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23A-036 (2)
BP-2022-0645 70 MAPLE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23A-036-001 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-2022-0645 PERMISSIONIS HEREBY GRANTED TO: Project# ROOF Contractor: License: Est. Cost: 11875 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date:07/08/2023 Use Group: Owner: ANYDOT REALTY MANAGEMENT LLC Lot Size (sq.ft.) Zoning: GB Applicant: DL WEST ROOFING CONTRACTOR Applicant Address Phone: Insurance: l 1 PLYMOUTH AVE FLORENCE, MA01062 ISSUED ON:06/06/2022 TO PERFORM THE FOLLOWING WORK: NEW 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: 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: 4.1 • I ,• 'f • I Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Buildine Commissioner , R /� R' The Commonwealth of Massachusetts GF/1/ (1 Board of Building Regulations and St f dar IFOR L1TY Massachusetts State BuildingCode, 780 C R r ✓!JN U Building Permit Application To Construct, Repair,4eno ate Or Demo4sp R ised ar 2011 One-or Two-Family Dwelli naT o� Thise!jjSection For Official Use Only yORT qM DON„v„. Buildin Permit Number: '( A A 004% Date Applied: 'Mq o,H2ONs &MI..)/s _r L 6,22a Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers C"1' 1.1a Is this an accepted street?yes no 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 O ner'of Record: c.3 W \ Giec 1-(ncavve_, AMA. .0 laces_ Name(Print) City,State,ZIP l �v pee ��- _ &t3) .�-S S-z No. dnd 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 Specify: I \ Brief Description of Proposed Work': Rem . 4.5piv, rcX tiles (f Cy ( c�s(in S 1, -Aa cif act-Corr-La-CZ. e1 ck,SPI�� -� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) _ 1. Building $ \,t ,,--ts _ 1. Building Permit Fee: $ _Indicate how fee is determined: i 0 Standard City/Town Application Fee 2. Electrical $ 7/ 0 Total Project Cost' (Item 6)x multiplier x 3. Plumbing $ _ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire —$ Total—� ,�I Suppression) To All Fees: l� Check No.lf� Check Amount: Le Cash Amount: ` _ 6. Total Project Cost: $ ,(1 S-15-'-- 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �CC `A W CSL- ��} �`e�¢� License Number Expiratioddd Date Name of CSL Holder ,(� C 11. P(,�ti� -1,1 ek List CSL Type(see below) V'� No.and Street) ,,,A�,A� /n� Type Description b(bC�� U Unrestricted(Buildings up to 35,000 Cu.ft.) � City/Town,/ State,� VV�L[P R Restricted 1&2 Family Dwelling M, Masonry ' Roofing Covering WS Window and Siding • / /J SF Solid Fuel Burning Appliances �I3ow-ow « cAtm_)-i'8-35-Csn l•c.ey,- I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) L+ C}-�'� Yl � r HIC Registration Number xpiration Date HI ,omoaanny Name ooruHIIC Registrant e j�(f=' � , .O(c 4 2 `,�1�r65_131 ( Email address City/Town, Stat '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 C .C.. (a4-- Kaza*.4, (adiraC/tj/- to act on my behalf,in all matters relative to work authorized by this building permit plication. --S\V‘'N (in ___ _ Li(1.-l-Cnb-Z-7._ Print Owner's Nam (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 contained ' this ap cat'on is true and accurate to the best of my knowledge and understanding. 4Nz Pr' s Au rized Agent's Name(Electronic Signature) Date NOTES: I. 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 G' :" S`5 sir ? F Massachusetts Q� -._ p DEPARTMENT OF BUILDING INSPECTIONS ; :' i 212 Main Street • Municipal Building j „4" Northampton, MA 01060 .P.3 �N,N' 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: a e_ CIA- 7_3 ko The debris will be transported by: Name of Hauler: r-O•L, Cs ,0Alt A� Signature of Applicant: Date: _ The Commonwealth of Massachusetts Department of industrial Accidents kg —,=1110114aw---- Pi) / Congress Street,Suite 100 e„44/ Boston, At A 02114-2017 www.;nass.gov/dw 41kr-r"'5,0' 'il orkers'I'intipensation Insurance Aflid a%it:Builder, ('i f II t rActuriVEIrrtrici A us/Plumbers,. TO BE FILED WITH I III PER:xi t I I ix ii:.,% I tiOitint Amalie/at Information Please Print Legihis Name inusuiess;orgaruzauoninaivukiai):J , - YS &'tJckc.._ Address: _ii ( ivy State/Zip: r44,J ..L..?(). 