31A-292 22 WASHINGTON PL BP-2021-1100
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31 A-292 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITI 1 UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2021-1100
Project# JS-2021-001860
Est.Cost:$2000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SHUMWAY ROOFING 105743
Lot Size(sq.ft.): 9801.00 Owner: SPELMAN ELIZABETH V
Zoning: URB(100)/ Applicant: SHUMWAY ROOFING
AT: 22 WASHINGTON PL
Applicant Address: Phone: Insurance:
PO BOX 522 (413) 549-4658 ()
HADLEYMA01035 ISSUED ON:4/2/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE GARAGE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. 13uiiding 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. n
X i -1 .
•
X�
Certificate of Occupancy signatu," • i
FeeType: Date Paid: Amount:
Building 4/2/2021 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
f
/ ��V4: .
4).--7---....„,„.,
The Commonwealth of Massachusett
:kit Board of Building Regulations and Stanrds ���' FOR
Massachusetts State Building Code,`780 C r��.` i UN)CIPALITY
. USE
Building Permit Application To Construct,Repair,Renovate-Or rD-eirfb4 i s._.; Revised Mar 2011
One-or Two-Family Dwelling ^1s
This Section For Official Use Only
Building Permit Number:ea,vl/--//Uv ate Applied:
/Et.)1•355 /,2 9-z-zo z i
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 1pe;ty�a Lss: 0 1.2 As§e�sois Map& Parcel Numb/,/�
i nl � f� Cj
1.1 a 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 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
,/ 2.1 Owner'of Record:
f—ft a 11, \7" c( - iVor-"hat.,,.p-1-6-1,-. MA v ICAvO
Name(Print) City,State,ZIP
. .9 kti k 5la i iAlfr-% P/ice I( )5-50 —3 9 Ca espec,c,,, a) stkl-1-1,4.t,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: (" avp t , (Q_ )ercAO-c
rot}ri
y,, (`7„/Yw-r i 5 r - r_ p u-/ 5d.yr alJ/ 5 L1-*.I $
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing , $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fee�s] Q
Check Nos 7 heck Amount: Cash Amount:
6.Total Project Cost: $ PCO 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES 1 11 i ✓?‘
5.1 Construction Supervisor License(CSL) l Q 9 7 Id / 1
.if
l'l,V'/' 1-"407 S*f , f License Number cation Date
Name f CSL Holder i
List CSL Type(see below)
No.and Street
9humwaY services Type Description
Po Box 522 p
Hadley,Ma 01035 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
1.\\(7 /ll��577 V� SF
I Solid Fuel Burning Appliances
IInsulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ii O 3 n D
HIC Registration Number -xp'ation Date
HIC Company Name or HIC Registrant rvices
ShUMWay
ux 522
No.and Street PO' Ma 01035 Email address
aff
Hadley,
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 . 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize -SA..---,-,..---1 ‘'•rvi ces
to act on my behalf,in all matters relative to work authorized by this building permit application.
'. /i)o,64-11-. V. jp.k.iv„,L.,.. -31/S2/-. /
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER1 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 application is true cc to to the best of my knowledge and understanding.
Print Owner's or Authorized Age Electronic Signature) Date,
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"
City of Northampton
�T r1j
,5 SI
{l/1 Massachusetts ��}5 :,_ t�W'
)#ee
DEPARTMENT OF BUILDING INSPECTIONS S:R07 212 Main Street • Municipal Building .,
Northampton, MA 01060 J D
ssy .. ���'�
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, 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: U I( C c l
The debris will be transported by:
Name of Hauler: 5-C., C"---
Signature of Applicant: PL. - Date: )l
The Commonwealth of Massachusetts
E! Department of Industrial Accidents
• =4 I Congress Street,Suite 100
,,=n1:>� Boston, MA 02114-201
-,�* w44 ww mass.gov/dia
1lurker`'('ompensation Insurance Affidavit: RuiiderslContractorsfEkctriciansWPlumbers.
7O BE.III.),I)%s till 1111 I'I.KNt1'TING At'7Iltw1'%.
Applicant Information Please Print Lesibls
Name I13usiness Urganwitio n.Individual l'
Shumway Services
Address: po Box 522
Hadley.
Ma 01035
City/State/Zip: Phone tt:
Are sun an emplusre(lie&the appropriate but: Type of project(required):
1. :--a cnipt.y.T with employees lfull ardor part-trim l.• 7. 0 New construction
2r3 i am a sole proprietor or partnership and has no employees roiling for ate in 8. a Remodeling
air capacity [NO workers'comp.insurance nyurnsl.l
9. ❑ Demolition
l❑I am a hornouwnc-r doing all work myself.[Vo worltTs'comp.insurance rccfwrctl.l'
10❑ luilding addition
4.0 i am a lwrn ownet and will be hiring contrm fors to..induct all work on my property. i will
ensure that all contractors either lute workers'compensation insurance or are sole 1 1.O Electrical repairs or additions
propnetarn with no employers
12.0 Plumbing repairs or additions
10 I am a general contractor and I hate hired the sub-ctmtractors tried on the attached sheet.
These sub-contractors hate employees and hale workers'comp msurancr I3❑Roof rCputrs
14.
❑Other
6,❑U.'e an:a eoipun n aiu and its officers has,:ctercinett their right of atcmpixm per bK.L C. --
152.C 1141.and w c hair no employees.[Nu workers'comp.insurance rcyuin:ii]
'My applicant that chts:ls hot al must also tilt out the section below show my then worker-s'compensation policy information
'Homeowners who submit this atfrdasit indicating the an:doing all w..ik and then hue outside contractors must suhnut a new at'fida it indicating tuck
:("ontracton that check this but must attached an additional sheet show me the name of the suh-co ntraetws and state w he her or not those entities base
employees It the sub-contractors has employee,,they must pros ide tl,.tr wioticr,.comp p.,licy number
1 am an employer that is providing r►'orlters'compensation insurance for me'employees. Below is the policy and job site
information.
insurance Company Name: C S CO
Policy#or Self-ins.Lic.#: Li%,/(C ,()( G� ! i Expiration Date: a Q 2.'!)
Job Site Address: J ��_ City State Lip: a 1 a 5
Attach a copy of the workers'compensation policy declaration page(showing the policy number and eupiration dale).
Failure to secure coverage as required under M(iL c. 152. t2SA is a criminal violation punishable by a fine up to S1.500.0(1
and or one-year innprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the s iolator. A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verification.
I do hereby certify u er the pains and penalties ojpvrfun•that the information provided abate is t e and correct.
Signature: Date.- -3 ' ! . /
IF I
Phone#: (''‘ 5 f 7 11
Official use only. Do not write in this area.to be completed by city or town official
City or Town: Permit/License b
Issuing Authority (circle one):
• I. Board of Health 2. Building Department 3.( ity A own('krk 4. Electrical Inspector 5. Plumbing Inspector
16.Other
Contact Person: Phone 4: