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37-082 (2) BP-2023-1228 6 DIAMOND COURT COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 37-082-001 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-2023-1228 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 21772 THOMAS ROBERTS 100333 Const.Class: Exp.Date: 07/03/2024 Use Group: Owner: KORNBLATT ANNE B& DEBORAH S STIER Lot Size (sq.ft.) Zoning: WSP Applicant: ROBERTS ROOFS CO INC Applicant Address Phone: Insurance: P O BOX 1312 (413)283-4395 2008W6216 BONDSVILLE, MA 01009 ISSUED ON: 09/07/2023 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: s Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: hqh )Oq . 16R Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner DocuSign Envelope ID:2F34ADAD-755C-432D-883A-41E81DD5C153 I/ The Commonwealth of Massachu tts Sep W Board of Building Regulations and S ndar s 4904,3 0 M FO IC[P LITY Massachusetts State Building Code, 80 ^�ooFC�i U Building Permit Application To Construct,Repair, Renova DetoYF R ised ar 2011 One-or Two-Family Dwelling N. N 0106 oNS This Section For Official Use Only Building P rmit Number: 6 A •' /yL' Dy Ap 'ed: &Ili a 5 e Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 6 Diamond Court 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❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Deborah Stier Florence,MA 01062 Name(Print) City, State,ZIP 6 Diamond Court 218-5920 dsstier©yahoo.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION_ / OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 6f Owner-Occupied lif Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2:Remove&replace shingle roofing on house and shed complete with all associated flashing details. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost' (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) Check No 13j j Check Amount: ALI° Cash Amount: 6.Total Project Cost: $21,772.00 0 Paid in Full 0 Outstanding Balance Due: DocuSign Envelope ID:2F34ADAD-755C-432D-883A-41E81DD5C153 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(C$I,) 7/3/24 �,. 100333 Thomas R Roberts,Jr - License Number Expiration Date Name of CSL Holder List CSL Type(see below) RC ( 400 Franklin Street No.and Street • Type Description U Unrestricted(Buildings up to 35,000 Cu.ft.) Belchertown,MA 01007 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry 2, tislaRC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-283-4395 info@robertsroofsinc.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 128264 3/16/25 Roberts Roofs Co.,Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name PO Box 1312 info@robertsroofsinc.com No.and Street Email address Bondsville,MA 01009 413-283-4395 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 Roberts Roofs Co.,Inc. to act on my behalf,in all matters relative to work authorized by this building permit application. —DocuSign.d by: Paged(' Stia. 8/8/2023 Prifirflatl biseae(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 in this application is true and accurate to the best of my knowledge and understanding. _23r1 /a-3 Owner' Authorized 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" r Commonwealth of Massachusetts !.let Division of Occupational Licensure Board of Building Regulations and Standards -Tl r Construct`Qbuper` $r Specialty .j CSSL- 100333 E cd,pires: 07/03/2024 ti THOMAS R F OBERTS . .JR -' 400 F RANKLAN STREET :. BELCHERTO° 'N MA 01007 :i _ w 1 11\Ze. 17 • f)1 11 .t X 13 , Corn riss:vncr eirtitG 4 "ni , THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aff and Business Regulation 1000 Washing wt- Suite 710 Boston, Massachusetts 02118 Home Im•rovement Contractor Re istration l� _ ~`Type: Corporation ROBERTS ROOFS CO. INC. ��• }registration: 128264 PO BOX 1312 _ j E Oration. 03/16/2025 BONDSVILLE, MA 01009 e T, C. IJ Update Address and Return Card_ THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE: Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 128264 03/16/2025 Boston,MA 02118 ROBERTS ROOFS CO.INC.f •-- THOMAS R. ROBERTS JR ., fiz. 400 FRANKLIN ST -- � �. ��Glsmli" 2, lLrt{!`t BELCHERTOWN,MA 010074�,�` Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents t=zV= t Office of Investigations _i _: 600 Washington Street _. _ Boston, MA 02111 „'-.'fir• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Roberts Roofs Co., Inc. Address: PO Box 1312 City/State/Zip: Bondsville, MA 01009 phone #: 413-283-4395 Are you an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with 2 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' insurance.: 9. 0 Building addition [No workers' comp.comp. insurance required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.El I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *My 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: Farm Family Casualty Insurance Company Policy#or Self-ins. Lic.#: 2008W6216 Expiration Date: 4/17/24 Job Site Address:6 Diamond Court City/State/Zip: Florence, MA 01062 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 a d penalties of perjury that the information provided above is true and correct. Signature: ' Date: --L ,-3 Phone#: 413-283-4395 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#: _,.....—,,N ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) k....---- 4/13/2023 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 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 Sean Rooney NAME: Sean Patrick Rooney,Sr.dba PHONE,Etlt): 413-887-8817 (NAC,No)c 877-771-8087 Rooney Insurance Services E-MAIL ADDRESS: y SBan.roone rm4amlly.COm 2341 Boston Rd. INSURER(S)AFFORDING COVERAGE MAIGI Wilbraham MA 01095 INSURER A: Farm Family Casualty Insurance Company 13803 INSURED INSURER B: ROBERT'S ROOFS INC INSURER C: 400 Franklin St INSURERD: Belchertown MA 01007 -- 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. iiiiir ADDL SUER POLICY EF'F POLICY EXP LTR TYPE OF INSURANCE INSD IAND POLICY NUMBER (MMIDD/YYYYI IMM/DD/YYYY) LIMITS /� X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ A X BOP X X 2007X0329 04/17/23 04/17/24 MED EXP(Any one person) s5,000 PERSONAL 8 ADV INJURY s 11.000.000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s4,000,000 X POLICY JET L_ J LOC PRODUCTS-COMP/OP AGG s4 000,000 OTHER: $ AUTOMOBILE LIABILITY 1 OMBItSINGLE LIMIT S 1.000.000 ANY AUTO BODILY INJURY(Per person) S A x ALL OWNED SCHEDULED X 2001C4685 04/24/23 04/24/24 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per accident) $ X UMBRELLA UAB X OCCUR EACH OCCURRENCE $1.000.000 A EXCESSLIAB CLAIMS-MADE 2001 E9999 6/30/22 6/30/23 AGGREGATE $ 1,000,000 DED RETENTIONS S WORKERS COMPENSATION PER X STATUTE OTH- ER AND EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N X 2008W6216 04/17/23 04/17/24 E.L.EACH ACCIDENT S SOO,000 OFFICER/MEMBERdcrI EXCLUDED? NIA) E.L.DISEASE-EA EMPLOYEE S 500,000 tf be under DESCRIPTION d OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sean Patrick Rooney,Sr. I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:2F34ADAD-755C-432D-883A-41E81DD5C153 City of Northampton 5 s p Massachusetts ��? .\ t, A. a: ye i DEPARTMENT OF BUILDING INSPECTIONS IC y; ,Z,° syyy 212 Main Street • Municipal Building v`., .C1 Northampton, MA 01060 f• A Ant:-=4:' 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: USA Hauling & Recycling, Hatfield, MA The debris will be transported by: Name of Hauler: USA Hauling & Recycling Signature of Applicant: Date: $/36/j3