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15B-046 (5) BP-2024-1323 610 SPRING ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 15B-046-001 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-2024-1323 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2024 Contractor: License: Est.Cost: 9875 DL WEST ROOFING CONTRACTOR 106007 Const.Class: Exp.Date: 07/08/2025 Use Group: Owner: O'BRIEN LESLEY J Lot Size(sq.ft.) Zoning: URA Applicant: DL WEST ROOFING CONTRACTOR Applicant Address Phone: Insurance: 11 PLYMOUTH AVE AWC4007036390 FLORENCE, MA 01062 ISSUED ON:10/10/2024 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: Ca,: Fire Department Driveway Final: Fireplace/Chimney Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 72 Fees Paid: $60.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEIVED 1 The Commonwealth of Massachu.etts 0 CT - 9 2024 J Board of Building Regulations and S 1:nd^a�ds OR Massachusetts State Building Code, 7:0 W UNI IPALITY OF SUIT DIN,INSPFC"IONS SE Building Permit Application To Construct,Repair, ' - . •. N ITY4fno"Tisti ".°Revise Mar 2011 One-or Two-Family Dwelling //99�'/` This Section For Official Use Only Building Permit Number: 06 �6'/30?3 ''Date Applied: 5re"?4 / fL'Utj 4S`-r- /O-/d a7 Building Official(Print Name) Si azure Da SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers (D SPkt1r 3 i l.1 a Is this an accepted street?yes no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use I Lot Area(sq ft) Frontage(II) 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 Record: o,^ 1d53 Lp�� a(Ar t.g4\ 0.14- esfercrt Name(Print) 1 City,State,ZIP W0 SQrit\S �,{.�' Z9t 3--64°8 IC,brtc.h 5l4 �a U, &a— No.and Street Telephone Email A r SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other I KSpecify:S' u e,- RAtica Brief Description of Proposed Work2: RQ.VtA01-' (.tS � � p�• 2 ,� ctin S a 1 ,a� r 'cam' ,.tA 4'K OW • SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ b 59-5' I. 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) S List: 5. Mechanical (Fire (� Suppression) S Total All F lU' Q Check No. I ,0►4yheck Amount: 6o.`Cas, • ount: 6. Total Project Cost: S l;8-f.5' 0 Paid in Full(6t4 0 Outstandin a ance Due: n SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) c c- le4 License Number Expi ati n Date Name of SL Holder List CSL Type(see below)a No.and Street Type Description « 'AAA _ _ O(cCZ Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZI Mw7 R Restricted I&2 Family Dwelling N�-� Masonry �/ Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 61'3)C'CY 73 Z( ve.oSin( €(5(44et(. (tea I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) L. iZo:.°A r 6 3Z.1- HIC Comp Name or HICegistran me HIC Registration Number E it ion Date � { I et rm�-c„<® di.(aWk No.ristreet`04.c kw!. ( Email ad s City/Town,State,ZI'P 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 .PC 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 'D.,.. (j E 1'tzczati...2 to act on my behalf,in all matters relative to work authorized by this building permit apation. Print Owner's Nine(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 containe this a p ca on is true and accurate to the best of my knowledge and understanding. 6C/5/1-6C4r Prin s o uth Ind 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" City of Northampton /1 Massachusetts 44 <<. ,.4. ! t 1 DEPARTMENT OF BUILDING INSPECTIONS r.• 212 Main Street • Municipal Building �,'" p=✓ Northampton, MA 01060 SSNir a'D‘.‘�' 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: ‘AtAleff 9 '2 f=,, ,c,.,. -or• ( . 1 1ln�. c• Y The debris will be transported by: Name of Hauler: O.L. .1 14s5c/a1t-A Signature of Applicant: Date: 3 2 � The Commonwealth of Massachusetts 1 � lii ir Department of Industrial Accidents i.W = - 1= 1 congress Street,Suite 100 '�: :'4—.--"..:• Boston, MA 02114-2017 •« - " www mass.gov/dia Workers'Compensation Insurance Affidavit:BuildersiContractursiElectriciansll'Iumbers. TO BE FILED WITH THE:PERMrrTrrG MITI toRI l V. Applicant Information / 1 Please Print Le eihly Name(l3usincssOrganrxatton'lndieidual): L„�� Address: A et,f YA„,„„44„ t ' City/StateiZip:Areu(4 �t(,,,i. )( 6Z. Phone#:60'3_)Cq.S.:-. 