35-217 (10) BP-2022-1240
18 LADYSLIPPER LANE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
35-217-001 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-2022-1240 PERMISSION IS HEREBY GRANTEI TO:
Project# ROOF Contractor: License:
Est. Cost: 7000 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2024
Use Group: Owner: D SCWARTZ GREGORY ADAM & BR ANNE
Lot Size (sq.ft.)
Zoning: WSP Applicant: JAMES ROBERTS
Applicant Address Phone: Insurance:
30 Edwards Rd (413)527-6078
WESTHAMPTON, MA 01027
ISSUED ON:09/30/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-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:
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 VIO ATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
II ) 3-11
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
RECEIVE
The Commonwealth of Massachusetts
Board of BuildingRegulations and Standard E P 2 9 FOR
i ... ��22 MUNICIPALITY
�' Massachusetts State Building Code, 780 CMR
•pit,;
USE
Building Permit Application To Construct,Repai4,Renee r ploirc to,j,Revi.ed Mar 2011
One-or Two-Family Dwel irk-___ r'oF�T"Ah"Ton,.r n.a 01060
This Section For Official Use Only
Building Permit Number: j2 , ),"' . .- 1 cf0 Date Applied:
i/eivii_s // C1'3()-ZOL2
Building Official(Print Name) Sign ure Date
SECTION 1: SITE INFORMATION
1.1 Prop Ad ess: 1.2 Assesso Map& Parcel Numb
�3 /Z-
1.1 a Is this an accepted str ?yes no Map Nui r Parcel Number
1.3 Zoning Informatio 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:
Zone: Outside Flood Zone'?
Public 0 Private 0 Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP' ��,,,/
2.1 O er'of Record: —'�/U
Name(Print 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 ❑ Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work'-: if
P` -(fit
SECTION 4:ESTIMATED CONSTRUC COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $/�` a d
CI 2.
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 i
Suppression) $ Total All Fe ]fj
Check No. 7) Check Amount: (J
6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due:
City of Northampton
?o�Yµa erti�` Ss r'
Massachusetts � � - '.;cam
*
I t 7 DEPARTMENT OF BUILDING INSPECTIONS ti t
t '
212 Main Street • Municipal Building b
Northampton, MA 01060 ss 101
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 License CSL)
License Number Expiration Date
Name o L Holder
3 C List CSL Type(see below)
No.and treet Type Description
U Unrestricted(Buildings up to 35,000 Cu.ft.)
l� a R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
Roofing Covering
S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation —
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) _
I C"Registra�tiod Number Ex atlon Date
HIC Company a HI/ •gistrant Name
No.and Street , Email address
lif
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 V t
to act on my behalf,in all matters relative to work authorized by this building permit application.
"g?�-�
Print Owner's a(Ele roni Signature) Date
SECTION 7b:OWNE 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.
qNc4 -01,'
Print O 's or Authoriz d 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 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/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 Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.govidia
— 'Workers' Compensation lasurance Affidavit: Builders/Contraetors/Ekciricians/Plumbers.
TO BE FILED WITH THE PERMITTING ALITHORITV.
Applicant Information Please Print Le.,ibl%
Name i 13 us incs s-Organtra hon.Ind i v tduali:
Address: 3(i
J&'
City/State/Zip: .
i Phone#: z--//3—4/9/ —0,_?5
Are yea oft eaopboyee Cheftit doe appropriate box:
Type of project(required):
I.E3 lam a employer with _i_sarployeesi(fWI and-or part-turret` 7. 0 New construction
20.1„Aorrs-,---ide proprietor or purtnersiirp and have no employees*orlon! for me m 8. 0 Remodeling
my capacity.[No workers'comp.insuranve impUrall
9. 0 Dernolitiori
3 1 am a homeowner doing all wurk myself.[No workers comp.sirsoranor impfired.r
la C1 Building addition
4.0 I am a horrioawner and\Axil be hiring contractors to conduct all w ork on my property. I will
ensure that all contractors other have workers-coammisation insurance or are sole I 14:3 Electrical repairs or additions
proprietors*kit no employees_
I 2_111 Plumbing repairs or additions
a he
.514,14: :--general contractor and I Kale laced the roh-curnractors listed on the attached S et -
13 ril • •-1 repairs
Thew rub-contractors More employees and hone workers'comp.insu=ce.:
14.E3Other
6.0'Ore am a corporation and as officers have exercised their right of exemption per WA_c.
I 3.1 4 1(4)..and we/use no ernployiees.[No workers'comp.insurance requiredi
`Any applicant that eher-ks Net ol must also till out the section helms%bossing their workers'compensation poliq information.
t Homey%rims who S litinut this affidavit indicating they arc doing all work and Men hire outside contractors must submit a new affidavit indicating suck
4.1:cintractors that check this box MUM,attached an additional%heel%bowing the name of the ints,contractors and state whether Or WE those entities hare
employees. If the sub-coratractors ha,e employ ees.they must proside their workers°...romp.7o/icy it writer
l am an employer that is providing ovorikers•compensation insurance for my employees. Belo kr is the policy and job site
information.
• ./ --'
Insurance Company Name:
Policy#or Self-ins.Lie.#: d Expiration Date: /—ez,?/ ',:;.214
Job Site Address: CityStateiZip:
Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NiGL c. 152,§25A 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 tine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
c 0 k erzipe i,erification. ..
f do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
nattire: Dale:
_.
Phonc,
.. ..
(If:Tidal use only. Do not write in this area.to be completed by city or town official
I
City or Tows: Permit/License#
Esau*Authority (circle one):
I.Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
.......ms.
City of Northampton
Massachusetts �� �._
DEPARTMENT OF BUILDING INSPECTIONS `�
�=`p, t 212 Main Street •• Municipal Building ti
- "� � Northampton, MA 01060 �s-p , 1"''
1
CONSTRUCTION DEBRIS AFFIDAVIT 1
(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: 0. ..ri),L....)
The debris will be transported by:
---
Name of Hauler:
Signature of Applicant: i r Date:
City of Northampton
air
Massachusetts 4{
Y
* DEPARTMENT OF BUILDING INSPECTIONS
x
212 Main Street • Municipal Building
Northampton, MA 01060 'PS
fx '-)11��
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)