32A-201 (21) 51 PHILLIPS PL BP-2020-0287
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-201 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-2020-0287
Proiect# JS-2020-000480
Est.Cost: $2650.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: DICKY MATOS 105917
Lot Size(sa.ft.): 11891.88 Owner: CARSWELL CAMERON
Zoning:URC(100)/ Applicant: DICKY MATOS
AT. 51 PHILLIPS PL
Applicant Address: Phone: Insurance:
3 GLEN ST (413) 530-5335 WC
HOLYOKEMA01040 ISSUED ON.9/4/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-METAL 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: 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 si�yntiture:
FeeType: Date Paid: Amount:
Building 9/4/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
t> Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
> Room 100 Water/Weli Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax I" s
V peci
APPLICATION TO CONSTRUCT, ALTER, Rr
2019 13,P- 6U --36 �, RENOVATE OR DEMO ISH ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: DEPT.OF BUILDING iNSPECTi bs setion to be completed by office
NORTHAMPTON,MA 01060
J �hi ��i�S ��QC•°Q, Map 2V Lot - �' .4 Unit
VAb14)0.cM�n r fy)0.61 b la O Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r S7 PhL11cps -fly,e,
Name(Print) Current Mailing Addres .
Telephone
Signature
2.2 Authorized Agent:
I- eA L/ /Va;&,s 3 07kO 5-� holy6k INAIO�qo
Nam rint) Current Maili g Address:
n ture Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to )e Official Use Only
completed by permit applice nt
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) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
a?
Signature: J"
Building Commissioner/Inspector of Buildings Date
rR
I�� �) 'C�1
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
r ,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
Building Department
Lot Sire
Fro r �
ntae
Setbacks Front
Side L:! R: L:= R:= � t
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces F
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ver been issued for/on the site?
NO Q DON'T KNOW F YES Q
IF YES, date
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW Q YES Q
IF YES: enter Book , Page and/or Document#i
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 Obtained , Date Issued:
Q .. � �
C. Do any signs exist on the property? YES Q NO (:J
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 G(
IF YES, describe size, type and location
E. Will the construction activity disturb (clearing, grading, exc ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
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) Roofing
Or Doors r7l
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[M Siding [p] Other[ol
Brief Descriat}pn of Prop se I
Work: '► l
Alteration of existing bedroom Yes No Adding new bedroom Yes /No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Iia.if New,house and or addition to exisflna housing, complete the followina:
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
g. 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 .
1. 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
1, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
ffla1, , as Owner/Authorized
Agent hereby declare tat the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
S'gned under the pains aan/d�penalties of perjury.
I 1 Y �Iftis
Pri mea, 9-4-/9
i
ig re of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder: Cls' / U 9 12
License Number
n o� &2o
Ae s 6 33 Expirati n Date
to
S' ature Telephone
9.Ren stered-HoMit-Irrtri ovemwil Contractor: Not Applicable ❑
Comi)anv Name Re-istra1tioc%new NumbeF
U�o modLL - 0S=6(jP-20Z6
Addres , Exp
iration Date
n) ()&phone 2�3bS3 —
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 building4ermit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
Massachusetts
DEPARTMENT OF 3UILDING INSPECTIONS
212 Main Street • Municipal Building
NorthamF ton, MA 01060 - �1
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("Inc").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, 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 registered contractors.
Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered.
Type of Work: Qf�� �L,� `j' ��o�-t�v D 1(` Est. Cost: 2
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 owner-occupied
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.L.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 permjL#s the agent of the owner:
o icLA rn odn(-�
Date ontractor N e 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
,A
DEPARTMENT OF BUILDING INSPECTIONS �'•
212 Main Street *Municipal Building
Northampton, MA 01060 fs{jti �
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:
�] ?h 1 111 ,2,s
P&de-
(Please print house nufnber and street name)
Is to be disposed of at:
a� e- / lot Wzk
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
9-4-/9
S nature of P mit Adblicant 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
UVC-
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
orkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lei 1
Name (Business/Organization/Individual):
Address: '�-
City/State/Zip: d Phone# &S
33
Are you an employer?Check t e appropriate box:
Type of project(required):
L f a am a employer with employees(full and/or part-time).*
2.Q . �New construction I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling
any capacity.[No workers'comp.insurance required.]
3.[:]l am a homeowner doingall work myself t 9• ❑Demolition
ys [No workers'comp.insurance required.]
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E]Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.[]PIbing repairs or additions
5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13.E-roof repairs
6.❑We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.)
*Any applicant that checks box#1 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 hive 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:
Policy#or Self-ins.Licc..#:-1l ` p y Expiration Date: 2-1212-6.
Job Site Address: S1 X City/State/Zip: OrQ
Attach a copy of the workers'compensation policy declaration page(showing the policy number and exp ation ate). too
Failure to secure coverage as required under MGL c. 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 of the DIA for insurance
coverage verification.
Ido hereby cer, under the pains nd enalties of perjury that the in formation provided above i tr/ue and correct.
Si nature: 1 Date: 9- .l9
Phone#: l
I6
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#•
3 Glen St 4 'CONTRACT
Holyoke, Ma 01040 PWR
413-530-5335 13
CS105917
HIC-1662166207 Date Aug 15, 2019
+ •
CT- 0639705 P.O.