3/( Are you an employer?('hick the appropriate but: 't)pe of project(required): 1.17.earn a enrpla»•a with.__ (___employees(full and or part•timel.• 7. 0 New construction 201 ant a sole pr.;pnetor or purtnct`ltip and have no employees working for me in 8. a Remodeling any capacity [No workers'comp.insurance required.I 9. 0 Demolition 30 I am a humase.net doing all work myself.!No workers'comp auurnkr required.]' 4.0 I ant a homeowner and skill be hiring coatroomsto conduct all work on my property. I will l0 a Building addition ensure that all contra:turs either have Wtrtiterx'compensation insurance or are sole 1 I.a Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 50 I am a general contractor and I have halal the hub-cuntrtrcturs listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance. 13 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. •Other 132.41(4t.and we have no employees.[No workers'cutup.insurance required.] *Any applicant that dm:Ls but al must also fill out the section below showing their workers'compensation policy ittforrrwtion. t Homeowners who subunit this affidavit indicanng they are doing all work and there hire outside contractors must submit a new affidavit indicating such. tCuntractors that check this box must attached an additional sheet showing the name of the sub-cururacton and state wlahher or not those eattitie- have ennployces. lithe sub-contractors Istve employees.they must Nov isle their workers comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job.,ire information. Insurance Company Name:_ m (V { 4,,a Aim ._61:). Policy#or Self-ins. Lic.#: A (,ec)9 -3 7CZ1 - Expiration Date: 5/( /7d"Z/— Job Site Address: (Q(0 refit`4 • City/StateiZip: tiP�S • d( Attach a copy of the workers'cthnpensation policy declaration page(showing the policy number anti expiration date). Failure to secure coverage as required under MGL c. 152. §25A is a criminal violation punishable by a line 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 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 co%erage verification. I do hereby cer ' ,um iI pains and penalties of perjury that the infi,rrnationprovid/e�d above is true and correct. Stenature: ,� ,� - Date: IJ" zg Phone : �l32 Gc5---_ -(( Official use only. Do not write in this area.to be completed by city or town official City or Town: Permitll.icense u Issuing Authority (circle one): I. Board of Health 2. Building Department 3.('ity,rhown Clerk 4. Electrical Inspector 5. Plumbing inspector 6.Other Contact Person: Phone#: �� DATE(MM/DD/YYYY) A CO CERTIFICATE OF LIABILITY INSURANCE 04l03/2024 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 (A/C No):o.EXU: E-MAIL - - - -__.------- -------- ADDRESS: 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 INSURER C: D L WEST ROOFING CONTRACTOR INSURER D: 11 PLYMOUTH AVE INSURERE: FLORENCE MA 01062 INSURERF: COVERAGES CERTIFICATE NUMBER: 993514 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 I AODL!SUBRI-- j—POLICY EFF !POLICY EXP LTR TYPE OF INSURANCE INSR I WVD I POLICY NUMBER (MM/DDIYYYY)I IMM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY I I EACH OCCURRENCE $ )—?---- I D om CLAIMS-MADE OCCUR I DAMAGE TO( a occurrence) PREMISES(Ea occurrence) I$1-1 MED EXP(Any one person) i S N/A PERSONAL&ADV INJURY $ _ GEN'L AGGREGATE LIMIT APPLIES PER ! GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS_COMP/OP AGG $ OTHER. 1$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I$ (Ea accident) '.ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED I AUTOS ONLY _ AUTOS NIA BODILY INJURY(Per accident) $ i HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY ,_(Per accident) $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE j S DED . RETENTION$ I$'WORKERS COMPENSATIONPER AND EMPLOYERS'LIABILITY Y/N X STATUTE ER A OFFCER/MEMBEREXCLUO D/ 00,000 ECUTIVE N/A N/A I N/A I AWC40070363902024A 05/01/2024 05/01/2025 EL.EACH ACCIDENT I$ 1 (Mandatory In NH) EL.DISEASE-EA EMPLOYEE S 100,000 If yes describe under DESCRIPTION OF OPERATIONS belowI E.L DISEASE-POLICY LIMIT i$ 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.gov/Iwd/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