31A-021 (2) BP-2024-1472
9 SANDERSON AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31A-021-001 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-2024-1472 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2024 Contractor: License:
Est.Cost: 9400 ROBERT THIBODO 65699
Const.Class: Exp.Date: 06/22/2025
Use Group: Owner: KUSIAK ANNE Y TRUSTEE
Lot Size (sq.ft.)
Zoning: URB Applicant: BOB THIBODO ROOFING AND SIDING
Applicant Address Phone: Insurance:
P 0Box 201 (413)575-1967 650UB-020N14
NORTHAMPTON, MA 01061
ISSUED ON: 11/04/2024
TO PERFORM THE FOLLOWING WORK:
STRIP AND REROOF
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:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: 72
Fees Paid: $60.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/'.-:--._.--.
The Commonwealth of Massac tisetts( ` 4 c'V2Q r� F R
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Board of Building Regulations an tan
/
Massachusetts State Building Code, 7 q�uo,ti,�� Iv�UNI SPEALITY
Building Permit Application To Construct,Repair,Renovate Or ,oh 9hi, c,v evis Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: S%f-1, 1', 1.7, Date Applied:
c Pf iL?d, /j-y•2 y
'wilding Official(Print Name) ature Dat
SECTION 1:SITE INFORMATION
1.1 P ert ddress• 1.2 Assessors Map&Parcel Numbers
'Y, alk-ty• soY, (NV
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❑ Private 0 Zone: Outside Flood Zone?
— Municipal Cl On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner c4 Record: ``�
1 \ s Q l< 11 Yc i ov� (�, O e1
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 ❑ Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
f Description of Proposed W 2
ve Avv5 f �est h- - TA\ Pry- cAA% cc , NI.. sti..VNCI1•ti
\/-e-(NA" r % E'i_�
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:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fe 0
Check No.XI I Check Amount: 60 Cash Amount:
6.Total Project Cost: $ )Li 0 0 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts �,, „., .... s,
?S 4:_ c'eG
fit, j . '; DEPARTMENT OF BUILDING INSPECTIONS y
=�: 212 Main Street • Municipal Building Jti I)/ 4:1
-- Northampton, MA 01060 s!;`
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND 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. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/ replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
9. Note any Conservation and/or special permit requirements (if applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW / private land by Building Dept.
13. Stretch Energy Code -all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
14. 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 Supe or License(CSL) �(� c c 9\ 1 ll% d a License Number Ex iration ate
Name of CSL Holder l- -
3 EA ac `hcVac sA- List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
l$NeN ( R Restricted 1&2 Family Dwelling
c,v4rn,State,Z M Masonry
p RC Roofing Covering
Jl, �tlL► WS Window and Siding
SF Solid Fuel Burning Appliances
15 Sn_S I —lAo I Insulation
Telephone Email address D Demolition
Re stere�d Home Improvement Contractor(HIC) al ,,,� r ,�,�1��
O j '` \� d HIC Registration Number bExpiratiioon Date
HIC Company ame or IcItegistrapt Name
'No. reef Email address
City/Town,State, 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 e of the building permit.
Signed Affidavit Attached? Yes 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 ) R\�' p% o 4
to act on my behalf,in all matters relative to work authorized by this building permit application.
��—� cam � �c1 lv 0 Cry 1 V1
' Print� Name(Electronic 5'gnatui�) 7 ` 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 accurate to the best of my knowledge and understanding.
e•%A\-a32a \A- 3 • �.,L1
Print Owner's or Authorized Agent's Name(Ele onic 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.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"maybe substituted for"Total Project Cost"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
.yam' 4 Massachusetts
* Y
r
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building %. ?'
Northampton, MA 01060 3,
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:
,�-�� A- �al\ T
Location of Facility: N � c�,,,�� -o ,ram � C�l.� e, 1
1
The debris will be transported by:
Name of Hauler: I 0 a.
Signature of Applicant: l Lo—ip Date: k1' �y
The Commonwealth of Massachusetts
ILNitw Department of Industrial Accidents
1 Congress Street.Suite 100
t —
r Boston, MA 02114-2017
www.mass.go►/dia
'%utkers'Compensation Insurance Affidavit:Builders/Contractors)ElectriciansfPlumbers.
10 BE FILED%•till THE PER 11-1I G Alr1 fORITl'.
.►aplicint Information Please Print l.eribls
Name IBusiness,'Orgatuza lion'Individual l: 1\t1
Address: �"" S� NN\��
City/State/Zip: c5A.\,,sir,44k Phone#:_ S 1
Are you an employer?Cheek the appropriate box:.
Type of project(required):.4l am a immloya with ^vl - employees(full swim parttime).* 7. CI New construction
20 I am a sok proprietor or partnership and have no employees witting for me in 8. O Remodeling
any eapa.rty-[No workers'conrp.insurance required.)
9. ❑ Demolition
i.0I am a homeowner doing all wort myself.(No worker:comp-insurance aqunod.)'
4.0 I am a hunicuwnm and will be hiring contractors to conduct all work on my property. I will
10 O Building addition
ensure that all contractors either lave workers'coinfie_saaiosn insurance or are sole 11.Q Electrical repairs or additions
proprieties with no employees.
12. lumbing repairs or additions
SO I am a general contractor ant I base hand the sub-contractors hated on the attaidied sheet
These sub-contractors base employees and have workers'comp.insurance.: 13 Roof repairs
6.0 We are a corporation and its otfeers have cxercised then right of exemption per Nit.l.c 14.❑Otlte'r
1.32. 1141.and we have no employees.[No winters'cranp iasraance rcyuircd.l
'Any applicant that checks box al must also till out the section leluu show mg their workers'compensation policy crdixmwtian
t Hoateuwnrrri wbu submit this affadas it uubcating they are doing a:l work and ibm hire owtside cemtractors much.submit a new affidavit indicating such.
!Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees If the subcontractors have employees.they most prvvidc their workers'vomp.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:
Policy#or Self ins.Lac.#: 11' - t o'3')'3 c9 ~( Expiration Date: • t d�S
Job Site Addres.s:C:1 5 nratt.4 by . slA. City/State.Zip:N OY"V do 1`ivy
Attach a copy of the workers'compensation police declaration page(showing the policy number and expire an date).
Failure to secure coverage as required under MGL c. 152,*25A is a criminal violation punishable by a fine up to S1,500.00
antiror 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 forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the ruins and penalties of perjury that the information provided above is true and correct.
SSitiatum Date:
Phone#: L4 (3 5
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 Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
(a.Other
Contact Person: Phone#:
ft
City of Northampton
,�r isr S,,, .sic;.,
i< j Massachusetts �,?'' �. '<<.
4. 4. ysr .t�
DEPARTMENT OF BUILDING INSPECTIONS ;
1.
i' 212 MainStreet • MunicipBuilding J� alb
Northampton, MA 0106010
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)