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36-367 (6) BP-2024-1501 151 EMERSON WAY COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-367-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2024-1501 PERMISSION IS HEREBY GRANTED TO: Project# DECK REPAIRS 2024 Contractor: License: Est. Cost: 36330 KEITH G ROY CONSTRUCTION 063810 Const.Class: Exp.Date:09/08/2026 Use Group: Owner: HEWLINGS, DAVID W&LINDA THIEL TRUSTEES Lot Size(sq.ft.) Zoning: SR Applicant: KEITH G ROY CONSTRUCTION Applicant Address Phone: Insurance: 54 MAINLINE DR SUITE E 413-485-7533 WC9082781 WESTFIELD, MA 01085 ISSUED ON: 11/08/2024 TO PERFORM THE FOLLOWING WORK: REPAIRS TO DECK 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: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 172_ Fees Paid: $277.50 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner g , The Commonwealth of Massachusetts Board of Building Regulations and Standar s NOV — 4N1C PALL Y 0 ' Massachusetts State Building Code, 780 C R USE Building Permit Application To Construct, Repair, Renovate 0 enm i_sh a Revised War 2,011 Ir;'i or milt DINC W'JSPi_CliGiiS One-or Two-Family Dwelling r;-,.,-H,1N..1"nu Al. ac This Section For Official Use Only 1 Building Permit Number:& '014—ASV J Date Applied: wilding Official(Print Name) ignature Date SECTION 1: SITE INFORMATION 1.1 Pro_perty Address: 1.2 Assessors Map& Parcel Numbers 151 Emelrarn 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use 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 Record: 1.tha \VW\\Ns OQCCL'1 pi Otrm, r V 0((AO 2 Name(Print) City.State,ZI 151 ern21:SW U -j uI -a3-7- a‘a dheW 1mpe wt t,con, No.and 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) 'j ' Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify Brief escription of Proposed Work': • ( �ur(ace C,�kttel J'V► O i�4 t Y\ `�'1'� i LVi1Q �Q(i✓ 4-. U- waO(t eta", �u r f c (1, 'tiU A7 X SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ 36 330 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: • 5. Mechanical (Fire $ Suppression) Total All Feqi C 1• Check No.AU eck Amount'. r' Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-0(03S1 D License Number Expiration Date Name of CSL Holder List CSL Type(see below) 5y 1J6,(NvolQ Dc.\Ve, No.and Street Type Description �c�.c\el Q`,. U Unrestricted(Buildings up to 35,000 Cu.ft.) W+ � R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofin Covering WS Window and Siding , SF Solid Fuel Burning Appliances i4 R-L4q<)y 533 O csm Yd.gtie etS`yt i CM'WM I Insulation Telephone Email address D Demolition 5.2 Registered Homen Improvement Contractor(HIC) l IA 4SG? G7i 3D j 2ca5 r 1QA G' t C) C�v u 17�, MCA HIC Registration Number Expiration Date HIC Company Name or ICRegistrant Name Street �vns. 17rt A. alkkP E O ct r t MC ,►c ' .cam No.and Street Q` � ," ~ \Ky2S P 1 ca ,NA kok C5 u 13-u$5-?533 Email address 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 .❑ 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 ` W r l 6- go to act on my behalf,in 1 matters relative to work authorized by this building permit application. ilf / 174 Print Owner's Name(Electronic ignatur 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 contain • 's application is true and accurate to the of my knowledge and understanding. i ," Z K er's or Authorized Agent's N (Electr ' Signature) ate 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" I UV I.VIRO1VRlYGLttL/I VJ irl laJC44.-IlitaCtia ==.:= Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 � .: Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):Keith G.Roy Construction,Inc. Address:54 Mainline Drive Suite E City/State/Zip:Westfield, MA 01085 Phone#:413-485-7533 Are you an employer?Check the appropriate box: Type of project(required): (.0 I am a employer with 6 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' p ty insurance.• 9. ❑Building addition [No workers' comp.comp.insurance required.] 