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21 ALAMO CT BP-2021-1025 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-237 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-2021-1025 Project# JS-2021-001749 Est.Cost: $1500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 10018.80 Owner: GEIS DANA J Zoning: Applicant: GEIS DANA J AT: 21 ALAMO CT Applicant Address: Phone: Insurance: 21 ALAMO CT (413) 265-1165 () FLORENCEMA01062 ISSUED ON:3/18/2021 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: 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 Signatur:I► • /, • II FeeTy pe: Date Paid: Amount: Building 3/18/2021 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner I RECEIVED MAR 1820 f 21 I— drTHAMMaSC ' OF BUILDING INSPECTIONS Th Commonwealth of Massachusetts TPTON MA 01060 Board f Building Regulations and Standards FOR usetts State Building Code,780 CMR - MUNICIPALITY USE Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This�Seyton For Official Use Only Building Permit Number: 6,- 7 f-IC 5 Date Applied: he=u►� 'Joss Z/7 3 1?) zoa( Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION IszPyoP ,4 js•e7 / cc._ 1.2 Am:it-gap&Parcel Number 7 1.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private❑ Zone' — Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: F-/O t-W ac:T I 4-14- 0/0 Z Name(Print) City,State,ZIP / / 1 i v C7 qi3- 21 t/Gs( i.oci✓�rus CAoJi 4/. l', No.and Street Telephone mail Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0, Specify: Brief Description of Proposed Work2: $7241 f /I,1-Cc ' /?QCA1 ( )7/A15 /r S SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 7 61)0 1. Building Permit Fee:$ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All F n Check No. M Check AmountW�{ IA()Cash Amount: 6.Total Project Cost: $ U 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling �' M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP Telephone SECTION 6: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 building permit. Signed Affidavit Attached? Yes 0 No .❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this applicati is true and accurate to the best of my knowledge and understanding. IA-101;-. j. 1 ..1 Print Owner's or Authorized Agent's ame(Electronic Signature) to NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. `Total Project Square Footage"may be substituted for"Total Project Cost" 7..e,.... . The Common astealth of Massachusetts 1 .11.0‘. Department of industrial Accidents 1 Congress Street,Suite 100 '-T#a� Boston. MA 02114-2017 . www mass.gov/dia 114okers'Compensation Insurance Affidavit:Rudders ContractorsfElectricians Pluinbers. 10 UlIO HE FILE!)With UBE PERMIT,INt.At 1•1l0RlI\. Applicant Information �/f ` ` / Please Print Leeibiv Name Iliustttcx ,ih antzaiion:lndetii uafl: J/T/�j� .. •/'_ C�' _ Address:__ / 4--/q/)90 -7, - City,'State _, ll�, 5/I)Zip:..__ r� U=r 'T/ ___ Phone#:_ �1�3j d C //CeS Are you an employer?C-herk the apprtrprLnttc troe: Type of project(required): 1.®I ant a employer',kith employees(full and'or part-time 1.° 7_ 0 New construction '. I ant a auk pntprictur or pcuincnhrp and have no employees wurktna fur me in Ile 0 Remodeling capacity_[No,+Laker;comp.insurance mined.] 9. D Demolition 3 l a -a h na.sswnet doing all wort.myself.'No'w ekers"comp.m,urara:c r.gaintL)` 10 0 Building addition I am a Iwnaauasncr and w ill bc-henna uuntr.tcturs to residua all w irk un trty pnrps rty_ I will un that all c<rrrtr a tsar citl>.r hate wrrrkers'e�urrapsmsalaoan insumnet ur ors sole 11.0 LIt'c'trical repairs or additions /( '4 prupnrtorsarthnuemployees. �( 1? Plumbing repairs or additions 50 I am a general contractor and I ha+c hind the aub.cuntracturs list:d ern tla-ait:aheslattcc9_ faitThese sub-cunlractura lune employees and haw workers'comp.nuurancc. Be oot repairs 6.0 We an a etnporauon and its officers haw rezerciscd their right Lit exemption per MGL.L. I 4_©Other 152.S 1141,and we haw no employer's.[No uurkcrs'rump.inserance rcyunt'd.I *Any applicant that cheeks box./ roust abu fill out the scctiaat beta*shots ina their u ur'.ct-,-compensation pot icy information. t Ilurnci wirers Hh4 submit tins attislasit indicating they J:doing all work and tb--r:•lure.xttsidc cunlra.tajn must submit a ncss affidasit indicating such. •L unvacton:that ettcck the:Ms♦roust atta-Ixd an addrtiunal claret show ons Fie name s>f the sui+-ctmtractsa-s and stare w$e[hcr or not those eattrpca haw crnpluscc,. II d,.Ai* r : -.I..r.c cmployecs.tic", must provide tfhra workers'comp.p.riiey number. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job silt' information. Insurance Company Name: Policy#or Sett-ins.Lie. ~: -- Expiration Date: Job Site Address: CityiStateZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to sec we coy criige as required under MGL e. 152_ y25A is a criminal %,tolation punishable by a fine up to$1,500.00 an i ur one-sear impnsonment,as well as ci,it penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DR for insurance eoveratie verification. I do hereby t-ertip tattler the pliaas um.,j.r n flint of per/art•that the in fornrutinra provided above e•it true and correct. y � /j - Z/ f+huti, / - �,s- i/ S ,,„,.,, Official use will. Do not write in this area.to be completed by city or town of/iciral City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2.Building Department 3.('ityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ('ontact Person: Phone*: City of Northampton Massachusetts 1 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 ( !,I HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, htitjA- (insert full legal name), born l5(Siwlsert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s)who owns 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 home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. a Signed under the pains and penalties of perjury on this L` day of , 20 a` • (Signat re) City of Northamptonr•' Massachusetts • •,10 4 1' ` DEPARTMENT OF BUILDING INSPECTIONS � 'I► ` 212 Main Street • Municipal Building ya Northampton, MA 01060 JSF.,y CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: e71J7`'1"/ a-4V)S&'( O�J Si The debris will be transported by: Name of Hauler: /4✓9/Cr✓U S Ra7 / J©i/e fic,40 /'u , y/J Co% j Signature of Applicant: Date: