31A-004 (4) 309 ELM ST BP-2017-0188
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31A-004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-0188
Project# JS-2017-000308
Est.Cost:$4600.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(su. ft.): 19340.64 Owner: BOOS STEPHEN C&KIT SANG BOOS
Zoning: URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT: 309 ELM ST
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663 () WC
NORTHAMPTONMA01061 ISSUED ON:8/11/2016 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP & SHINGLE GARAGE ROOF
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 t/ Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department 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.
Certificate of Occupancy signature:
FeeType: Date Paid: Amount:
Building 8/11/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
ity of Northampton Status of Permit
RECEIVED
wilding Department Curb Cut/DnvewayPermit
212 Main Street
Sewer/SepticAvailability
AUG I 12016 Room 100 AvailabilitywaterNVan
No hampton, MA 01060 Two Sets of Structural Plans
13- 87-1240 Fax 413-587-1272 Plot'Site Plans
oE'1 CFB .I➢N ii OCA
rv,,,�„•.- Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address This section to be completed by office
Map Lot Unit
3rD El ( 1 • Zone Overlay District
lJ tel` M\ (� Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
5'C-ev � a h S 3 0 9 AIM S-k 1\I or} "a mNam Current Mailing Address: 1` `�
Telephone SUS • 61 '
Signature
2.2 Authorized Agent: 1 \\�
L . V _ . a Q 0 � o ( 4,b l \`l u�c\N wt?}o/•
Nam -nut) Current Mating Address: r
f ^1 , n VI
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection (�
5. Total=(1 +2+3+4+5) I Li Cm n C) ,Check Number /(l 9 I #1
1 This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomptefr Information
Existing Proposed Required by Zoning This column tube fi'.led in by
Building Department
Lot Size
Frontage
Setbacks Front :-
Side L: .._ R L R
Rear
Building Height - -
Bldg.Square Footage r_._. %
Open Space Footage(Lotareaminusbldg&paved _ __.. .....
parking)
P of Parkins Spaces - --
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeps?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page. and/or Document:
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
IF YES, describe size, type and location
E. Will thheel construction activity
ru over 1 acre,
(clearing,grading excavaticn, or filling)over 1 acre or is it part of a common plan
e? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors C
Accessory Bldg. ❑ Demolition ❑ New Signs [G] Decks [[] Siding CI Other[DI
Brief D cription of Propose���]//�� n 1 `t`{ 1 �n ('
WorkN`e Cy I 2lT� er a C , �\1^�—� �) 1. 4A 1V"e g IGIV
J
Alteration of existing bedroom Yes ` No Adding new bedroom Yes No 1
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea. If New house and or addition to existing housing, complete the following:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 fr. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
J. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 4 15C VC- ' Y O O 5- as Owner of the subject
property
l
hereby authorize t r 1 \ f� a `-YCI
Itoyaact on m in in all tive to work authorized by this building permit application. C—
SignatureofOwner r------ -"\
�\} ! Date • I I I v
I, \� c \ y \� D Q j as Owner/Authorized
Agen ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under�the pains and penalties of perjury.
2j \k) C) (,\()....0
Prin ame '
2rk ` 1ne � , • r I • 1 L
Signet - of Owne Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable�£ �
blame of License Holder'. 1 4{f 0 Cm S C- 5
�^ Licens- Number
ik " \41x' 1 y • 1 1�
f•••.-
Address Expiration Date
-.A _ —.A .• XO ` . —
Si.nature Telephone
9.Reaistered Home Improvement Contractor: of A licable £
C3 rA\ 0 vTh_a
Com Company Name
1e sfiI
Address j (� Expira ion Date
±21��� I^��i V =.24X4 Telephone
SECTION 10-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 uilding permit.
Sinned Affidavit Attached Yes. £ No...... £
•
11.- Home Owner Exemption
The current exempdon far"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures. 4 person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official, on a font acceptable to the Building Official. that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated.you may be Gable for person(s) 1,
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
, r The Commonwealth of Massachusetts
r' Department of industrial Accidents
t1—.r. Office of Investigations
12
k1 600 Washington Street
c Boston, MA 02111
k 4...
www.mass.gov/dia
Workers' Compensation insurance Affidavit: Puilders/Contractors/E1ectrielans/Flaumbers
Applicant Ianformation Please Print Leaebly
Name (Business/Organization/In�diviiddu-al): <DT k� e -)
Address:'3 3._€ S \ mccs, 'cl\S\r-e... st
City/State/Zip: _ e"4 ••�� -or\ Phone#: 5 D� ^1 (0(p7
Are you an employer? Check the approp'ate box: Type of project (required):
1. --{, I am a employer with 1 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑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 g, ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P Ty 9. ❑Building addition
[No workers' comp. insurance comp. hlsurance3
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L. tnnbing repairs or additions
myself. [No workers' comp. right of exemption per MOL 12:il Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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./� YAC or`r 0,\
Policy#or Self-ins. Lia #:1o5CO LO a.50 N 4 Expiration Date: 3 -,4---1 l c-\
Job Site Address: 3d C\ 1 In/. ‹ City/State/Zip: 11O�'\ ' 0✓1
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration .
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
foe 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 3250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is trueand correct
Signature: e �- �s.�1- .. — •,..... _ Dater /
I 1 ' I "O
e
Phone#: C —li1( c.,c03
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#:
City of Northampton
Massachusetts ` \t
J
3?ART.MNT OF BUILDING INSw-TIONS "./
i` ,,
F'tn.- 212 Main Street o Municipal Building
Northampton. MA 01060 -F
y 1
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends to be, a one or two family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in a two-
year period shall not be considered a home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footinas (before backfill). sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 1150A.
Address of the work:r30 I S1- N
The debris will be transported by: o ) i\-) °QO
The debris will be received by: VA:�\-C ttk ‘
Building permit number:
Name of Permit Applicant o J
\ \�1
Date Signature of Permit Applicant