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23A-119 (3) BP-2023-0644 11 CHESTNUT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23A-119-001 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-2023-0644 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 8600 ROBERT THIBODO 65699 Const.Class: Exp.Date: 06/22/202 Use Group: Owner: D LAS LLE JOHN J&MARGARET Lot Size (sq.ft.) Zoning: URB Applicant: BOB TI-IBODO ROOFING AND SIDING Applicant Address Phone: Insurance: P O Box 201 (413)586-0391 UB0250N144 NORTHAMPTON, MA 01061 ISSUED ON: 05/17/2023 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 VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: • ,2 . f Ti, . , , Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax (413)587-1272 Office of the Building Commiss. ner 1 /' 4' • \ ter: . The Commonwealth of MassachusettG.� p Board of Building Regulations and Standard-,�tio� �� !,t`' FOR W Massachusetts State Building Code, 780 CMR ti�tis `/ MUNICIPALITY �q Fc � USE Building Permit Application To Construct,Repair,Renovate Or i pjisii a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Buildin Permit Number: Z P-d'3""i/(y Date Applied: �_v�,� % ,5 1/�/ 5-16-2023 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 P�pertyAdde ss� N V 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 Diiiensions: 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 Owner'of Record: c In.Y C GY C r Ls\ S`C\\Q c)Y{vN -k `1 it, Name(Print) ` City,State,ZIP \ \ C\Ve c\ ry ( c * STC (r3 3.,) .3 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check ll that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) Per Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': new ay.0 c.,c3\h'`n r 'C" M\ a, 'ctWc© k) t\ .1: 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 $ ❑Standard City/Town Application Fee ❑Total Project Costa (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: ,�j O r. Check No. Check Amount:' t 6.Total Project Cost: $ Cj 0 v 0 Paid in Full ❑Outstanding Balance Due: .t SECTION 5: CONSTRUCTION SE VICES 5.1 Construction Supervisor License(CSL) O(�_ Gam+ cl ( - �Y License Number Expiration Date Dame ofCCSL Hodder {xQ List CSL Type(see below) 3 No.and Street Type Description Unrestricted(Buildings up to 35,000 cu.ft.) SfN-\ L t'� VIA b Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry e'— a„.1=c;i:k1RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1-1 V3 5---) T i I Insulation Telephone Email address D Demolition 5.2 Re istered Hom Improvement Contractor(HIC) + S ;1 I `I. (. 13' HIC Registration Number Expiration Date HIC Company Name or HIC Registr Name S Di-Ink No.and%teat S'k ��� M\ r 1+cSSIS k%.—\ Email address � h Q �- 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 Issu ce of the building permit. Signed Affidavit Attached? Yes Lo(/ No .❑ 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. it^c _ r-tIV \ -407(S-C\\c S• 15 ' c)3 mt Ownr's,,Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AG INIT DECLARATION By entering my name below, I hereby attest under the pains and penalties o perjury that all of the information contained in this ap true and accurate to the best of my knowled and understanding. % Print Owner's or Authorized Agent's Name(Electronic Sigma e) 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.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 Alassachusetts 15) ,i. a ,----. Department of Industrial Accidents 1 Congress Street,Suite 100 _ V t-50- Boston, MA 02114-2017 wwwmass.gov/dw IVorkers'Compensation Insurance Affidavit:BuildersiCiintractorsfElectricians/Plumbers. TO BE.FILED WI III THE PER:111141N t.:AUTHORITY. Anilkitit I ill fo rut a tion Please Print 1..eg Name ilittittscssiOrgantznttorf Intitviduall.: i 6 Address: ' 3 )., Gs-k.-`1McAy-A.. , c CityiStateiZip: (.74.. Phone g: 14 0 51 5" 15 Ate yaw aa etriplo,cr?4 deck the a ppropriate bat: Type of project(required): 1.4 am a employer with,,3„_,_,,,empiuyves(full traitor part-hinct,' 7 0 New conStruiction 20 I 3M II aale proprietor ur pura act-slap and have no catritoyeca,wanting tar me in g. 0 Remodeling [Iv.*takers comp.insurance required I 9. Cil Demolition ....1...J I ant it homeowner dumg all wort mpelf,[No wmitas'curry,imuratice requital.) i O 0 Building addition 4E31 am a hataltarwman:mil will Ix hinny cormacturs to conduct ult*oil 1111 tay property. I will miaure that all coiaractors either hare*mien'compernation insurance or arc Alc l 1.0 Electrical repairs or addition) proprietors with nu employetm„ 12_0 Ittnbuttt repairs or iidtigiutt_.. :SO I am a irencrat control:tat anJ I haat:him the..ub-cunttoctun,Imbed 1.113 the atu‘heil beet 13 Roof repairs The Alb-contractor%ba ‘-naployce%and ha.e*Later;comp.triAinuacc,: 14.0 Other ii.E3 we tire a evaporation and its Laken ha‘c exercised their right al ettmaniun per Skil.c, , 1 . 1141.and we kepi:au employces.iNn Amiens'camp,imurance TIAN:real 'An,l,applicant that cheek.%but al mint alau fill unit ill,.se,..ticii l•citya,hiSOWinv thca Is or .kit,'omnpematiutt pultey information, # I lorncouincrs,who submit this affultmi nudicatinu t11,..y are-.2,';r151 ail work and then ha. atom&euntrociots must sahrrat a new'altridaNrd nadicaun such. :Contractor%dot check this boot mutt atueset1 nn Airliniuttul sheet slow ing the mink of the sith-continetot,3 and,stotc whethet ot nut thusm,.mtlEtt.t haVe tanpkryces If the aub-corarao.-tors base carloyees,they must pro+.id e their worker;comp.polie:,,,nunx,r , . 1 am an employer that is providing workers'compensation insurance for my employees. Below it the pokey and jub.%ile information. Insurance Company Name: \-- V() Policy#or Self-ins.Lie.#: r3 t-33 0 1\i 1 -ILI "1 Li Expiraiion Date: 3 a.-7 • „00, , Job Site Address: \\ C ‘..t's-A'hu\'' 5-k- City'State:Zip: 01{,v-N CR \MN Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 151§25A is a criminal violation punishable by a fine up to SI.500.00 and/or one-year irnpnsonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator.A copy of this statemerit may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I du hereby eerrifj.under the pain!, und!knell:les ofperjttry that the information pro tile!ahore i., true and ctorrect. Signature: - Nicti?,-,, ,9. Date. S 1 ce:' Phone#: k...-I I'3 55" I ci Official use only. Do not write in this area,to he completed bt'rift or town official City or Tow n: Permit/License Issuing.‘tuliority(circle one): I. Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing inspector 6.Other Contact Person: Phone#: - . City of Northampton x Massachusetts t DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building : —^" Northampton, MA 01060 . 1 � 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: (Du'.i) Ck Location of Facility: N p N'CWcMP A-o ►1 The debris will be transported by: r2p� ' `� d "'(' Name of Hauler: o� T �� U &) Signature of Applicant: e •t rI' Date: . 1 5-. 1) City of Northampton : , Massachusetts `- il if' 1 DEPARTMENT OF BUILDING INSPECTIONS fa.;" , ,� 212 Main Street • Municipal Building .0 Northampton, MA 01060 °�j'k,- '''' 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)