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38B-173 (3) 40 FORT ST BP-2001-0554 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:38B- 173 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofing BUILDING PERMIT Permit# BP-2001-0554 Project# JS-2001-0970 Est. Cost:$2840.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CONRAD CHAFFEE HOME IMPROVEMENT 117496 Lot Size(sq. ft.): 18774.36 Owner: BEIJER GUNTER H&ANIELA Zoning:URB Applicant: CONRAD CHAFFEE HOME IMPROVEMENT AT: 40 FORT ST Applicant Address: Phone: Insurance: 20 MILL RD (508) 943-6957 DUDLEYMA01571 ISSUED ON:12/6/00 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE NORTH SIDE OF ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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. Certificate of Occupancy Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 12/6/00 0:00:00 1503 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit ,t/� Zone Overlay District �V Elm St. District CB District, SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: /11_41) (gi/rVC1-5?e /1/ ,•17 p?0//1//e-- if=?Z Nam (Pit) Current Mailing Address: cbe Z-V7;1737---r----A-- Sign e Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant Byil�iing (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: 4111ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing Or Doors 0 Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Z , jc / ,c-7 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ di 4-, Pt :. ; $or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? ilkType of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a -OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS 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. Signature of Owner Date hereb ec arethat (2-/APIree— , as Owner/Authorized Agent y d the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under th s ands penaltiesof rjury. 0#1/ Print Name . Ga /2// friOrd Signature of Owne i1fiL1. Date SECTION 8 -CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: License Number Address Expiration Date Signature Telephone .�a,S'.➢' � use.;ysa;�wa- 'a te�^'c�Yrr 7 +s -- w q ��'t_ '" p E Sr �n� `� f . Not Applicable ❑ ��,J� (1 ; ► // 7V2Y‘ Company NTme Registration Number 80 7H/LG- / /d/lZ/?_G02- Address �/�j�,2 / - p Expiration ate `'4</r U�S 7( Telephone J v�� l-, SECTION 10-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 1.1. Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own 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 homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature ,,tAxfpi.. .,.0 . 4; ,,,,.. k.... ,-„,, Gitg al a G't d iaiaacip:setts —� * `psi yam_ �fi, — -mil= 'W DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' —_ ., Northampton, Mass. 01060 tti'' ' WORKER'S COMPENSATION INSURANCE Ale.F.WAVIT I, ) J / 'Aq --- (u /iermi ) with a principal,place of business/residence at: e). c . 0/S7(Phone#) S9y/?69 (btu city/statehip) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) 1. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) r (Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet if nemc.ry to include information pertaining to all oo t actors) XI am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. • NOTE:please be aware that while homeowners who employ persons to do...ins*..,,,-.construction or repair work on a dwelling of not more than throe units in which the homeowner reside or on the grounds appurtenant thereto are not generally considered to be employers under the worker's ore e-rm“ion Act(GLI52,ss 1(5)),application by a homeowner for a licrnse or permit may evidcnoe the legal status of an employer under the Worker's Compensation Act I understand that a copy of this statement may be forwarded to the Department of Industrial Axideats'Office of Insurance for the coverage verification and that failure to seams coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Ord -and a fine of 3100.00 a day against tne. • For departmental use only Permit Number / ' ��� gyp# Lot# -f f. s of Li e e Conrad Chaffee Home Improvements 20 Mill Road Dudley,MA 01571 Home Improvement Contractor-MA#117496/CT 553064 508-943-6957/800-829-6.772 Residential Contracting Agreement Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. Notice: All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by provisions of chapter 142a of the general laws,must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director,Home Improvement Contract Registration,One Ashburnton Place,Room 1301, Boston,Ma. 02108. Designated Registrant's Name: Conrad Chaffee Home Improvements Registration Number: 117496 /Salesperson's Name: Conrad Chaffee This Agreement is made on /t /i�' /Z0'(date)between Conrad Chaffee Home Improvements, hereinafter Called"Contractor" and (-1(//1/1 /I /t hereinafter called "Owner"of _.S— r addressl/t-7--- (:-/--/eeer--/Ae /17/51. Detailed description of work to be performed: Contractor agrees to perform in a good and workmanlike manner all work described below. Such work consists of the following: Install new shingle roof as follows: Strip slate shingles from rear face of roof and dispose of them, Furnish and install 1/2"CDX plywood to roof deck.Apply Ice and Water Barrier 3 feet wide along eave of roof.balance of roof deck to be covered with 15#felt paper. Install new drip and rake edging and vent boots as needed. Furnish and install Certinteed brand Seal King 25 year warrantee roof shingles to match front roof shingles.Work to be done only where existing roof is covered with slate shingles.All material and clean-up is included.