Terms
Bill To
Cameron Carswell Ship Via
51 Phillips Place Ship Date
Northampton, Ma 01060 p
came roncarsweI19yahoo.com
Ot", Description Unit Fxt
1 METAL ROOF 2,000.00 2,000.00
1 GENERAL FRAMING 650.00 650.00
Re-frame porch
_ Total (2) $2,650.00
Signa a -—_—
��4U tl �FPCdf117 � `�^/F [.a�L.�lHt1�a�IJ N 1111VSegI e�,pL� �m
�`A'�uMt NCE ���IfDO11fY
THIS CERTIFICATE IS ISSUED AS A MATTER OF INPORYATION ONLY AND CONFERS NO RIOH7'S UPON THE 02/22/2019
CERTIFICATE DOES NOT AFFIRMATIVELY OR NENFORIJ T AWMD, CERTFICATE HOLDER. 1
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT , MCMND OR ALTER THE COVERAGE AFFORDED BY THE pOUC
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDW VfE A CONTRACT BETMIEEN THE ISSUING INSURER(S), AUTHOW
IMPORTANT: If tit®cerifficift herder Is an ADDITIONAL INSURf:D 4�a
If SUBROGATION IS PiilAIVED,subject to the terms and cNSURM,th P Iay'(�)must have ADDPIIONAL INSURED pro is bns or be moo;
this certificate does not c----or rights to the cettii9cate holder POII certain policies may�Iue an
PRODUCER In lieu aP such S Snd n10ftL A statOPnpn1
CHI Insurance Agency,Inc. Heather Feu
416 Main Street PtioWE . 4131 536-2685
E htleu chi n com
FAX 413 5324ME
Hol oke IWSU S COVERAC4F
IWSURED MA 01040 WSURER A, ACE AMERICAN INSURANCE Go
2266.
Dicky Matos dba DMR Roofing ��PAR
B
3 Glen Street INSURER C:
INSURER D
Holyoke INSURER E:
COVERAGES MA 01040 � I IWsuRER F
THIS IS TO CERTIFY I -'RT1 -ICt1T11
E f�t9G�BER:
THAT THE POLICIES OF INSURANCE LISTED BELOVif REVISION RIU ;
INDICATED. NOTVI BE SSANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W11 H RESPECT TO WHICH Th
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIESTTOR D TO THE INSURED NAMED ABOVE FOR THE POLICY PERM
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAV+?BEEN REDUCED BY PAID CLAIMS.
IWsaDESCRIBED HEREIN 15 SUBJECT TO ALL THE TERN
TYPE OF INSURANCE ADDL SUBR
COMWERCIAL POUCY mummm PW ICY EKP
—r— A1ERA1.uABILITr LIAM
-- CLAWISMADE ^OCCUR EACH OCCURRENCE $
� rD r
PREMIS SEa oc:a.irrencp $
--�
MED EXP(Any one person) $
GEN L AGGREGATE LIMIT APPLIES PER; PERSONAL&_ADV INJURY $
Ij _
POLICY❑IECT LOC GENERAL AGGREGATE $
OTHER: PRODUCTS-COMP/OP AGG $
AUTOaWBILE LIABILfiY
ANYAUTO EOMBIN rSINGLELWr $
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY(Per pereon) $
�
HIRED 1 NON-OWNED
BODILY INJURY(par acd $
�
AUTOS ONLY AUTOSUTOSONLY
! der�)�
PROPER DAMAGE ccMen $
UtABRELLA LU1B
j
EXCESS LIAR OCCUR $
CLAIMS-MApE
DED EACH OCCURRENCE $
RErENT10N AGGREGATE $
WORKERS COYOPENSATIkX11
AND EB9PLOYERS LWBILIty $
ANY PROPRIErOR/pARTNER/EXECUTIVE YIN STAME ER
A OFFICER/MEMBER
hi N R EXCLUDED? ❑ MIA UB1
If yes,deambe u Wx X36443 MMII 1I>I 02112,2020 EL EACH ACCIDENT $ 100 000
DESCRWTION OF OPERATIONS bobw E L DISEASE-EA EMPLOY $ 1001000
E L DISEASE-POLICY LUT $ 500,000
DESCRIPTION OF
OPERATIONS/I-OCATIOWS/VEHICLES
(A('ORD 101,
Certificate issued as evidence of insurance. I Relmft Schee A,may be aftechad if mdse space Is require
k
I
CEI IFICATIE HOLDER _
I ;ANCELLATION
n
SHOULD ANY OF THE ABOVE DESCRHWD POLICIES BE CANCELLED BEFORE
jTHE EXP11RA7M DATE THEREOF, W0710E VA-L BE DELIVERED IN
ACCORDANCE WM THE POLICY PROVISIONS.
REPRESEWTATIVE
i
AA?-
ACORD 2642016/03) 0198&2015 ACO RD CORPORATION. AN rlahis r+ticI
The ACORnno".. n___ --.
Commonwealtt --P M1Aassachuserts
?• ?3' Division of;,Protessional Licansure
Board of Bu;wing Reguiations and Standards
Constr�.ic;ria�,Su�er�rsor
�5-'089"' , Xpires :i3,` U;3U20
DICKY MATOS
;:.
3 GLEN STREET M F
HOLYOKE AAA 01040 �`Ar
Comrnissioner
�Sfif/�J-
Office of Consumer Affairs and Business Regulation
One Ashburton Place- Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
DICKY MATOSTYpe: individual
Registration: 166207
3 GLEN ST.
HOLYOKE,RNA 01040 Expiration: 05/06/2020
SGA i .'y 20M-05/17 UPdate Address and Return Card.
Of ift of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual Registsatilon valid for individual use only
Real— st— trr—_anon Expiration before the WMIration date. if found return to:
166207 05/06/2020 Office'Uf Consumer Affairs and Business Regulation
DICKY MATOS One Ashburton Place-suite 1301
Bostor`,,ANL► 02108
DICKY MATOS
3 GLEN ST.
HOLYOKE,MA 01040
Undersecretary Not valid without Signature