31A-010 BP-2022-0252
275 ELM ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31 A-010-001 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-2022-0252 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 3000 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2024
Use Group: Owner: K FOLEY REBECCA B &KEVIN
Lot Size (sq.ft.)
Zoning: URB •
Applicant: JAMES ROBERTS
Applicant Address Phone: Insurance:
30 Edwards Rd (413)527-6078
WESTHAMPTON, MA 01027
ISSUED ON:03/17/2022
TO PERFORM THE FOLLO WING WORK:
SECTION 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:
Gas: Final: Final: Rough Frame:
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
• 'if • y2 • (NT
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Ci4' �'�V J T"T' i ns i n -FULL �&1:: if I
I
The Commonwealth of Massachusetts BAR 1 6 r� FbR
Board of Building Regulations and Standards 2022 LJNIIPALITY
� / • Massachusetts State Building Code, 780 CM;I.,, USE
':� rrrllf?In��
Building Permit Application To Construct,Repair, Renovate( f',Derd t,Wirrr eviseld Mar 2011
One-or Two-Family Dwelling "'` ' �'0
This Section For Official Use Only
Building Permit Number: 6P" 4-3-" .26-]... Date Applied:
4:01(..) a ss / 2'
3- ri-zozz
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Propecty A esr✓��n 9y�✓'" "J 1.2 Assessors Map& Parcel Numbers -
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 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
fi 2.1 wnert of Record
/r/l/jJl 7i
Name(Print) iti
City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'-(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 0 Specify:
Brief Description of Proposed Work': (
()Yli .Azi-t-i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item ( Materials)
timated Costs: Official Use Only
or and Maals)
40._1. Building /j1. Building Permit Fee: $ Indicate how fee is determined:
V ❑ Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa (Item 6)x multiplier x
P
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $a
Check No.)l 3 Check Amount: 40
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Co'truction Supervisor icense CSL) d y O 4 /-a5I-c
r License Number Expiration Date
Name of L HoA.a
, V l /7 List CSL Type(see below)
Crl ��(/ - TypeDescription
No.and Street � p
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP �f / /� �j' M Masonry
��" "l V l L'(7 L,'+�� Roofing Covering
Vile' Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Im rovement Contractor(HIC) /,` / ram / r -
HIC Company Nam r HI gis ame HIC Registration umber Expiration Date
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 0 No 0
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.
p , O . / (Print£2-/3 (1A
er's Name(Electronic Sig ture Date
SECTION 7b:OWNER1 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.
3 —/
Print Owner's o Authorize Agent's Name(Electronic Signature) ate
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 oh the HIC Program can be found at
www.mass.eov!oca Information on the Construction Supervisor License can be found at www.mass.tzov/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 Massachusettstti==° -- . Department of Industrial Accidents
_+ .mow 01
g 1 Congress Street,Suite 10
Boston,Ala 0 11 -201
'?; _. t i i. mass.govldi x
Workers'Compensation Insurance Affidavit:BuiltlersiContractorstEkctriciansiPlunt.bers.
TO Bk FILED WITH THE PER MI I TE'G AUTHORITY.
Applicant Information Please Print Legibly.
Name tl3uainess/OrzAni7att lnclnndua$1: ___#
Address: 5 o fiR
t . .p �i . _!��___ __.
Ct State'Zt ' Phone#:
•
Are you an empk►yer?Cheek the appropriate hot:
Type of project(required):
LID 1 sin• employe-.with tMr11...:ts(tint airtd part-tint:0 7. 0 New construction
23 ant a w1e proprietor ur}xarincrsuip and have no oaplca!axs working for me in 8. D Remodeling
any capacity.iNer workers,'ccm,p.insurance stsoirerki
9. 0 Demolition
3.0 I am a homeowner.r doing all work myself [No workers'ernlyr.insurance rcquirerl_]'
4.0 I Ara a homeowner and iritl he hmaig,conzr•:sitars eu wnduci all work on my property. I will I aBuilding addition-- ensure that all contractors either have workers'compensation insurance or are sole I 1 C Electrical repairs or additions
proprietors with no entployc
12.0 Plumbing repairs or additions
3 I am a general eontractor and I have hired:he sub-contractors Listed on be at;:auted sheet_
These sub-ewum:tors hove employees and have workers'Bump.insurance.: ]3 W�rt p:7ir3
I-I.0 Othin
6.3 V. are a corporation and its nt ri nt have eaneisesi their richt of exemption per WI_e.
1{2 §1t4l,and we have no employees.[No workers'comp.insurance required.]
*Amy applicant that cheeks box al most also till out the seezion below shuwinsr their workers'tiompr.rsariun colic inkrin atissrr_
I Houieowners who submit this atritl:atit mishearing they are oIoirrg an work and then lure outside eoranieturs movr xuhntit a new affidavit iatia atarg stilt.
+Cone ctors that check this box most ata;-bed an ad iitior al sheet showing the name o*Pthe suls-etrattratteri anti state whether or mit those es.titic-s hn.e
employees.. It:he sub-coutrac:urs have tangloyees.they must provide their Yaurke.s'camp.pule y number.
I rem 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: --ce7J —p`
Job Site Address: CityStateZip:�__
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required tutdet MGL c. 152. §25A is a criminal violation punishable by a fine up to S1.500.00
and-or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement may be fi'r•.c.infed to the Office of Investigations of the DIA for insurance
coverage verification_
I do hereby certify under the pains at twines of p.rjt<rty that the information provided above is true and correct.
Si_matun: IG�zhQ� Dal::: "-7 `J
Phone K: y 6 --_, tycd
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.City'fTown Clerk #.Electrical Inspector 3. Plumbing Inspector
6.Other
1
Contact Person: Phone#.
City of Northampton
•
Massachusetts __
DEPARTMENT OF BUILDING INSPECTIONS IT t
}: r 212 Main Street • Municipal Building
Northampton, MA 01060 � ;ZJ0
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, 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:
'L (11)
The debris will be transported by:
J
Name of Hauler:
Signature of Applicant: Date: (-3'—j�����