35-121 (8) 31 DREWSEN DR COMMONWEALTH OF MASSACHUSETTS BP-2021-1790
MPermit: :Lo 3es121-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1790 PERMISSION IS HEREBY GRANTED TO:
Project# Contractor: License:
Est.Cost: 1800
Const.Class: Exp.Date:
Use Group: Owner: THIBEDAU KRISTIN M and JOSHUA P
•
Lot Size (sq.ft.)
Zoning: WSP Applicant: THIBEDAU KRISTIN M andJOSHUA P
Applicant Address Phone: Insurance:
31 DREWSEN DR
FLORENCE, MA 01062
ISSUED ON:08/25/2021
TO PERFORM THE FOLLOWING WORK:
STRIP&SHINGLE FRONT ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Set-Nice: 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.
Signature: I
�• f b >2 •
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
irge C -ealth of Massachusetts
° Boar of siding Regulations and Standards FOR
202 h State Building Code, 780 CMR MUNICIPALITY
__ USE
• Permit ply -on To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
C ne-or Two-Family Dwelling
'',1 t;osr,otis
This Seton For Official Use Only
Building Permit Number. ' I• Date Applied:
41;10.J4Z j// g Z11-ZOZ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 P _Address: 1.2 Assessors Map&Parcel Numbers
n/ O2 F•1.o<t1Nc-e 3j I 24
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: lA 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 IV Private❑ Zone: Outside Flood Zone? Municipal❑ On site disp l system a17 Check if vesIg
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: \
So 4r,.rq (\ C(1\Th 'trUIN Y\ \ O 1 d b
Name(Print) City,State,ZIP
�\ C�"W Q n cJNA e A k‘3 D 0 9 l<6 S6,)0, ',-n1a.,,.t) \)
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ❑ Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work: (L. . Q-0 1-11" P O LO 11S6.k- 3T 4 rsls 5
Cr�r� \ S'10, lye'..-v ,N.Q S kck W F (3NR4u
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
Cl Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression) ci-6j,
Check No.10 I Check Amount:"T Cash Amount:
6.Total Project Cost: $ 14 ❑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.)
R Restricted 1&22 Family Dwelling
City/Town,State,ZIP 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.LIP 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 IJ No .I7
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 application is true and accurate to the best of my knowledge and understanding.
' 'i,Owner's uthorized Agent's Name(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 rid have access to the arbitration
piugrarn or guaranty fund under MG.L.c. I42A.Other important information on the HIC Program can be found at
w ww.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
/j "' -; Massachusetts �2 ..._ 'c�,
G
d . 1 E i' I EPAiiTIENT OF BTILDING INSPECTIONS
y
#,... it'' 212
212 Main Street • Municipal Building Ca
y
a... Northampton, MA 01060 sswh. B4O��J
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: "VW P3i'2
The debris will be transported by:
Name of Hauler: 0 > R V\Sci tO 'b' 1 --t) (AA)
Signature of Applicant: \_, ! Date: la 73. /
The Commonwealth of Massachusetts
is r ;�;,d Department of Industrial Accidents
ilma•. i 1 Congress Street,Suite 100
`'` =i.. Boston, MA 02114-2017
wwu:massgot•/dia
1?uikers'('umpensation Insurance Affidavit:ButilderslCeutr ctorsiEkrtrkians Plumhers.
I t)Bt. HUD WITH THE PERMUTING Atf1NOR1T1`.
Anp6cant Information Please Print I &Libl,
Name(Husttacss Organization lochs rduaI): \J(, ibekc VN,
Address: \
City/Stateizip: J ( QM � Q 1 O b Phone#: -54<4./
.Art'you sit employer?Cheek the appropriate lost:
Type of project(required):
1.E 1.:rst:t.riiptc*±:cr With .,._._ uY ti(fade autos prat-urns)." 7. 0 New construction
.soda wk pruprvets,r or pestrarrAup and have nu entspierycrx working Sur na.art S. O Remodeling
ant c.atxia1ty.[No aurf%rrs'caaaip.imia trx0[ maimamti
9. 0 Demolition
z6A I am a hoinomi.nct d.+tny all wane myself INo wsrrker''coup.iraiuranta required)*
i.0 I am a huoncau s mcr and w i11 be hams c macisws*di conduct ail weak on on proporty_ I wilt I Q Building additiontom_ �t c7ts=tiLlaall VirtgitirtOrS eittlfr.7 1wr men"ccura-ax rtxn to istaw i.sx are act 11CI I.Iec ncal repairs or additions
prupneton w ills no employacr
12.0 Plumbing repairs or additions
SC3 I am a general caratar.sat and I have tinad the s t4otatra►avts listed to true au adtcai sheet
These -curs aunts have ye s:a3d Et ounce 't _irmur�xe= 13 ;`�`ICctari'r�paitffi
6.0 we are a corporation and its officals have exercised their nghi of exemption per}aces_c. 14. Other
152.§1611.and we have no rmpitr t (Na workers'comp.rusunince rryairrd.l
'Any applicant that cheeks box#1 must also fill out the section below show ins their workers'compensation policy information
s lknncvwnc7s who subnut this affidavit indicating they are doing all work and then hire outside contractors must subnut a new affidavit indicating Much.
:Conoactun that check this box must attached an additional sheet show ing the mane of the sub•cottractars and state whither or nut thus:entities have
rinpluyce. It the sub-confirm:tort.hat cirtt.:loytss.they trust prowtdc their uaurkcra'txrmp.purity number
I ant 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.Lic.#: -__- .-_..__ Expiration Date:
Job Site Address: City/StateZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGi.c. 152,§25A is a criminal violation punishable by a fine up to S I,500.0u
and/or one-year imprisonment,as well as civil 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 DIA for insurance
cos erage verific-ation.
I do hereby certify under the pains and penalties u/perjure that the information provided above is true and correct.
t t
Signature:
Phone#:
Official use only. Do not write in this area,to he completed by city or town official
('itv or Town: Permit License
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3,City/Town Clerk 4.Electrical laapeetor S.Ptumbing Inspector
6.Other
( antac t Persan: Phone At:
City of Northampton
Massachusetts
11 r �G
Of �� ;c' DEPARTMET OF BUILDING INSPECTIONS •
,, : 212 Main Street • Municipal Building 1„
Northampton, MA 01060
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, J vlvt\ 0,2<Q_k_ 1 h‘►\Q�,c�.. (insert full legal name), born (insert 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 qualifij 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.
Signed under the pains and penalties of perjury on this day of , 20 .
(Si tore)