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23D-031 (6)
BP-2023-1597 43 MILTON ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23D-031-001 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-2023-1597 PERMISSION IS HEREBY GRANTED TO: Project# 2023 ROOF Contractor: License: Est.Cost: 13680 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date: 07/08/2025 Use Group: Owner: B SIMEONE MARIO A&FLORICE Lot Size (sq.ft.) Zoning: URB Applicant: DL WEST ROOFING CONTRACTOR Applicant Address Phone: Insurance: 11 PLYMOUTH AVE AWC4007036390 FLORENCE, MA 01062 ISSUED ON: 11/15/2023 TO PERFORM THE FOLLOWING WORK: STRIP&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: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: a >Q - • r I � Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner C : The Commonwealth of Massachusetts t= p Board of Building Regulations and Standards FOR F Massachusetts State Building Code, 780 CMR 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 Permit Number: BP202..2 — I5.17 Date Applied: 1/-I1l-Z023 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: / 11.2 Assessors Map& Parcel Numbers 1.6 a tU 1 2-33D-03l-0o 1 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: (1 (3 _ .2 1-47 acre 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 Owner'of Recg `l3 SI. _ illorAcnofin I°tk A. 6COCo a Name(Print) City,State,ZIP Mr i wiz on,c _ at3)WS=149/ No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 I Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition 0 I Accessory Bldg. ❑ Number of Units Other 0 Specify: Brief Description of Proposed Work': —�b c.� _ — 0.S1-4 I ac yet ci sf �!� V�a,c u 5 cinT `315`�ut r c 'eL\i� s.. Nr4.'�, ct.sP L uilA SGIt~s� - J SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ `� ft,$G 1. Building Permit Fee: $ Indicate how fee is determined: f 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: $40-4 " Check No./372 Check Amount `f 0, Cash Amount: 6.Total Project Cost: $ - 6`d-', 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 65i — e!'6� `7/6/�Z-3 ,,�A.4.� U..) -,Sk License Number Exptra on Date Name of CSL Holder /) ��t"� j�, List CSL Type(see below) /'[,C� No.andStrebt 1/i•` Q Type Description ci 1,�•1�`1 0 C64 U Unrestricted(Buildings up to 35,000 cu. ft.) City/Town,State,Z �-+ R Restricted I&2 Family Dwelling M Masonry C Roofing Covering Window and Siding SF Solid Fuel Burning Appliances 610)4.55_731( 411 t1SeCC J elr�. Cr°'" I Insulation Telephone Email address D Demolition 5.2 Registered HomeQ Improvement Contractor(HIC) �, S 3Z bsc,• e�"xnln.r 4 Or HIC Registration Number 44-r.______r:sz'-i n Date HIC Com any Name or HIC Registt Name ti Qs cr$_,,P. cii.,0-1-'8 -50. nk CPttn Nond ire Y" . c5e -Z 11- -*3/( Email addr s City/Town, Stag,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 TZr . 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_ �. L. ()---1.4-(L(lc:lc: to act on my behalf,in all matters relative to work authorized by this building permit application. cVv..e. .. Vk l eI lzS:3z-3 Print Owner's Name(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. CjUt (pj-(--- 11V°c(--ctr)Z3 Print Owner's or 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. I 42A. 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 SNflM j u4'- ,S ,'`. SIC ''" 5:' Massachusetts hw.. �_ / DEPARTMENT OF BUILDING INSPECTIONS a`` w 212 Main Street • Municipal Building Q Ca, fit . ; Northampton, MA 01060 44.11, 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: VoLLLE4 RaiC<<1/44, The debris will be transported by: Name of Hauler: C .,(--, C.)=) - Signature of Applicant: Date: . • The ( ommonwealth of Massachusetts ..,11....—gi Department of Imiustrial Accidents I=•.0.0 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.goWdia SVorkers'f'ompensatiott insurance Affida%it: BuildersiContractorvElectriciansiPlumbers, 10 HE FILED WITh nit: PERMITTING AtritiR1 I\. Applicant Information Please Print Leribly Name tilusinetor'Orya niza iron 1 ndisichial 1: t Ls Address: \JV ett „.„0,, ek...4„.., City/State/Zip: c:-63- AAA. C,Locc-c. Phone#: EY:W_Ctet c----4.-. i, t %re e nes an Natpitt:k er?