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25-062 (6)
BP-2021-2284 1 l l OLD FERRY RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25-062-001 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-2021-2284 PERMISSIONIS HEREBY GRANTED TO: Project# ROOF Contractor: License: Est. Cost: 4000 SHUMWAY SERVICES 105743 Const.Class: Exp.Date:01/14/2022 NIEDZWIECKI JILLIAN M &PATRICK V Use Group: Owner: NIEDZWIECKI Lot Size (sq.ft.) Zoning: SC Applicant: SHUMWAY SERVICES Applicant Address Phone: Insurance: PO BOX 522 (413)549-4658 O WWC3509999 HADLEY, MA Ol 035 ISSUED ON: 12/14/2021 TO PERFORM THE FOLLO WING WORK: REPLACE LOW SLOPE 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. Signature: I >9 . I • " II Fees Paid: $40.00 • 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner The Commonwealth of Massachusetts w EC , Board of Building Regulations and S 0 202 T F R Massachusetts State Building Code, 780 C Building Permit Application To Construct,Repair,Renovate medA q ise Mar 2011 rlr-r,,, Cl IONS One-or Two-Family Dwelling MA o l oe o This Section For Official Use Only 13uildin Y Permit Number: & A I-' 4 4 y y DateDa Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property dtlre 1.2 Assessors Map&Parcel Numbers k \\ 01 cfy (J- A.5 aCia 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 e.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: amp -. A tip 'C -Z.L.fr,'c-C 14, We r4-A-t c � j (a c N (Print) City,State,ZIP \\\ a Q r-e-R'7 rz 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 CI Specify: Brief Description of oposed Work': r, P i,/4, I r ,,. 5 to(LC Rom,4- �t e.2.,, , E.,1 ( e e- L c o c,rc. i Z f'l } TA() L-e..P- (a I t-e c l x2---- 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 $ 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ 4j Suppression) Total All Fees:/� v`v Check No.1G Y I Check Amount: 6.Total Project Cost: $ vo ❑Paid in Full 0 Outstanding Balance Due:, City of Northampton SNS...r SAC Massachusetts ��t,'. e DJ 44 DEPARTMENT OF BUILDING INSPECTIONS �••,. ' 212 Main Street • Municipal Building b••.• Q� •!! `�� Northampton, MA 01060 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS, DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR, ETC. 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work(Digital and hard copy). 3. Construction Debris Affidavit filled out and signed by applicant. 4. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance. 6. Energy Conservation Compliance Certificate (new/replacement windows). 7. Home owner's License Exemption Form (if applicable). 8. Note any Special Permit requirements (if applicable). 9. Energy Code—all new construction (Gut/Rehab) requires a HERS Rater Affidavit 10. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. The Commonwealth of Massachusetts Si= Department of Industrial Accidents j 1 Congress Street,Suite 100 ''" Boston,MA 02114-2017 -y� www mass gov/ilia %%utkers'Compensation Insurance Aflidasit:Buildersl('oatracturs'Ekctrician iPlumbers. 'Ill BE FILED WITH-THE PERMITTING At''tltOltl'hl. Applicant information Pkaw Print Lrtiblt Name ititnmcu,•Organiiatiodlndividual): 5 hvt-t. ---44-1 c,4j1,_,t‘,e < Address: t (50yr- 5 .)t e?-- . City«t p: --0. ,4=- -------- Phone#: V..,‘ Am ea pley'r v (lark the appropriate bee: Type of project(required): 1 am a employer with ( employees lion and ur part-tune 7. 0 New construction 2.0 t ant a sok proprietor ear puinlrshrp and hart no employees working fur me m $. RCrltodrlin, any capacity.[No workers'comp.insurance myuired.l � 9. 0 Demolition 0(am a homoonner doing all nor►myself.[No wurkur'comp. rnsurrnc requital' 100 Building addition 4E:1 1 am a hors nuwnr and will be linkup cvNrarlon to conduct all wile on nty property. I will ensure that all etiritraetot either lust:wVrkrr% lT1llIper 1ia1Nin an%UraMY ear arc%lic 11.0 Electncal repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions !4:1 l am a yearend contractor and I lease hired the sr ascontraciot lotted on the satiated sheet. 13 oaf repairs These coand sub-contractors base employees lire workers'rump.uatrranc. 6.0 N'c ate a corporation and its officers Rase exercised their right of exempted per 4(IL c. 14'0 Other- — — — 15?§l(4).and vie hate SO miployev.'s.INu wlxkrrs.comp.msiranec required.