29-151 (4) 107 SPRUCE HILL AVE BP-2019-1424
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 151 CITY OF NORTHAMPTON
Loc 1101 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv:ROOF BUILDING PERMIT
Permit# BP-2019-1424
Proiect a JS-2019-002305
Est.Cost.$14000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: RONALD KEITH 085204
Lot Size(sa. ft.l: 88646.80 Owner. FUNGAROLI DONNA M
zoning: Applicant: RONALD KEITH
AT: 107 SPRUCE HILL AVE
Applicant Address: Phone: Insurance:
5 BIRCH MEADOW DR (413) 584-5589
HADLEYMA01035 ISSUED ON:6118/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP ROOF, SISTER MEMBER BROKEN
RAFTERS, REPLACE 7 SHEETS
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: 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 611820190:00:00 540.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
` I Department use only
City of No CE�V E istu of Permit:
BUII(Jing pa urb ut/Driveway Permit
212 Mai St et 19 ewer epkc Availability
Room 100 �UN 1 20 star ell Availabilky
Northampton, MA 10 0 o Be of Structural Plans
phone 413-587-1240 ax 1 -
DEPNMsPEc,; loscans
OF our-"1, 11ONBr SpecifyO
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE ORR-two
�FAMILY DWELLING
SECTION 1 -SITE INFORMATION e ro
1.1 Property Address: ��yy'�,,,, This section to be completed by office
JOZ SPl'V�C �` Ary— MSP eZiq Lot If Una
Puxe w' q0t Zone Overlay District
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
3)on - 0.v Ol 54xv D�
Name(Prim) Cunent Mailing Address:
413. 5ffiI••'�YfStk
Telephone
Signature
2.2 Authorized Agent:
OYNOL� Kef}h C tvycdicn 5 cath l�todoL� a7r. �4cr(lu� }lfl
Name(Print Current Mailing
��Address: p�
6 • SOS • tel
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
6. Total=(1 +2+3+4+5) I Itur'DoO W I Check Number
This Section For Official Use Only
Building Penin k Numb r: Date
Issued: p
Signature: - 1 S - ZD)O
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
�4r e
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Ibis cotumn to be filled in by
Building Depemnent
Lot Size O O O
Frontage O O O
Setbacks Front �� 0
Side L= R:O L:=r R:= D D
Rear u 0
Building Height O O
Bldg.Square Footage
Open Space Footage %
(I&area minus bldg&paved 0 0
aro
4ofParking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued forlon the site?
NO O DONT KNOW O YES O
IF YES, date issued:L
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book 'L _ _. _ , _ JI PageC and/or Document#L-7
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:
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. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 arse? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK Ichack all applicable)
Now House ❑ Addition ❑ Replacement Windows Alterstion(s) Roofing
Or Doors C3
'Accessory Bldg. ❑ Demolition ❑ New Signs [17:1] Decks [Q Siding[[31 Other(CA
Brief Descd ion of Propos
wok: ro o , t-Skw' Foam ter 10rt1[Ar\ m ev f e plar� Z tkagALS
Alteration of wasting bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
60. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family X 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?
I. Method of heating? Fireplaces or Woodskwes Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
I. Is construction within 100 ft.of weflands?_Yes No. Is construction within 100 yr. floodplain_Yes_No
j. Depth of basement or cellar floor below finished grade
k. Will building condom to the Building and Zoning regulations? Yes No.
I. Septic Tank_ CitySewer Private wellCity water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, V CKVrA P! CLY-C-A as Owner of the subject
property O
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building pe it a (ration.
k,(- *&
Signature of r Date
I, Z6 \C&C' �--e ' ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are we and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
gtar\MA& lc '4A
R ntNa
��2a�f9
Signature of Owner/Agent Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SS�uopendso�r: ,y ` N1ttJ oApplicablee ❑
Name of License Hold. W �/`�^ �/�`^Tt_, /(. • y9 JZ04
License Number
5 0l lleoa&r�w fir. Edi µA tilalzoal
Address _ Expiration Data
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
90(\OA Ye. cck l k tent t— ci c"
Company Name Registration Number
bow 51w17-OLo
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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...... ❑
City of Northampton
Massachusetts tr
DEPARTMENT OF nD3rLD2NG TNSFECTTONS O
212 rqIn Stet aunicipal auilding
Northpvptgv, rA alalia 'fid
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
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, altembon, renovation, repair, modernization, conversion,
impmvement, ramoval,demolition, orconstruction of an addition to any pre-existing owneroccupied building containing
at least one but not mom than fourdwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:Ifthe homeowner has contracted with a corporation or LLC,that entity mast be registered
Type of Work: c% Est.Cost: luFr OOt�
Address of Work: to-T 5(Woe V'il\ AJE , P O 4m-Nco 1�R
Date of Permit Application: tkkVk k
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 ownero cupied
_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 HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.G.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
iflzq I 19 fLond�d� V_ e A ) 11'515 j
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 Name and Signature
City of Northampton
Massachusetts
F
DEPARTMENT OF BUZLDZIPG IIrSPECTIOBS �
212 Nair 9trcat a N icipal R,Ald W 5 �F
Northeaptoc, NA 01060
Massachusetts Residential Building Code
Section 110.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 farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section 110.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 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 liable for person(s)you hire to perform work for you
under this permit.
