 1,000,000 MED EXP(Any one person) $ 5,000 PERSONAL tE ADV INJURY t Z000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (Ea ac NED ident81NGLE LIMIT) $ 4� ANY AUTO ° 4'' r1 '`' 7':o-, BODILY INJURY(Per person) $ OWNED SCHEDULED ,i1'4! AUTOS ONLY AUTOS `,�,« BODILY INJURY(Per accident) $ _ PROPERTY AUTOS ONLY AUTOSO I LY {Per atrMAGE $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE --_ 3 DED RETENTION S S B WORKERS COMPENSATION - X PER EATUTE EOTH AND EMPLOYERS'L AEIILnY ANY PROPRIETOR/PARTNER/EXECUTIVE R V/N 06�0411 Z1084-1$1488 3/30/2021 3/30/2022 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ ,__-- DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) WORKERS COMPENSATION IS VALID ON STATE OF CT ONLY. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thomas Morin ValleyRoofingand Restoration THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 162 Pendleton Ave Chicopee,MA 01020 AUTHORIZED� REPRESENTATIVE [ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A coREP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DO/YY) 101/2020 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 Chris Hess NAME: Southwick Insurance Agency PHONE (413)746-2822 FAX (413)746-2901 IA/C,No,Ern: (A/C,Not: 562 College Hwy E-MAIL chess@southwickinsagency.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC n Southwick MA 01077 INSURERA: Crum&Forster Specialty Insurance Company 44520 INSURED INSURERS: Thomas Monn DBA Valley Roofing&Restoration INSURER C: 162 Pendleton Ave INSURER D: INSURER E: Chicopee MA 01020 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2010103435 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 AODL w /Y POLICY EFF POLICY EXP LIMITS LTRINSD V0 POLICY NUMBER (MM/DOYYY) (MMIDD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 1 DAMAGE TO RENTED 100.000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) S 5,000 A BAK-69939-1 09/25/2020 09/25/2021 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 X POLICY JECT LOC 2,000,000 PRODUCTS-COMP/OPAGG S OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED PROPERTY DAMAGE s AUTOS ONLY _^ AUTOS ONLY (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE S `— EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION S S WORKERS COMPENSATION I STATUTE I r I EORH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If ves describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Rita&Sam Hurly ACCORDANCE WITH THE POLICY PROVISIONS. 281 Western Circle AUTHORIZED REPRESENTATIVE Ludlow MA 01056 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD rk.w.wevw,w,7///r'. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 185148 08/08/2022 TOM MORIN DB/A VALLEY ROOFING AND RESTORATION THOMAS MORIN 162 PENDLETON AVE. CHICOPEE,MA 01020 Undersecretary �� Commonwealth of MassacrH•selts Division of Prcfessional Licensure Board of Building Regulations anti Standards Const` fl tipvrvisor :.:S-112460 Expires: 07/23/202: THOMAS D MORIN 162 PENDLETON AVE CHICOPEE MA 01020 Commissioner