5. ❑ We are a corporation and its 10.E Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 I.111 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.E Roof re.pArs insurance required.]+ c. 152,§1(4),and we have no !� �f (/cei employees. [No workers' 13.U Other lT K-C, 6 comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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:Selective Insurance Company Policy#or Self-ins.Lic.#:WC9082781 Expiration Date:5/14/2025 Job Site Address: 151 Emerson Way City/State/Zip:Northampton, 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 cer '•• nder the • •nalties of perjury that the information provided above is true and correct. ..r ill Date: l (1 OIL/ L Signa ``— Phone#:413-485-7533 Official use only. l)o not write in this area,to be completed by city or town official Project: Project Address: 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#: KEITGRO-01 JOCELYN ACORO CERTIFICATE OF LIABILITY INSURANCE DATE 5/9/2(MM/DD/YYYY) /9/2024 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 NONTACT Jocelyn M Douglas Phillips Insurance Agency,Inc. PHONE 1 FAX 97 Center Street (A/C,No,Ext): (A/C,No): Chicopee,MA 01013 nD ss:Jocelyn@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC N _ INSURER A:Selective Insurance Co INSURED INSURER B:Selective Ins Co Of South Carolina 19259 Keith G.Roy Construction,Inc. INSURER C: 54 Mainline Drive,Suite E,Rear Bldg INSURER D: Westfield,MA 01085 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INS() MD (MM!DDIYYYYI IMM/DD!YYYYJ A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR S 2399511 5/14/2024 5/14/2025 DAMAGE TO RENTED 1,000,000 PREMISES(Ea occurrence) E MED EXP(Any one person) $ 15,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JEL'T X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: EPLI $ 100,000'. B AUTOMOBILE LIABILITY (EOMacCidEeD SINGLE LIMIT $ 1,000,000 ANY AUTO A 9108142 5/14/2024 5/14/2025 _B ODILY_IN JURY(Per person) $ OWNED X SCHEDULED _ AUTOSRES ONLY AU N ONLY� ONLY _ AUTOS BODILYBODILY INJURY(Per accident) $ X AUTO X TOS ((Per M PROPERTY DAMAGE , $ 1 $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ ~— EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ B WORKERS COMPENSATION X PER AND EMPLOYERS'UABIUTY STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y� WC 9082781 5/14/2024 5/14/2025 E.L.EACH ACCIDENT $ 1,000,000 FlCER/MgMBBEER EXCLUDED? I I N/A Mandatory m NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Construction Supervisor r ®y Division of Occupational Licensure Unrestricted-Buildings of any use group which contain less than Board of Building Regulations and Standards 35,000 cubic feet(991 cubic meters)of enclosed space. Const /ionf go'pprvisor CS-063810 ixpires:09/08/2026 KEITH G ROT ; 54 MAINLINEIARIVE SUITE E 6 WESTFIELD fiA4 Z 40, i 'im ?�ML 01Vdi1O�o Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner et / s Contact OPSI:(617)727-3200 or visit www.mass.gov/dpl/opsi THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Im•royement Contractor Re istration (to rx' F ne =3. Type: Corporation KEITH G. ROY CONSTRUCTION, INC Registration: 188456 Expiration: 07/30l2025 7.4 54 MAINLINE DR SUITE E „ •-=� ; WESTFIELD, MA 01085 = : :• k, r rOl• 144 gs 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 Registrajon Expiration 1000 Washington Street -Suite 710 188456 07/30/2025 Boston, MA 02118 <EITH G. ROY CONSTRUCTION. INC KEITH ROY 3 BRAYTON DR yr/n��, ,z!�s.l • SOUTHWICK, MA 01077 Undersecretary Not valid without signature City of Northampton ! may' Massachusetts ��t5 y, ce` -, . ;; r DEPARTMENT OF BUILDING INSPECTIONS y, fts 4r 212 Main Street • Municipal Building J,.. ,a Northampton, MA 01060 rsY `"o 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: 555 --ta1,.,oC,f Ed G c-cdd C1 O( OFO- The debris will be transported by: Name of Hauler: U 5Y\ otta, .\--kiJ I i 419 c\- r (I I1< Signature of Applicant: ✓r,) Date: (( 6 LK