11A-054 (3) 15 VILLONE DR BP-2019-1381
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:BI k: IIA-054 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateeorv: ROOF BUILDING PERMIT
Permit# BP-2019-1381
Proiect# JS-2019-002221
Est.Cost•.$12504.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor.- License:
Use Group: DAVE MINER 99953
Lot Size(sa.R.): 29272.32 Owner: KALLAUGHER STEPHEN
Zoning:URA(100)/ Applicant: DAVE MINER
AT: 15 VILLONE DR
Applicant Address: Phone: Insurance:
347 NEWTON ST (413) 533-0481 WC
SOUTH HADLEYMA01075 ISSUED ON:613120/9 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: FireDepartment 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 6/320190:00:00 540.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
(2a)C=
— City of Northampton status of permit Deparment use only
.> Building Department cum cudomreway Pemdt
212 Main Street Sewer/SepEc Awilabiliry
(. Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plane
phone 413-587-1240 Fax 413-587-1272 Plods
APPLICATION TO CONSTRUCT,ALTER,/REPAIR,,RENOVATE OR O MOUSH A ONE OR TWO AMI WELLING
SECTIONI -SITE INFORMATION / ' /6" MAY 31 2019 /��._ofy
1.1 This aaClbntO YofNae
DEPT OF BUILdNG IN3PECTIDNS
Mill N RTHAMPTVAuAOICfiO UM
�J VI II ci r- Pit-
Zona Owrisy Dislrkt
I?cps
Elm SL Drali CB aetrlct
SECTION 2-PROPERTY OWNERSHIP/AUTHORQED AGENT
2.1 Owner of Record:
11�41I<vrLr7 / f V11{ oweyo, I-ee IS 11712
Nems(Prim) Cuewd Malin,Address:
soR - � sr:
e,n}1•f F Telephone
Signure
2.2 Authorised Agent:
DA-�e I1hinr2 So. la-� Per 2r
Name(Prim) Cueenl Magrg Md..
�� Y7Y —c7to
Signaturo Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(DDlians)to be Official Use Only
completed bmnit applicant
I. Building (a)Building PemB Fee
J S•o y
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee +L f
4. Mechanical(HVAC) L
5. Fire Pmtac im,
6. Total=(I -2+3+4+5) s-6 'y Check Number
This Section For Official Liao Only
Building Perk Num Dais
ssued:
Signature: 5
Building Commlesionerllnspecor of BDINiws Dao
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
�rr� va.a f
Section 4. ZONING7 All Information Wat Be Completed.Permit can Be Denied Due To Incomplete Irdonnalion
Existing Proposed Required by Zoning
This coLmu to be filled is by
Budding Depvtmest
Lot Size
Frontage
Setback. Front
Sim L RLJ LT R—
Rear L_
Building Height O
Bldg. Square Footage '.. '� F
Open Space Footage %
(tut
new muss bWg@Paved
hill
#of Parking Spaces
Fill:
volmealafadOa -
A. Has a Special Pemlit/Vanance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#�
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O ,Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES,describe size, type and location: j _J
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES,describe size, type and location:-
E. WAIT Cie constructionacavhy disturb(dinning,grading,excavation,or filling)over 1 acre or is it partof a common plan
Cortwill i isWrb over 1 acre? YE-0 NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows ANsratbMa) ❑ Roofing ❑
Or Doors El
Accessory Bktg. ❑ Demolition ❑ New Signs J]] Decks ® Siding 0] Othv g7]
Brief Description of Proposed
Work: /1iCw I.oc
Alteration of exisorg bedroom_Yes No Adding new bedroom Yes No
Attached Narretive Renovating unfinished basement _Yes No
Plans Ateched Roll -Sheet
m. 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 adacletl?
d. Proposed Square footage of new eonstrutiun. Dimensions
e. Numberofskines?
I. Method of heating? Fireplacesor Woodstoves Numberof each_
g. Energy Conaervation Compliance. Masscheck Energy Ccmpliance form attached?
h. Type of construction
I, Is eon auction within 100 ft.of"fiends?—Yes —No. Is comAnxton vnthin 100 yr. floodplain Yes No
J. Depth of basement or cellar floor below finished grade
Ic Will building conform to the Building and Zoning regulations? Yes_No.
1. Septic Tank City Smar_ Pdwe well_ City water Supply_
SECTIONta-OWNER AUIHORMATKIN-TO BE COVSIL- D WIEN
OMENS AGENT OR CONTRACTOR APPMES FOR BOLDING PEFBBi
1 frJA- �Ct ��a.�/�t/ as Owner of the subject
property
hereby authorize TJ fast Ml Aty
to act on my behalf in all maters relative to work authorized by this building permit applicatlon.
e. L( f/,8ix,9
(traa d ower Dee
I. ,as Owner/Aulhonzed
Agent hereby declare that the statements and information on tie foregoing application are true and accurate,to the best of my Imowledge
and belief.
