12C-104 „.. BP- 2011 -0520
GIS #: COMMONWEALTH OF MASSACHUSETTS
A M` ' : ` ` CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categor BUILDING PERMIT
Permit # BP-2011-0520
Project # JS- 2011- 000850
Est. Cost: $4500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 10018.80 Owner: MOULTON RALPH R & GLORIA J
Zoning: URA(100) //RI/WSP Applicant: BOB THIBODO ROOFING & SIDING
AT. 35 RICK DR
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527 -7663 () WC
NORTHAMPTON MAO 1061 ISSUED ON :121712010 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department 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.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 12/7/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
Building Department
212 Main Street
0
Room 100 a abt
- --
oWzanVton A 01060 ��
phone 413 - 587 -1240 Fax 413 - 587 -1272
2;
n � r —
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION `1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address
Map Lot Unit
r
3 Y\ \ L\� �\ -9, Zone Overlay District
- EIM St., CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current Mailing Address:
i✓- 1 ,%�%� "Lc 7U Telephone
Signature/ I
2.2 Authorized Agent:
Nam Print) Current Mailing Address:
t--
T L2
Signature Telephone
SECTION 3- ESTIMATED !CONSTRUCTIO COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit appli cant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6 ,
3. Plumbing Building! Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) s CV L Check Number Co
This Section For Off►clal Use drib
Date
Building Permit Number: Issued:
Signature:
Buflding Commissioner /Inspector,_of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information '
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front i
Side L: R __..j L _- .... R ._..
Rear
Building Height
Bldg. Square Footage `° - %x F
Open Space Footage _ % M _........_
(Lot area minus bldg & paved
atkir)
# of Parking Spaces
Fill:
(volume & Location) -- -
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:"
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW _0 YES 0
IF YES: enter Book : .. _ Page` j and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: `
D.__rMe ere any propose ° anges to or a itions o signs inte - nided - f& tFie property ? YES 0 NO 0
IF YES, describe size, type and location:
E. WII the construction activity disturb {clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES
/"N NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Ur Uobr5 0
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding [❑] Other [❑]
Brief Des ' tion of posed (�
Work: i -�.� C� ' O 'j No
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa_ ifl einr.# muse arar&& acIclrtlon - #ouuing:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Num ber of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a:,- OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES. FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize ; O ��
to act on my p alf, in all matters relative to work authorized by f its building permit application.
I Ito
Signature of- owner Dat
as Owner /Authorized
Agent hereby declare that the statements a d information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
S1
Print
Signature of Owner /Agent ��� Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder : a c, � ` d (11 S CI
Address Expiration Dated V �—
Signature Telephone
B:. Reaistereil3rlorrteklmpr "oiierrteG4ntrat;tri Not Applicable ❑
,
C, \S' - k 1 ~I
Company Name Registration Number
A d ss 1 � �
o �1 Expiration Date
A Telephone
S ECTION 10- 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 buildi g permit.
Signed Affidavit Attached Yes....... No...... ❑
'
Ini
T_he_curmnt_exemption for `_`homeowners" was ex tende d to include_ Owner- occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner Person (s) who own 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 homeowner
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference'to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability'of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
o: amp on r mance , a a ettsfrener- al- L-awsAnnotated.
Homeowner Signature
The Commonwealth of Massachusetts
- Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 01111
- ' r t-: Z , . www.massgovIdia
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print LegibIv
Name ( Business /Organization/Individual):
Address:
City /State /Zip: CD Phone. #:
Are you an employer? Check the appropriate box: Type of project (required):
1. �am a employer with 4.. [] I am a general contractor and I
employees (full and/or part- time).
* have hired the sub- contractors 6. ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no enip loyees These sub - contractors have 8. [] Demolition
working for me in an capacity. employees and have workers'
Y P tY- $ . 4. Q Budding addition
[No workers' comp. insuran _ comp. .;nsumme_ _ _ -
required.] 5. E We are a corporation and its 10.E Electrical repairs or additions
3.E1 —11 mg repairs or additions
m sel£ ' co right of exemption per MGL
Y � o workers �P• 12.tZ Roof repairs
c. 152, ,
insuran required.) t § 1 4 and we have no 13.❑ Other
employees. [No workers'
- comp. insurance requiredj.
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit: indicating they are doing all work and then. hire outside contractors must submit a new affidavit indicating such_
( Contractors that check this box mist attached an additional shed showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees; they must 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
formation. ,.
mP Y 1 l 1
Insurance Co an Name: -Q "
Policy # or Self-ins. Lic. #: d �S t LI �1 ,) C) 0 Expiration Date
Job Site Address: SL C \C (;y_ R 4&- , C City /State /Zip: T� nl
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required umder Section 25'A of MCTL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or 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. lie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insuran coverage verification
-
I do hereby certify under thepains and penalties ofperjury that the information provided above_islruenrid correct
Si nature: Date:
Phone #: -
Official use only. Do not wTrfe in this area, — to he completed by city or fawn official
_City or Town: Permit/License #
Issuing Authority (circle one):
1: Board of Health 2. Building Department 3. City /Town Clerk 4 Electrical. Insp S. Plumbing Insp ector_
6. Other _
Contact Person: Phone #: