30C-018 (5) BP-2022-1054
495 BURTS PIT RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30C-018-001 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-2022-1054 PERMISSION ISHEREBYGRANTEI TO:
Project# ROOF Contractor: License:
Est. Cost: 5000 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2024
Use Group: Owner: ROGER GUERTIN SHIRLEY&
Lot Size (sq.ft.)
Zoning: SR Applicant: JAMES ROBERTS
Applicant Address Phone: Insurance:
30 Edwards Rd (413)527-6078
WESTHAMPTON, MA 01027
ISSUED ON:08/25/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-SHINGLE
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
Fees Paid: $40.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
i?k
The Commonwealth of Ma$sac tts
I,141
Board of Building Regulations a •rds�� \ _, FOR
Massachusetts State Building Code, . ,� R �sc� '/SEUSE
��'�'% �
BuildingPermit Application To Construct,Repair,Rend* DemZSTishMar 2011
PP eP
One-or Two-Family Dwelling oti>''►so
This Section For Official Use Only /o
Building Permit Number: '�-'^'10`' / Date Applied:
4.,e2_05 i/' 7 8 ZS-ZDZ.Z
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Pro/rty_ drev �� �, 1.2 ssors Map& Parcel Number '
1.1'a.Is this an accepted street?yes no Map Number Parcel Number
1.3 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'
2.1 r'of Record: '
,,,e.
Na e( rint) City,State,ZIP
6;C,W ;
No.and Street ,r�� 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'
J-117(------e
(�C e Q
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Larfand Materials)
1. Building $ �Gr 1. Building Permit Fee: $ Indicate how fee is d#termined:
❑ Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fei(V�
Check No. A heck Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
Pr 212 Main Street • Municipal Building
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.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor ' se CSL) Vd (. /
I
,er/i) 426,. License Number Expiration Date
Name of C L lder
G�Lair List CSL Type(see below)
No.and S t .�— Type Description
SP/; -' ` '" ` /0 `7 U Unrestricted(Buildings up to 35,000 cu. ft.)
�/ d R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
C Roofing Covering
Window and Siding 1
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Reg' e ome Improvement Contractor(HIC)
HIC Registration Number Expiration Date
6-JY'
HIC Com any Name or HI egistrant Na 2
No.and Street ��7 1 3J
1ilad&ess
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 tq 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 a..I
to act on my behal in all matters relative to work authorized by this building ermit application.
r---. 5---..;
Print er'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 applic 'on is true and accurate to the best of my knowledge and understanding. �,
F.--1--
Print Own 's or A ho 'zed 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 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.govidps
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"
11":,....,\ 'IIIIIIIIIIIIIII
The Commonwealth of Massachusetts
-,..
Department of Industrial Accidents
N 1 Congress Street,Suite 100
t. Boston, MA 02114-2017
$sloncntass.govidia
Workers'Compensation Insurance Affidas it:Buiklers/Contnictors,'ElectricianstPlumbers.
TO BE HEED WITH l'HE PEILMITTING AUTHOttat.
Applicant Information Please Print Legibly
Name(1,3 us incss.Org,AnIzattorilndry bloat 1:
Address: 30
City/State/Zip: " 4 1;•::,;"r--- Phone#: Lf(3 —q 41 1 ---- 0, 0
Are you an rmlikryer?Check the appropriate box: Type of project(required):
1.0 I sin employer with em it ployees(fall anor part-tunet." 7. 0 New construction
; ,2
2 a wk proprietor or punnerxhip and have no employees working for me in
2
an Capaeity.[No NIalrit.T1'0.31rnp.1.11Surance required.] S. 13 Remodeling
9. 0 Demolition
30 i sur a horneowner doing all work myself{No workers'comp.insurance required
10 CI Building addition
4.0 I Mifl a horricriwiter and Arl..1 be hiring contractor,to conduct all work on my property, 1 will
ensure that all contras-tors either hair worker!:1.-KMTNIC11.5111)Cil insomnia:0/iife sole 1 I.0 Electrical repairs or additions
proprionies with no empoyees.
l 12.II Plumb'ng repairs or additions
5 a general contra:tor and I have hired the lub-contractors listed on the:studied sheet
These tub-contractors have employees and have worker, cinrip.insuninee.: 13 70, • -4 6 feepairs
6.0%Se are a corporation and its officers have exercised their right of eseinpuen per MICA c. 14.0 Other
152_§It 4)..and we have rst,cmployees.[No*oriels'cernp.insurance Tenoned.]
• °Any applicant that chocks box 2r1 must also fill out the section below shiny in thea lA orkers'compensation policy information.
+HOCKKOWtietS who submit this affidavit indicating they are doing all work ant]then hire outside 4:x41u-scion must submit a new affidavit ind.n.nting such_
;Contracktri that check this but mud attached an alilitiorral sheet showing the name 4,1`the sub-contructors and gate whether or not those entities lust
employees. lithe 4Ub-4:111graCEilf%11314V einplo ces.they mum preside their workers'oomp,policy number.
I am an employer that is providing workers'compensation insurance for my employees_ Below i8 the policy and job site
information. .----
Insurance Company Name: _
Policy#or Self-ins. Lic.#: Expiration Date: /721-—0,--3
Job Site Address: CityrState/Zip:
Attach a copy of the workers'compensation polic declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NAG!.c. 152,425A is a criminal violation punishable by a tine up to$1,500.00
andOr 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 thiN statement may be forwarded to the Office of Investigations of the DIA for insurance
cut.t-ni!.:i: A en fi L.-a tion.
I do hereby certify gander the pains and penalties ofperjun that the information provided above is true ant,correct.
Signature:
.t---771-P--ez--",),, I)ate.
Phone#: iy4-( 44 ( — 0`3,...c U
Official use only. Do not write in this area, to bc completed by city or town official.
City or Town: Permit/License#
Issuing Authorit,(circle one):
I. Board of 1 I r alth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
o. Otlicr
I I C on[Act Peruin.
IP ' . Phone#:
City of Northampton
BHA
Massachusetts _ f
DEPARTMENT OF BUILDING INSPECTIONS ?„ ;
= /4P 212 Main Street • Municipal Building
a _ Northampton, MA 01060 ssyyt �ryti�
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:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: (J Date:
City of Northampton
fr Massachusetts *; . '`w.:!ec,
!F t, ,t:. ,i,4 t
DEPARTMENT OF BUILDING INSPECTIONS r x
212 Main Street • Municipal Building ��
1 Northampton, MA 01060 ^.:. ik.......) r
J'}y uy
)%�'"
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
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 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
qualify 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_.
•
(Signature)