Signed under the pains and penalties of perjury.
f 1to-z 111/AY1
RIM Name
/_-- It 9
SI natue ase/ M Date
ly
SECTION 8-CONSTRUCTION SERVICES
8.1 Licermed Construction Suarvhw: Not Applicable ❑
Name m Li,,,Hold,DR�c- /h 14,f S995rJ
License Number
347 s)- So, 144,Ik4 MS- oi.- r !o/xo/( 9
Address apaawn Data
�74�0730
slaMture Tekplorw
9.Rawl ileal tome ImuovameM COMnelar: Not Applicade
17fl'�C /t'1laLfr {�fc%ne% /�•. r �r�ra�rnn•nlT LLL js&rfZ
Registration Number
1N/26
Address jAq
Expiration Data
Telephone
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,$25C(8))
Workers Compensation Insurance affidavit must be completed and submitted vnth this application.Failure to provide this affidavit will result
in ft denial of the issuance of Me building penult.
Signed Affidavit Attached Ves....... No...... ❑
City of Northampton
^' Massachusetts Fry"' trc<r
c
1 x
DEFAR2TrRRT OF aDILD IN6P 10015
212 naln atrwt " M, W pal ft tl6tnp
Np[CTyQtm, !p 0106,
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
petitioning work on such homes,a contractor must be registered as a Home hnprovement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction,aaeration,renovation,repair,modernization,conversion,
improvement,removal,damoBim,or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by reeistered contractors.
Note:if fire homeowner has contracted noir a corpmafion or LLC,that entity must be registered
Type of Work Est.Cost
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owneroceupied
other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVR ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
1 hereby apply for a building permit as the agent of the owner:
A-)a�4 " � r� r l % (n S5Z
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Namc and Signature
City of Northampton
Massachusetts
2
DSPdRf 8 OF BOZLD rNSP ldP ,
212 lYfn 9the lNn 010 BullElnq
No[tr,saptan, M 01060
Massachusetts Residential Building Code
Section I I O R5.1.2
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 farts structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section I IO R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5,provided that if a homeowner engages a person(s)
for hire to do such work,then such homeowner shall act as supervisor.
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 thejob 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 liable for person(s) you hire to perform work for you
under this permit.
City of Northampton
Massachusetts
.t W x
� ..' ;L� DBPIAII�NT OF BUILDING INSPSLTIONS � �,"
212 I n SL t Wnieipal But
'" lalBq
Nort4aogtm, !W 01060
Debris 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.
The debris from construction work being performed at:
/ sVI 110.
(Please print house number and street name)
Is to be disposed of at:
V IIr-) /� .ycl,�i
(Please print name and I ation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Dale
If, for any reason,the debris will not be disposed of as indicated,the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
�\ 7Ae Commonwealth of Massachusetts
Department ofindustriolAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017a 7
S srm'w.m rssgov/dia
11 orkers' Compensation Insurance Affidavit:BuBders/ContraMn/Electridaas/Plumben.
TO BE FILED WITH THE PERMITT'IN'G AUTHORITY.
Applicant Information / L Please Print Lesdl,
Nente(Ba®nesoOrgalmornooludivldual): jPA,,e rylfnzi
Address: 7W > rfe—)" $'L
City/State/Zip: So- lMIc, y`IA Phone#: Y-67 io
Aneyou an stutterer?chert the appropriate box: Type of project(required):
kj!7T—.aemployerwhh—z—empioyeas Ma md/apartdime).' 7. ❑New construction
2❑Iam,eolepmpnetmaPaMashiP andM1rvenoemployen working fmmem g_ p�g(j�
anyeapseity.Mo woman'emW.inur,nce no amedd
3❑Iam,hoes.doing all work myaeY.Mo wriknn'eon,unarm.ounired.l T 9. Demolition
a❑I am ahommwmv rad wdl benving mmaemm m mmmtan worsen dor property.
twill to❑Building addition
nears mat an emuaaora ame<harxwortas'canpauatiov mamma ormeolc I 10 Electrical repays or addition;
pmprivam prim m meloyeo.
12.[]Plumbing repairs or additions
501 aaagmmal eowaaor and l have hired fle, oaoa Mn Izabal on a.nawod thus.s d h13❑Roof
'Thee.ubtiovtramn have emplo§canal worsens'cmM.'res.t mpeim
60 We am acorpommmandits ensure base canosedthemfight ofcxemanper MGL c 14.[:]Odw
152,H(4t and we havero maPloyme.[No wmkmn'comp.imumme re,minal I
'Any WilieaN aesthetics box#I mmt.lea Most the section babes,lem mg their workers'eamPsuation policy infnmulim.
t moo mama who submit an,adicievit mdiatmg they me doing an wore and men hive ounide mmm mcmmust salient,a new atRdesn,in hating such.
hCmhaeNn does chase oris box must altachcd an additional sheet showing the name of the sul-ontautera and state whether m rad nose mans h,vc
employees. Ifine orb—tmat ahaveemployes,they moat prwidemc& wudam'comp.pnliey number.
lam an employer that u'providing nwrkem'compensation insurance for my employees. Below is the poacp andjob stte
informmton.
