35-013 (6) BP-2024-1113
173 WEST FARMS RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
35-013-001 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-2024-11 13 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2024 Contractor: License:
Est. Cost: 9200 ROBERT THIBODO 65699
Const.Class: Exp.Date: 06/22/2025
Use Group: Owner: KAREN KORVEK ZIGMUND &
Lot Size (sq.ft.)
Zoning: WSP Applicant: BOB THIBODO ROOFING AND SIDING
Applicant Address Phone: Insurance:
P O Box 201 (413)575-1967 650UB-020N14
NORTHAMPTON, MA 01061
ISSUED ON: 08/29/2024
TO PERFORM THE FOLLOWING WORK:
STRIP AND RER(X)F
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: 772_
Fees Paid: $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
RECEIVED
AUG 2 9 2024 The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
PT.OF B . t;;,, NAppli ration To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
NORTH • ' 'One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number:6 p^.1.ci ` I I/.3 Date Applied:
Sim P/~ -�— �.. e-o'-zy
Building Official(Print Name) ignature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.la 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 CI _Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Read: Oh C bT VI k
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(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 Work2:<Rem ovA V)ab.ktn CiZa•P;h" ll
�Skj�� �0- V-fan�f SG\ 1
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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 Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:
Suppression)
Check No.).� Check Amount$(jP
6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due:
A
City of Northampton
, :1 Massachusetts 47
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• ' • • DEPARTMENT OF BUILDING INSPECTIONS a
212 Main Street • Municipal Building yJyy A.
�'� ' Northampton, MA 01060 .1,4.4�.._f",�OP
1—
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR, ETC.
•
I. 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.
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) fl.GPS
1-, a S,•
, License umber p Expiration Date
Name of CSL older
3 3. G v\A List CSL Type(see below)
No.and Street Type Description
St.A`��`^i O� U Unrestricted(Buildings up to 35,000 Cu.ft.)
1 \v{"l ✓R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
, n RC Roofing Covering
�A •
., WS Window and Siding _
SF Solid Fuel Burning Appliances
Li 0 5 s-1 CI(v"'1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home I rove ent Contractor(HIC)
J rl HIC Registration Number Expiration Date
C ny Name or C Reg' rant Name •
a `` � l
No.and treet \b_4}�l o bleb V0pgvi�� 1—� 9
EASA% ��' ,tom S'15 1 6`1 Email address
City/Town,Stat .
,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 191 No .O
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 () C ) �� 9 0 C143
to act on my behalf,in all matters relative to work authorized by this building permit application.
<axle r � '�. �-
Print Owner'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 application is true and accur o the best of my kn ledge and understanding.
4.c;t• a _L ,
Print Owner's or Authorized Agent's Name(Electronic igna 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
ww•w.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,fmished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable robin 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"
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The Commonwealth of Afassachuseits
►le.
c Department of Industrial Accidents
== 1= 1 Congress Street,Suite 100 .
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-- r Boston.MA 0211 a-2017
- ww►i:mass.gor/dirt
%%others'Compensation Insurance Alydas it:Builders/Contractors/Eiectricians/Plumbers.
10 BE FILED WITH THE PE:RNIII I'lNC Atr1'HORI'1'Y. . ' . , . .
:% t beans Information Please Print l-e••ihls
Name(t3usm s.s(h :rnezationn/ruin tduai): )_ \
Address: 'N' Q S
City/StateiZip: ixw,,,Q 1-t,,,, '* Phone#: i.lt..13 • S'hS' 15(=l—
Are yore ua employer.?C6tek tilt apprittriate•bix:
Type of project(required):
1.6 I am a employer with employs(full tit or part-Hume) O New construction
2fl i am a•oIc ptvpricttit'or puroa rship and Mate no entplopi CA working for me in 8. Remodeling
any*nee!,[No workers'comp.insuran4.`C required. •
9. ❑ Demolition'.
301 am a hanreow-n r doing all wort myself.[No worksas°comp-111:Airmcc moulted]'
10 o Building addition
40 I am a homeowner and will be luting oontrrciors to conduct all w ark on m4 pmper1V- 1 will
ensure that all contractors either haw workers'compensation t.tburanY or are sole 110 Electrical repairs or additions
proprietors w ith no empluyee>.
12.0 PI tubing repair,or additions
50 I am a general contractor and I hint lured the sub-contracture listed on the attae'hud ahcct 13 Roof repairs
These nub-contractors lime tmplo)ccsaril have winters'comp-insurance.;
60 WC are a corporation and its offwer>have eaim.cd them ngbt of exemption per MUc. 14. Other
152.tic 1(•1).and we base no employees.[No waiters'comp.insurance required.]
`Am applis.nrt that chexka box 1$I mint also till out the weeti.in bckr.shoo mg then Workers'compensation policy information
t Itcmcuw uy,:rs who subunit this Alan it mtdicaurte they arc doing all wink and then hire outside contractors must submit a new afiidas it indicating arch.
'Contnietori that check this bc,x mint att wb.d an additional sheet show in the name of the sub-sevatractuti anti state whether or not those entitle.,have
cniplu)ee..- If the sub,-contractor,ha,c tsarloseea.they riut,t provide their workers'comp,policy number
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 1 11-C G) c r
Policy#or Self-ins.Lie.#: 0'0 1 VJ tD3-") 3 et(4 Expiration Date: Cr= �.1 1 S'
Jab Site Address: V1 W e s; crowirsm.r T,A City?State:Zip:cI out he
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. 152,;§25A is a criminal violation punishable by a fine up to S 1,500.00
and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a line of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verification. •
I do hereby certify under the pai
n
sstit penalties of perjuty that the information providded above is true and correct.
Si{'natu c v - b Date: ?� '
r
Phone«: Li 13 5"1 S. 1gion
Official use only. Do not write in this area.to be completed by city or town ofcial
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
(i.OI her
('mitact Person: Phone#:
City of Northampton
"� •. Massachusetts
f.
DEPARTMENT OF BUILDING INSPECTIONS A.
*.,,nA- AL' 212 Main Street • Municipal Building
Northampton, MA 01060 sSp,y 1,?c"
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: N by-4 o
The debris will be transported by:
Name of Hauler: r3
Signature of Applicant: Date:
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City of Northampton
Ce, Massachusetts -
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building 4 .Cb
Northampton, MA 01060 J'g'." &,*-^�
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)