City of Northampton
Massachusetts
\' DEPABTMELiT OF BUILDING ZBBFECTIOBB 2. `
212 Mein 9trwt eMu clpal B il6 ng ti Cm
NortTampton, N 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:
jCq-sq"c,-- il�Kll Air— Pkorenw—
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
R''N\U-�CN cwCM1C--�C.Y�
(Company Name and Address)
u/f24j14
Signature of Permit Applicant or Owner Date
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.
The Commonwealth of Massachusetts
Department ss Street,
Suite
100 pts
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
MIX.rkers' Compensation Insurance Affidavit:Builders/Contmetors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): (,p(bt!t6 ret{.! CCr-VSt QAACn
Address: 5 eimcNS N pcal&zx� rpt . I`ipA5n "
City/State/Zip: Phone#: H1b-`3V- 9589
Are you an employer±Chek Ike appropriate box: Type of project(required)'
I.5l am a employer with emptWom fraf and/or part-hnw)a 7. Q New construction
2. I em a sole Oroprimm or permaship end have no er�layces working for me in 8. ❑Remodeling
any mpmity.[No workerscomp.insurwws regoued.]
3.M 1 am a homeowner doing all work myself[No workers'coag.insurance required.]t 9. ❑BuildiDemong
4.n I am a homeowner and will he hiring committers to cormoctdl workon my pmpeny. 1 will 10 Building addition
ensure Net all contractors either haveworkers'compensetion insurence or are sole I I.C:]Electrical repairs Or additions
proprietors withm employees.
12.n Plumbingparepairs or additions
5.❑lama general contractor eemplod I mandhaveborken'concommuchurs,.edov Ne attached shce[. 13. ROOf IIS
TTwe subcontracmrs have employees end have workers'comp.insurance.:
reps.
6.C:]We are a corporation atN its officers have overtired their night ofexemption per MGL c. 14. Other
152,41(4),and we have no employees.Mo wmiece comp.insurance required.]
*An,,stressed that cbmks box#1 must also fill our No section below showing their workers'comen
psation policy information.
t Homeowners who submit this affidavit indicating they non doing all work and Nen him outside comm omm,most submit a new affidavit indicating such.
rCmnmsemrs that check this box must Wished an additional sheet showing the meow ofthe sub-contractors and stare whether or not those entities have
employees. Ifthe subcontractors have employes,they moat provide their workers'comp.policy numbe,.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lia#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy ofthe workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to secure coverage as required"der MGL a 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance
coverage verification.
\ L Ido hereby ceq&under thepains andpenaides ofperjury that the informatioaprovided above is true and correct
Signature: Date'
Phone#, KU-C�554 •5S�"
Official use only. Do not write in this area,to be completed by chy or town official
City or Town: Permittl.icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 0.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee 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,in any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trusty of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be m employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor 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 presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply in your situation and,if
necessary,supply sub-contractor(s)mantels),addresses)and phone number(s)along with their certificatc(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned 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 workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space a the bottom
of the affidavit for you to fill our in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/lieense applications in any given year,need 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 affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit most be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required in complete this affidavit.
the Department's address,telephone and tax number:
The Comi nonwealth 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
A�d CERTIFICATE OF LIABILITY INSURANCE
6/30/2019
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: N the cartMcate holder Is an ADDITIONAL INSURED,th,policy(Mrs)mug M Endonsd. H SUBROGATION IS WANED,subject in
the terms and conditions of the Policy.certain policies may require an endonem[m. A atetemenl on this uNflcals does not cooler dghte to the
certificate holder In lieu ofsuch endomemen s.
PROWLER Christi" SaCHCL
Aquadao A AsseoiatatM1ONa (613)586-7373 .1413311114-OOe
Bone 355 Bridge St., P. 0. B357 4WL
IMW a APIOMmO IONIC
Nosthaalpton IA 01061 aMuwRA:P"feered Mutual Insulmunce Co 15024
RIEue"m IMENIERa'
RONALD KEITH DBA Kl CONSTRUCTION IxauREA c: _
5 BIRCH MEADOW RD Bwa[R o:
N R R
HADLBT MA 01035 tesuroutF:
COVERAGES CERTIFICATE NUMER:CL1652007665 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDING 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 CIAIMS.
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF NORTHAMPTON THE EXPIRATDN DATE THEREOF, NOTICE WILL BE DELIVERED IN
212 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS.
NORTHAMPTON, !A 01060
ANiNoOR[PRetexTA ,
015884016 ACORD CORPOSA TION. All Hghte .served.
ACORO 26(2014/01) The ACORD name and logo are registered marks of ACORD
IN3025(m...I