0A04. 4010.2 Phone#: 63) ea5--13 I ... ou an ertiphiyer?Cheek the appropriate but: Ty pe of project(required): iaLL.;a i a employer Nkith -- et riployees(fall and,Or part-tinsel.4 7. 0 New construction 20 I am a sale proprietor or parinership and have no employees working fist me in B. (:) Reinodeling airy capacity (Nu workers'cmnp.insurance required) 9. 0 Demolition ;DJ am a homeowner doing all 6kuri.myself.iNo 4<krloas'emir /rum-ante regained]* i 0 El Building addition I am a liorntsikk rim and kk ill he hiring .‘ontraCturs Exi...-tinduct all work on my property. I will ensure that all contraeiors either hake workers'corripensation LIESurance or itre MAC 110 Eksctrical repairs or addition Faupnetora with no innplovinia. I 2.0 Plumbing repairs or addition, am a general curitractor and I Kase hired the sub-contraetors listed on the attached sheet. i 3rit oolrepairs These sub-ekintractors have employers and have A takers comp.illbUrail .; * Afbal . Li 1/104..) na We are a LNPIVOIC-Aburi and ita ntlicors hake exercised their right of tAtniption per MU c. i 4OPEll I 52,f 1(4),and kve ha'e no employees.No workers'comp.insurance required.] *Any appliL.; , ..li,...eks bat al must also fill out the section below showing their workers'comperisidion policy information. I.Horneowney ., , -.timid this atridak it oulicanrig they an thong all work and then hire outside cendractors mint submit a Mr*Aides-it indicating such. tfiuraractors that.. ,..,..i.this Ixi,s must attached an additional sheet show feu the mum of the sads-contractors and state whether or not those entities hake ▪iiployeci. It the:5 ub-contractuni Diets onipluyixs,Ilii.- mu,/pi coi idc their s,orkers*oattap,poli,4 iiiiiiik:t I am an employer that is providing a-Priers'compensation insurance for my employees. Below is the Frolicr and job site in proration. ,—.—.., Insuram'e Company Name: .1-e • - (P. - ...,.._ Policy#or Self-ths. Lic.#4)1/..)0{,vb3-ta3Ce3TOZPZ/ 4- Expiration Date: Job Site Address: tO V\AAp(e -5e--, CityiState/Zip:jay co./4 0AA. O(0c Attach a copy of the workers'cohipensatkan policy declaration page(showing the policy number and eipiration date). Failure to secure coverage as requited under MOF c. 152, §25A is a criminal violation punishable by a line up to S1.500.00 anitor one-year iniprisorunerit,as well as civil penalties in the fiarin of a STOP WORK ORI)ER and a line of up to 5250.00 a clay'against the violator. A copy of mi... sz.iterrient may be forwarded to the()Bice of Investigations of the MA for insurano: ,.'.....-r...n.!e‘ertfica ion. ,, • , ' - I dr+hereby ee ) and Ire ins and penalties of perjury that the infOrmation/ provided/ho ,e ij.true and correct. Signature: '/4 phone ( (- ) Official use only. Do not write in this area,to be completed by city or town officiaL City or Tossn: 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 4: __.. ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 06/03/2022 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 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 NAME: Travis SIBS KSK INSURANCE AGENCY INC PHONE .EXu; (413)527-7859 (A/FAX No): ADDRESS: travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAIC N EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: DANIEL WEST INSURER C: D L WEST ROOFING CONTRACTOR INSURER D: 11 PLYMOUTH AVE INSURER E: FLORENCE MA 01062 INSURER F COVERAGES CERTIFICATE NUMBER: 781048 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 SUER POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MMIDD/VYYY) (MMIDDIYYVY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ • N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG_$ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED _ AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X ST H ATUTE ER AND EMPLOYERS'LIABILITY Y/N A OFFICER/MEM EREXCLUDED?XECUTIVE N/A N/A N/A AWC40070363902022A 05/01/2022 05/01/2023 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 ACCORDANCE WITH THE POLICY PROVISIONS. Matt Murphy Construction 329 Southampton Road AUTHORIZED REPRESENTATIVE westhampton MA 01027 Daniel M.Crow)ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD