29-559 (5) BP-2024-0771
38 BIRCH HILL RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
29-559-001 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-2024-0771 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2024 Contractor: License:
Est. Cost: 13895 DL WEST ROOFING CONTRACTOR 106007
Const.Class: Exp.Date:07/08/2025
Use Group: Owner: DAVIAU, MICHAEL& DAVIAU-HAYES, SUZANNE
Lot Size (sq.ft.)
Zoning: WSP Applicant: DAVIAU, MICHAEL&DAVI AU-HAYES, SUZANNE
Applicant Address Phone: Insurance:
38 BIRCH HILL RD
FLORENCE, MA 01062
ISSUED ON: 06/14/2024
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:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.Signature: 7��'
t�
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
RECEIVED
The Commonwealth of Massachusetts
W Board of Building Regulations and Standar s ,JUN 1 4 2( PR
Massachusetts State Building Code, 780 C R I PAL TY
E
Building Permit Application To Construct, Repair,Renova e O NG N ar 2 ll
One-or Two-Family Dwelling NORTHAMPTON MA01060
,l This Section For Official Use Only
Building Permit Number: 43���/'771 Date Applied:
4,iJ (1 4 //4 i-1'i•Zay
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
t\kkCe 'S « klbrc .„ , a(tfeZ
Name(Punt) City,State,ZIP
3$ @At'rAA U.i:(\ n S 230--(053 e tes., . .
No.and Street Cr/8-Telephone Email Ace
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 ❑ Accessory Bldg. 0 Number of Units Other eIRC Specify: ` \K.a..-) tee:.P
Brief Description of Proposed Work': R 0,6 sit g Sp____ iY.S�4,..Ll
Q t -tSe(nCc V
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ c5 $15, — 1. Building Permit Fee: $ _Indicate how fee is determined:
1 0 Standard City/Town Application Fee
2. Electrical $ 0 Project Cost'(Item 6)x multiplier x
3. Plumbing $ _ 2. Total Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All F ie , V
Check No. l Check Amount: Cash Amount:
6.Total Project Cost: $ I 3''M,3"; ❑Paid in Full 0 Outstanding Balance Due:
,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C `—If-el:n.01-- 8 j
Dexx (d -� License Number Expi at n Date
Name of CSL Holder
t k\ List CSL Type(see below)
No.and Street `,�,, /1 Type Description
ELmresA V &A• C'COCC� U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
Roofing Covering
WS Window and Siding
!, SF Solid Fuel Burning Appliances
�rQ, 2 3 U 460--fers-ectvwd ( .Co(At 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Im rovement Contractor(HIC)
`�•4 Coin e.-�r — t �21- Cie
HIC Registration Number pir lion Date
HIC Company Name or HIC Re rant Name
N Ili Wtol /1 CL) -. 467 (•tott(.L0 /\
bt
N�o.and Street Email address
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 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 Z.�•� d �,S4Ntt`6r,, (l
to act on my behalf,in all matters relative to work authorized by this building permit a ication.
fi'Vt(e- ' CAS)tc1-, C-ti 12.124,Z1
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.
ICI-( (ix (-
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. 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"
1 '
City of Northampton
YH.M T
y ✓r `' Massachusetts 4a4 x_ <<\
* c,
DEPARTMENT OF BUILDING INSPECTIONS 0,
Vr '"' , 212 Main Street • Municipal Building � a
�` r Jv";i Northampton, MA 01060 SSE,lY .; 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: VcA, ( ' C1(1AS
The debris will be transported by:
Name of Hauler: c),.�` ( -- fk fe -5 G oare-6G�r---
Signature of Applicant: Date: 6e117(Zo2r
t
The Commonwealth of Massachusetts
! 1- Department of Industrial Accidents
la1 4F I Congress Street,Suite 100
%• l• Boston, MA 02114-2017
�' t�;, ►vww.ntass.gav/rlirr
U,,,kern' Compensation Insurance Affidavit: Buildersi( ontractors/E ectricians'I'tuntbr•,•
TO HE FILED WITH THE PERMfl'1' ING AII1'HORITY.
Annlicant Information p Please Print l.eitiblt
Name(BusincasiOrganixationtindivithtal): • . (j r rt'�() ,c • •C...
