43-164 (3) 58 GREENLEAF DR BP-2021-1230
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:43 - 164 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 At BP-2021-1230
Project# JS-2021-002053
Est.Cost: $24421.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DAVE MINER 99953
Lot Size(sq.ft.): 77101.20 Owner: OSEPOWICZ EDWARD C&SUSAN
Zoning: Applicant: DAVE MINER
AT: 58 GREENLEAF DR
Applicant Address: Phone: Insurance:
347 NEWTON ST (413) 533-0481 WC
SOUTH HADLEYMA01075 ISSUED ON:4/27/2021 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. cs...1,1 •
Certificate of Occupancy Signaturci
FeeType: Date Paid: Amount:
Building 4/27/2021 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
APR 2 6 202
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
1VIullo'AurY
Massachusetts State Building Code,780 CMR rw vsUSE
Building Permit Application To Construct,Repair,Renovate Or Demolish a 4tevised Mar 2011
One or Two-Family Dwelling
a This Section For Official Use Only
Building Permit Number: 8p a I r 11 Date Applied:
iieiHAA/ 2 - _y_p_i__. a.,_
Da
Building Official(Print Name) l Signature Ti� V U
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
f ar n /if- �'ik. 43 i(r4
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) f
Front Yard Side Yards Rear Yard
Required Provided Required 1 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 ElElZone: _ Outside Flood Zone? Municipal On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 r'of Record: /
(25 e, Q�l C 2 /o/ rv4cG
Name(Print) City,State,ZIP
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 l Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 I Number of Units Other 0 Specify:
Brief Description of Proposed Work2:
.1- c. ...�:¢. /5
1Cr4'Ir,rr
• SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees:$ _ , `
1, Check No. j 7d.6c-heck Amount: �I O Cash Amount:_
6.Total Project Cost: $ - `l/ �/ 0 Paid in Full 0 Outstanding Balance Duo:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 0 _ c/:1`,/
Ali"t-e 1. License Number Expiration Date
Nagle of CSL-Holder / List CSL Type see below
Address / Type Description
U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
3 7 e — v7 RC Residential Roofing Covering •
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
1c L LC. / g 3'12
MC Company Name or HIC Registrant Name Registration Number
3 `( ? A) 4 c.,f-. 5.3 S' f-1_.(/t&7,, /w
Address 2 I t,'
�- .7 77`G'?L Expiration Date
Signature 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 No ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S A GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
rd , as Owner of the subject property hereby
authorize 0 A v P /1/1 , fr ft_ to act on my behalf,in all matters
relative to work authorized by this building permit application. r
—4-- K ('�) I 1-
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
19 A i 41 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
l--
Print Name
t-t/ � l
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.FL) 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"
The Commonwealth of Massachusetts
�! Department of IndustrialAccidents
111, NEa 1 Congress Street,Suite 100
Boston,MA021142017
o�
d� wwH.mass gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE lt'iLED W1TH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): D, VC' y t i vv r f I l z f r j ."^-6 p L Z. L
Address: 3 it 7 W 5�--
City/State/Zip: N-c 7 of Phone#: _7 7 Y "6 ? .
Are you an employer?Check the appropriate box:
Type of project(required):
1. am a employer with ) employees(full and/or part-time).* 7. D New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. r emodeling
any capacity.[No workers'comp.insurance required.]
9. • Demolition
3.Ej I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 0 Building addition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance? ❑
6.[]We are 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 hire outside contractors most submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name ofthe 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: J ! t
Policy#or Self-ins.Lic.#: l .2 Z U/3 4 fy5 a i, // r> Expiration Date: /8/�-frA/
Job Site Address: d I Ct-'+- 1C c/�' PA.. City/State/Zip: F i,- , v.4 r
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 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 ofup 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.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date: /
Phone#: _7 7 I(
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#:
City of Northampton
i��M SAS ..S/C..
,4? ,.,' Massachusetts �'.. . .- fc.
(JL.r
( II ( DEPARTMENT OF BUILDING INSPECTIONS J C
•R titP t 212 Main Street • Municipal Building yvf �1,•
a�1 Wiz"' Northampton, MA 01060 ssN Ne 3 l0
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: V h ,7 Pr CL11n)
7
The debris will be transported by:
Name of Hauler: ✓'t !l t✓ 5 '7 v 'r6 t kl-1
Signature of Applicant: a/ ) l
Date: ��
DAVE MINER Date: tZCI /2
Exterior Home Improvements
(413) 533-0481
www.DaveMinerRoofing.com
347 Newton Street,South Hadley,MA 01075
MA Registration#186552
Customer Name: Telephone Number 4, 1 7 8 d - YC/ .6
Address, City/Town, State: & 1.)4 6/
CertainTeed Roof System
• Strip off existing roof and remove all debris from worksite
• Line all edges with 8" aluminum drip edge
• Install feet of WinterGuard ice & water barrier along eaves and up any valleys
• Install . Roof Runner Diamond Deck synthetic water resistant underlayment
• Install CertainTeed Landmark Landmark PRO Landmark Premium
Other shingles to manufacturers specifications. Color:
• Install SwiftStart starter strip along eaves eaves and rakes
• Install using 4 nails 6 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-flash chimney with lead flashing as needed. Install Cricket at chimney.
• Plywood
Install 1/2" CDX plywood
Install 1/2" CDX plywood as needed @ per sheet
• CertainTeed SureStart Plus 4-Star 5 Star Warranty Coverage
• All workmanship is guaranteed for 10 years unless otherwise specified.
• 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$ 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 manner according to standard practices.
Any alteration or deviation from the above specifications involving extra costs will be executed upon written orders,and will
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 be withdrawn
by us if not accepted within 30 days
Acceptance of Proposal—The above prices, specifications and conditions are satisfactory and we hereby accepted.
You are authorized to do the work as specified. Payment will be made as outlined above. 1
Signature: Signature: i_. .X
Date of Acceptance:
This agreement may be cancelled by Customer within 3 days of acceptance for any reason as detailed in the accompanying Notice
of Cancellation Customer's Initials '