( *Any applicant that checksbox ill ream alxr fill out the section below 7.howrnr then weaken'cuarpeosifioapolies inhumation. t liutnww nets who inbuilt this afti des it Andeating they an:doing all work and then hire uut%rak euntrktun mad subnut a new aliitas it mdicatmg such.. :Contractors that cheek tbie bus must attached an asldutonal sheet,h on ing the name of the ulrcoreracGms and state whether aX out those entrtu-s hose cirlplarsees. lithe.still actur%lase cir;ilt'oxs,Ili must l'ri:".tale'their waarkcrs-h.vair parley smuttier. I urn an employer that is pro►'idink rr orhers'compensation insurance for my employees. Below is the policy and job.site 01 nation. Insurance l'ompany Name: 'e C. ' Policy.#or Self-ins.Lie.#: I:Apirauun Date: 0 ).4 ), Job Site Address: 1 1 -�� ( iIytState Lip:© I Q 6 C Attach a copy of the workers'dos panty declaration page Khowiag the policy nntiber and criptratitin date). Failure to secure coverage as required under MGL c. 152,1125A is a criminal viokttiani punishable by*fine opt()S 1.500.1 ) andkor one-year imprisonment,as well as civil penalties in the font of a STOP WORK ORDER and a fine of up to S250.O0 u day against the violator.A copy of this statement may be forwarded to the Office of Invcsttigations of the DIA hit insurance coverage verification. I do hereby certify under the pains and pen�.f ptelrJary+that the information it ri i tided above is true and correct. • Signature: 1 1j"7 ,_ , Date_ Phone w: —� 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): I.Board of Health 2.Building Department 3.('itiilown Clerk 4.Ekctrical Inspector 5. Plumbing Inspector 1 6.Other I Contact Person: Phone#: 11 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1 C 7 L 1 �V M Lrct S ,L 5 License Number Expir 'on Date Nam of CSL Holder / U List CSL Type(see below) No.an_Street Type Description �'1 � II 0 i c\-2j 5 U Unrestricted(Buildings up to 35,000 Cu.It.) j 1 ,� R Restricted 1&2 Family Dwelling Cmy/T -own,State, 113 M Masonry RC Roofing Covering WS Window and Siding 1 SF Solid Fuel Burning Appliances ��1 / `1 1- 13 7 I Insulation Tel one l 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 ❑ No ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIESLI FOR BUILDING PERMIT • I,as Owner of the subject property,hereby authorize t� l'' to act on my behalf in all matters relative to work a orized by this building permit application. Pectfer,g r✓r zwl ec64.! / Of 7/2-0 2 J 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. 10 /4)) Print Owner's or Authorized Agent's Name(Electronic Si ature Date g �► ) NOTES: 1. An Oi,It r 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/dvs 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 Opal 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton 1 ir_whi,, Ste ' C % � ' Massachusetts ,�a3 t._ lt� r t. A A. J ,, DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street • Municipal Building y r Northampton, MA 01060 fsfrh 10‘" 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 n a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: ‘! crl 1(e , 6-76 The debris will be transported by: Name of Hauler: rmilic. el v-A-ti 4-A--c - . Signature of Applicant: Date: \ 611?7/2 City of Northampton ss... u .r sic Massachusetts ,$ G DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street • Municipal Building �., Pam` Northampton, MA 01060 y4"" N'Na HOMEOWNERS'EXEMPTION E GIBILITYAFFIDAVIT I, (insert full legal name), born_ (insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to t homeowners'exemption to the permit requirements of the Massachusetts State Building •<• codi at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I 'id le:al title. 2. I am not engaged in, and the project work for which I am seeking the aforementioned homeowners' exemption, does not involve the field • • 'on of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Is••'s defin' on of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel f land on whirb 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 arm structures. A person who constructs more than one home in a two-year period shall not . • considered a home owner. 4. I do not hold a valid Massac-usetts construction supervision license and, except to the extent that I qualify for and will abide by t ' Massachusetts State Building Code's requirements for the supervision of the project or work on my p• cel, 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 . (Signature)