32A-027 (3) 30 CHERRY ST BP-2017-0677
GIS4: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 32A-027 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-2017-0677
Project# JS-2017-001105
Est.Cost:$9865.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT D THIBODO 065699
Lot Size(sq. ft.): 7448.76 Owner: KUBASEK ANDREW E&MARGARET W
Zonine: URC(1001/ Applicant: ROBERT D THIBODO
AT: 30 CHERRY ST
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527-8966
NORTHAMPTONMA01061 ISSUED ON:11/16/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE MAIN HOUSE ROOF & INSTALL NEW
SHINGLES
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 II 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 11/16/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Depattmentuseonl
_.. _ City of Northampton
Building Department Curb`CutlDtiyeway Permit
212 Main Street S@wedSepticAvailability
NOV4 2„' Room 100 Waler/WellAvalfability
N rthampton, MA 01060 Two SetaofStmctural Plans
'841 587-1240 Fax 413-587-1272 PlDVSde Plans
OthBi Specify -
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION / 7 G 77
1.1 Property Address: This section to be completed by office
Map Lot Unit
30 CI-\-r"�r'LJ\ S� one Overlay District
J Elm St.District CR District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
K vb o s c,k 3 o c k\-Q-rYm 5' A
pma(Print � . _ Current Mai(ipp Q.ddr�es1s:
Telephone C'fl'4}
ignature , ,
3.2 Authorized Agent:
64.0 -2 c c>x v _v `
Current Mailing Address:
+rte_ . . A ..><.y Sit C 19 (::2`l
Sign-I e Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by penult applicant
1. Building (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(MVAC)
S. Fire Protection { Wig "
&. Total=(t +2+3+4+ 5) - - p� Check Number �j)?-A// ��
This Section For Official Use Only
Date
Budding Permit Number: Issued:
signature: 7--/-5— `
Building Commissioner/Inspector f Buildings Date
Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size .__— __... 1
—____—. '
Frontage —
Setbacks Front -- �'
L
Side L R:= LlIR ---'
Rear
Building Height ,
Bldg. Square Footage _� I %
Open Space Footage — ----.
(Lot area minus bldg&paved _� 1_____,
._ _ -
parking)
#of Parking Spaces _" -" —
Fill:
lb .
(volume&Location) --
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES 0
n
IF YES, date issued:I: I I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES Q
IF YES: enter Book Page: I and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q
, Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location: l
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
IF YES, describe size, type and Location:
E. Will the construction activity disturb(clearing,grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? 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 n Addition ❑ Replacement Windows Alteration(s) n Roofing u
Or Doors C
Accessory Bldg. ❑ Demolition ❑ New Signs [171 Decks [q Siding [CJ Other(CD
°7(e. f 4 l h `
Brief iption of Proposed 'Jry, V� o
Work WlllV-� mCi1 Y1 Q1.1 1 V 1nC� PIS.
Alteration of existing bedroom Yes No Adding new bedroom Yes No J
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
5a.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 Woodstoves Number of each
9. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft 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, ON Nr• rLSI C\-) \N-:/ ev5 V `C. ,as Owner of the subject
property 1� \
hereby authorize O� 1 ✓\\ N (\,t
to act on my behalf,(jin all matters relative to work authorized by this building permit application.
(.M/..[LA A.,•) t 957...J1a kl \\ — V)._ 1
Signature of Owners Date
IIIIII
I, OR) 1 k' ` ,'b 0 , as Owner/Authorized
Age 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 pena ties of perjury.
/)5 \ \) a w
PrinName
41
.AN aw.11 I , \\ \a\\Lo
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 licensed Construction Supervisor: ��---Tcc-- Not Applicable O
(>
Name of License Holder; �7 )c3 , , r
a ko 0 1 I 1
c? Si)
p erase Number
sio
Address ExOratt
UDate
Signa ure i Telephone
9.Registered Home Improvement CContrac r: Not Applicable p
\ 0/3 \ � Ib � 5 � llt1-
Comiew Name c) Registrati n Nu ber
Address .�w�� Expirati D to
'r• .5�1,. A_ r ':._ Telephone�]� S k Ci
r o'
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(60
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.,..... LI No.,.... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an inditidual for hire who does not possess a Peptise,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.A persoq who constructs more than one home in a two-year period shall not he considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form 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 tthis 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 liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with dr State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws andState of Massachusetts General Laws Annotated.
Homeowner Signature -„
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 150A.
Address of the work: 3 rJ C\f vY The debris will be transported by::e7 irl \C)ll d
The debris will be received by: 4,5\\, k- C ty, ��1/4
Building permit number: \
Name of Permit Applicant Lj 1 ' �i� a 6 (�
-\ \\,-a\to RTh3r-:\Civ_CLar
Date Signature of Permit Applicant
The Common wealth of Massachusetts
Department of Industrial Accidents
1= Office of Investigations
1 Congress Street,Suite 100
? Boston,MA 02114-2017
"T-�•"'. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information '-----its
\ Please Print Legibly
Name (Business/Organizationindiviiid-ual): ' (5' > t ' `x o ?elf _
Address: 4 leg \ Yr a Qv\\(tS' ._
ty `t'ate/Zip: „ - ,,,frCs. AV� v Phone#: Th S 1 C1 (:(Th
Are ou an employer?Check the appro mate box: Type of project(required):
I. 1 am a employer with 4. 01 am a general contractor and I 6. ❑New construction
employees(full anchor 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 S. 9 Demolition
working for me in any capacity. employees and have workers' 9. 9 Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1I.❑Mlimbing repairs or additions
myself. p 1'7. Roof repairs
insurance required.] t e. 152, §I(4),
[No workers' comp. right of exemption per MGL Y—/
Yand we have no
employees.[No workers' 13.9 Other
comp.insurance required.]
'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information_
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating soah.
tContractor5 that check this box must attached an additional sheet showing the name of the subcontractors 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 warners'compensation insurance for my employees, Below is the policy and job site
information. \
Insurance Company N'me: \ -e � �- Act,/ ( -5 ^--y I /
Policy#or Self-ins.Lic.4:C-,5(0 O. U% "`Qa J o1`i H 4-1— iration Date: 3 (.- t tom,,,,
Job Site Address:5 Y _ v ..City/State/Zip: I . [. I G,.1 1
Attach a copy of the workers'compensation pone declaration page(showing the policy number and expiration d.te).
Failure to secure coverage as required under Section 25A of MGT 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 da hereby might under the pains and penalties of perjury that the information provided above t true and correct
Signature: ' �• v. .. / ,.,:�4 Date: 0_ \
Phone#: . `�S \ c t 'C}� ._
Official use only. Do not write in this area,to be corrrpieicd by city or town official
City or Town: Permit/License# •
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3, City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:_ ,_ Phone#: ____ ''