Address: to e 1,„r,,„
City/State/Zip: 'AAA . o jr'(,Z Phone#: 22)WS 1-3 ( (
Are you as employer?Cheek the appropriate bog:
Type of project(required):
l rani a employer with_ ` __employees(full indur pan-lime(.• 7. 0 New construction
2.0 I am a mule proprietor or punnet hip and have tau employees working for mein 8. p"'""(Remodeling
any capacity. [Nu workers'comp.insurance required.)
I, 9. 0 Demolition
30 I am a hunXxtuner doing all work myself.[No workers'comp.irouranca required.]'
4.0 1 ama humummer and w ill b conduct hiring contractors to onduct all week on my property. I w ill
10 0 Building addition
casun that all contractors either ha'e workers'compensation insurance or arc colt; 1 I.0 Electrical repairs or additions
proprietors with no employes.
12.0 Plumbing repairs or additions
>n I am a general contractor and I have hirers the sub-cuntractor.listed un the attached sheet_
These sub-contractors have employees and have workers'comp.insurance.; t 3�ROOf repairs
6.0 we are a omporatiun and its officers have exercised their right of exemption per MGL c.
14.�Other+k29J `�v
152,that,and we have no employees.[No worsen'comp.insurance required.)
*Any applicant that clucks bon t+I mint also fill out the'section below showing their workers'compensation policy information.
+homeowners who aubinit this alildayit indicating they are doing all work and then hire outside.contractors must submit a new alydas it indicating such.
:Contractors that chalk this box must attached an additional sheet showing thre name of the sub-eu tractors and state Maritsa or not thuisc entities Base
employees. If the.ut.cui:tractors IravV t-inpluyees.they ilium provide their workers'comp.policy nwrilier-
I ant an employer that is providing workers'compensation insurance for my employees. Below is the polio'and job site
information.
Insurance Company Name: Af- M. t 1 Cif ` &.
Policy#or Self ins. Lic.#: A4L extr esye ZVZ'f/ -- Expiration Date: c f i/2202 S
Job Site Address: 2 S tjitZJ& 1.4(1` kc.x. City/StateiZip: 6.Q)tl u.1. OC°(PZ
Attach a copy of the workers'compensation 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 SI,500A0
andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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
coverage verification.
I do hereby cer •under th 'ns and penalties of perjury that the information provided above is true mad correct.
t.
Signature: �� Date: 1 Z/(v l`L/
Phone#: eaV(4c'13tt
Official use only. Do nett smite in this area.to be completed lily city or town official
City or Toss n: PermitiLicense#
Issuing Authorit) (circle one):
I. Board of Health 2. Building Department 3.('ityrTown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Aco?L7 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
`....----- 04/03/2024
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 Travis Sias
NAME:
KSK INSURANCE AGENCY INC PHONE (413)527-7859 FAX
(AIC,xo,Ext) (A/C.No):
ADDRESS: travissiaslksk-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
INSURER C
D L WEST ROOFING CONTRACTOR INSURER D:
11 PLYMOUTH AVE INSURERE:
FLORENCE MA 01062 INSURER F:
COVERAGES CERTIFICATE NUMBER: 993514 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIFTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I
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 'ADDLJSUBR POLICY EFFT POLICY EXP
LTR TYPE OF INSURANCE I INSD I WVD POLICY NUMBER (MWDDIYYYY)1(MM/DD/YYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE '$DAMAGE T
CLAIMS-MADE I I OCCUR PREMISES(EaEocccuED ence) $
_ MED EXP(Any one person) $
N/A PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: 1 GENERAL AGGREGATE $
1
i 1 POLICY JECO-- 1 LOC I PRODUCTS-COMP/OP AGO $
1 OTHER $
AUTOMOBILE LIABILITY i I COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED N/A BODILY INJURY
I AUTOS ONLY AUTOS (Peracddent) $
I HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
i $
UMBRELLA LIAR OCCUR EACH OCCURRENCE I$ _
1 i EXCESS LIAB CLAIMS-MADE N/A I AGGREGATE I$ -
i i DED RETENTION$ I $
WORKERS COMPENSATION ,I I X 1 STATUTE ERH
1AND EMPLOYERS'LIABILITY ------
ANYPROPRIETOR/PARTNER/EXECUTIVE YIN I EL.EACH ACCIDENT $ 100,000
A !OFFICER/MEMBEREXCLUDED? N/A NIA N/A : AWC40070363902024A 05/01/2024 105/01/2025
(Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 100,000
If yes describe under I DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000
I
N/A I j
DESCRIPTION OF OPERATIONS!LOCATIONS I 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.govAwd/workers-
compensatiorVinvestigations/.
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
1
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