Insurance Company Name: /
Policy#or Self-ins.s.Lie.#: 71Z u/j F F L.97/Jb /6 Expiration Date: lo/a. 115'
Sob Site Address: 16- us 1 ease dAL City/Statelzip: 4.,A /17 A-
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 prmisbable by a film up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 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 certify under the pains and penalties of perjury that the information provided above is true and correct.
S' t= D le
Phone# ?7
Official are only. Do not write in this area,to he comphded by city ortown official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cirs/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts Gancral Laws chapter 152 requues a0 employers to provide workers condensation for their employees.
Pursuant to this statute,anemployee is defined as"._every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ofan individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more then three apartments and who resides discern,or the occupant ofthe
dwelling house of another who employs persons to do nmintemme,construction or repair wok on such dwelling house
cron the grounds o building appurtenant thereto shell notbecause of such employment be deemed to bean employer."
MGL chapter 152,§25C(6)also aaas that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or m construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the imumove coverage required,"
Additionally,MGL chapter 152,§25C(7)slates"Neither the commonwealth car any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been pmw;nled to the contracting authority."
Applicants
Please fill out the workers'compenslion affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-conhacto(s)camels),addresses)and phone mmntsm(s)along with their cutificele(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Parhrmhips(LLP)with memployees other than the
members o partners,ere mtreq=W m curry workers'compensation insurance. If an LLC a LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents fo comfnmatiom of imsurarce courage. Alm be surem sign and date the affidavit The affidavit should
be resumed to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a wokers'
compenmtion policy,please call the Department at the comber listed below. Self-insured conparrics shodd enter their
self-inemeoce license comber an the appropriate lime.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bonen
of the affidavit for you to fill out in the event the Office oflnvestigations hes to contact you regarding the applicant.
Please M sure w fdl in the permit/license mmber which will be used m a reference number. In addition,an applicant
that must submit multiple pendVlicense applications in my given year,rued only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)"A copy of the of davit that has been officially samped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit ism file for future permits or licenses. A new affidavit must be filledouteach
year.Where a Mme owner or citusm is obtaining a license or permit net reared to any business or commercial venture
lie.a dog license or permit In bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and ax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
Tel.#617-727-4900 ext 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
AND
a OX hN, Date: // ij) .l
E:esrlor Roes leprorsesnb
(413) 533-0481
www.DaveldinerRooang.com
347 Newton Street,South Hadley,MA 01075
MA Reghtration#186552
Customer Name: `><1-✓r �l S o �' Telephone Number -
Address,City/Town, State:
BETTER ROOF SYSTEM
Landmark Pro
• Strip off existing roof
• Line all edges with 8"aluminum drip edge
• Install feet of WiaterOuard ice& water barrier along eaves and up any valleys
• Install RcayfRunner water resistant underlayment
• Install CertainTeed Landmark PRO architectural shingles to manufacturers specifications
• Install SwiftStart starter strip along eaves
• Install using 4 nails for maximum wind coverage up to 130 mph
• Install a ridge vent along the length of house approx. 15"in from edge of roof
• Install new vent stack collars
• Replace step flashing as needed along walls and chimney
• Re-Rash chimney with lead Dashing as needed.
• Plywood
Install 1/2"CDX plywood
Install 1/2"CDX plywood as needed @ (! — per sheet
• CertainTeed SureStart Plus 4-Star Extended Transferable Coverage
(50 year non pro-rated full coverage warranty for material defects)
• All debris removed from work site
• Protect siding and exterior of house
• Protect trees and shrubs
• Magnet ground for loose nails
• See Other below for any additional work or comments
• Other
Contractor is not responsible for any damage to interior of home.Any loose articles on walls/shelves should be removed before work starts
We Propose hereby to furnish material and labor-complete in accordance with the above specifications for the sum of:
dollars($
A deposit of 1/3,$ //// ? ,is to be paid before materials are ordered
A Payment of$ 1i) - is due at the halfway point,and the balance of$ paid upon completion.
All material is guaranteed to be as specified.All work to be completed in a workmanlike mummer according to standard practices.
Any alteration or deviation from the above specifications involving extra costs will be executed upon written orders,and will I
become an extra charge over and above the estimate.Our workers are fully covered by Workmen's Compensation Insurance and
Liability Insurance.
Authorized Signature: Note: This Proposal may he withdrawn
by as iitnor accepted within 30 days
Acceptance of Proposal—The above prices,specifications and conditions we satisfactory and we hereby accepted.
You are authorized to do the yvork as specified.Payment will be nude as outlined above.
Signature: '�-- Signature: - - --
Date ofAceeptance:
This agreement may be cancelled by Customer thih 3 days of acceptance for any reason as deailed m the accompanying Notice
of Cancellation Customer's Initials
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