(inerk the/I pptopriate Ina: Type of project(required): .4l..ani a empleler vital employees(full ardor parf-nmer• 7. 0 New construction ...:.3 I am a wk.,proprietor or panne/strap and have no einpkeyeee Mk Otkinv for me in 8. 0 Remodeling any capacity.(Nu workers'comp.insurance' renpareell 9. D Demolition 301 arn a hurnerreeerm doing all work myself.No workers'comp.mietimince remeired.1* 10 El uig 40 I am a bornetowrun and will her hinny oontrador.to conduct all work on my property, I will B ldin addition mane that all coatrooms eiihcr ha s.c workers'compx-manon insurance or are sole I I C1 Electrical repairs or additions proprietor.A ith no employees. I 2.0 Plumbing repairs or additions ID I arn a general tontractor and I have hued the sub-citraractors Listed on the anaehod sheer 13.5/Roof repairs These sub-contractors tune einriboyees and base workers'einrip.insurarice.'; .q , RoCce MC]We tut a corporatni and its officers has e exercised then nyhi of exerninion per MC&c, 140111et 00,,a, 152,f 1(4).<and we hoot no employees iNo workers'comp.insistence required.] ' *Any applicant That cheek.%be. ni1.s.zil,,,till out th,...,:,:r ton below showing diseir workers'compensation polity information. 4.Homeowners who submit this allidai.s.Inds:mane the!, are doing all work and then hire outside contractors must submit a new affidavit indicating suck TContractors that check this IVA must arta:bed an additional sheet showing the name of the.uit-emitructors and state whether LW not those minim how employees, If the.sub-contractors base employees,they mum pit irk their workers"wiry whey mai tli:t I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. r\ , r,A Insurance Company Name: rt ,.L.- I-X dAlkiSc-aretA.L.G.4. (.4!:3 • — Policy#or Self-ins.Lie.#: 46-3(--Ltocri-c,343TD?DZ.:7)A- Expiration Date: Sli/Z0Z`l Job Site Address:_ 4-6 j'Ait:lik/42,A /3 -.• City/StatelZip: arCelArat VIA• 6 We? Attach a copy of the workers'compensation policy declaration page(showing the policy number and piration date). Failure to secure coverage as required under Mfil... e. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and.,'or one-year imprisonment,as well it,eivil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator.A copy of thi., -:.iieinent may be lonvarded to the Office of Invest I:.:it Ions of the DIA for insurance cos.erage veriticat. in. Ida hereby cer ,um th 'pains and penalties o 1"pedury filar the lotorniation provided above is (rue and correct. Signature: -- Dale: Ill 1(1-151-3 Phone::: Official use only. Do not write in this area.to be completed ht'city or town Vivant City or Town: Permit license# Issuing Authority (circle one): 1. Board of Health 2,Building Department 3.City rroviii Clerk 4.Electrical Inspector 5. Plumbing Inspector 6,Other Contact Person:_ Phone t,i: ., ...... ..,..—...........,„ „„,..., ,..— , .. _ AC R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `-� 05/19/2023 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 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 NAME: Travis SIBS KSK INSURANCE AGENCY INC PE (A/C.No.Ext): (413)527-7859 FAX No): ADDARESS: travissias@ksk-insurance.com 203 NORTHAMPTON ST INSURER(S)AFFORDING COVERAGE NAIC# EASTHAMPTON _ MA 01027 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B DANIEL WEST INSURERC: D L WEST ROOFING CONTRACTOR INSURERD: 11 PLYMOUTH AVE INSURER E: FLORENCE MA 01062 INSURER F COVERAGES CERTIFICATE NUMBER: 893862 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. 1LTR INSD SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE (MMIDD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 1 OCCUR DAMAGE TO RENTED 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) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY — ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A AWC40070363902023A 05/01/2023 05/01/2024 - --- (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 I 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 Daniel West ACCORDANCE WITH THE POLICY PROVISIONS. 11 Plymouth Ave AUTHORIZED REPRESENTATIVE Florence MA 01062 Daniel M.Crowley,CPCU,Vice President-Residual Market-WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD