25-070 (2) 43 RIVERBANK RD BP-2021-1427
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25-070 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-2021-1427
Project# J S-2021-002367
Est.Cost:
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SHUMWAY SERVICES 105743
Lot Size(sQ.ft.): 11543.40 Owner: KILLINGER PAUL
Zoning: Applicant: SHUMWAY SERVICES
AT: 43 RIVERBANK RD
Applicant Address: Phone: Insurance:
PO BOX 522 (413) 549-4658 ()
HADLEYMA01035 ISSUED ON:6/3/2021 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.
3-11 6
Certificate of Occupancy Signaturei 0
FeeType: Date Paid: Amount:
Building 6/3/20210:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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Building Permit Application �.„Zbo Vs
6fin,7f o/ 9
/f This Section For Official Use Only
Application Number: I 0 --Ad a"/4-1.1 7 Date Applied:
Approved by Building Official: `/ _ v- I-Z01)
Signature Date
SECTION 1: SITE.INFORMATION
1.1 Property gd.ress: 1.2 Assessors Map&Parcel Numbers
V � r 2_ •,?4- 0 '7Q
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:
Zone: _ Outside Flood Zone?
Public lsa/ Private 0 Check if yes❑ Municipal 0 On site disposal system
SECTION 2: PROPERTY OWNERSHIP'
0________2.1 Owner'of Record;
" /
Ict, /a/ //,i e� /{.•��t.�ii, rie4s ilo 12 /14 610�0Name( t) c City,State,ZIP
VRiVtA6 c,P1 lam' /C 1-3,7-632. v I s- 90-/A. /. Cowl
No.and Street Telephone mail Adds ss
SECTION 3: DESC'IPTION OF PROPOSED WORK'-
/One or Two Family Dwelling t 0 ,mmercial 0 Mechanical 0 Other
Brief Description of Proposed Work2: Remove shiny es,install new ice barrier,synthetic felt and 30 year
architectural shingles
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 $ O Standard City/Town Application Fee
O Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $ -
Suppression) To l All Fees 1
1
C ck No.1t t Check Amount: Cash Amount:
6.Total Projec Cost: $
Paid in Full 0 Outstanding Balance Due:
c,_
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 105743 Q A/a,
Shumway Services License Number Expiration Date
Ike of CSL Holder
PO Box 522 List CSL Type(see below) U
No.and Street
Hadley MA 01035 Type Description
City/lawn,State,ZIP U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
M Masonry _
413-687-9400 shumwayservices@gmail.com RC Roofing Covering
Telephone Email address WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
D Demolition
5.2 Registered Home Improvement Contractor(HIC) 178390 L
Su 44— if1
HIC Registration Number Expira ton Date
H1C Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M1.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.
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
CONTRACTOR OR OWNER'S AGENT APPLIES FOR BUILDING PERMIT/
I,as Owner of the subject property,hereby authorize 5A 044( 4,7 5-en dices/rh,/ 5 wti,
to act on �.ehalf,in all matters relative to work authorized by this building permit application.
O• ner's Signature D to
SECTION 7b: APPLICANT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in 's application is true and accurate to the best of my knowledge and understanding.
5 / 1 7/a
Contract // s Agent/Owner Signature Date
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 gig 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"
The Commonwealth of Massachusetts
• Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
wwwmass govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information f�1' / !Please Print Legibly
Name (BusinessK)rganizationtlndi+'idual): I�rt/�, $tte i+.ae( itifr "t. `Ze f
Address: (Adt 12*2 t
City/State/Zip: ,t t t(.) t'l ek �C? Phone#: -13 4,7 '4-t 071
Are you an employer?Check the appropriate box: Type of project(required):
I: I am a employer with 3 employers(full and/or pan-time).' 7. 0 New construction
2.0 1 am a sole proprietor or partnership and have no employees working for mein 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.)
3.0 I am a homeowner doing all work myself.[No workers'comp,insurance required.]'
9. El Demolition
4.0 I am a homeowner and witbe hiring contractors to conduct all work on my property. I w ill
10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 P1u repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs
These sub-contractors have employees and have workers'comp.insurance.;
6.0 We are a corporation and its officers have exercised their right of exemption per MGI.c.
14. Other
152, I(A).and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 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 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 anti fob site
information.
Insurance Company Name: kriric 1)
Policy 0 or Self-ins. Lic.#: L✓ G "3 5 it i I Expiration Date: a X
Job Site Address: City/State Zip:
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 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.
I do hereby cern:6,u er the pains and penalties of perjury that the information provided above is 1 and erred.
Si a re: Date:
Phone#t:
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 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work:
The debris will be transported by: ?r A6.4ck Trc )*
The debris will be received by: ,fu /1c re-c5c IC
Building permit number:
Name of Permit Applicant 54,-/1-k j $Te /V,4 5
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Date Signature of Permit Applicant