42-124 (3) ,.
A BP -2011-0035
GIS # COMMONWEALTH OF MASSACHUSETTS
. * t CITY OF NORTHAMPTON
Lot: -001 f PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0035
Project # JS- 2011- 000063
Est. Cost: $5200.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin BOB THIBODO ROOFING & SIDING 065699
Lot Size(sa. ft.): 37897.20 Owner: STONE PETER A
zoning: SR(100) //WSP II Applicant: BOB THIBODO ROOFING & SIDING
AT: 150 GLENDALE RD
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527 -7663 () WC
NORTHAMPTON MAO 1061 ISSUED ON. 7/14/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK.- & SHINGLE 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:
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 7/14/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton
Building Department
x,12 Main Street
1toom 100
- Forth pton, MA 01060
phone 413587 -1240 Fax 413 - 587 -1272
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
\50 V\ Aa-Iz- Zorie OverlAy Districf
Eirr%St °District CB District
SECTION 2 - PROPERTY' OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Prin Curre t Mailing Address:
Telephon
Signature
2.2 Authorized Agent:
ei%000 qco:
Name rin t) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED!CONSTRUCTfON COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
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) D Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissionerllnspectorgf Buildings - Date
/ av
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 Departmedt j
Lot Size 3
Frontage
Setbacks Fron
Side L: :......_.,.._= R: L: _ ' R:
Rear_
Building Height
Bldg. Square Footage % ?"
Open Space Footage T _ % I _
(Lot area minus bldg & paved
p arkin g)
# 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 issuedn
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES Q
IF YES: enter Book Page; I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
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 0
IF YES, describe size, type and location:
s` .� re t ere any propose�C changes o or a ltions o�signs i�`'nencTed for - the property ? YES Q NO 0
IF YES, describe size, type and location:
E. Will 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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
a
SECTION 5- DESCRIPTION OF PROPOSED WORK ]check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [o] Other [D]
Brief D s ' tion of Proposed �'�!� Q 1
Work: V ly
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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. Number 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
act on my behalf, in 611 matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner /Authorized
Agent reb eclare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains nd enalties of perjury.
Rte
Print Na
Signature f Owne /Agent Date
-
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor i Not Applicable ❑
Name of License Holder � �d,�
License Number
cq'A " — C,; i �1-1�
Address Expiration Date
SigngtdW Telephone
9MRde[istered tto ne?l ` "rt! etri t Z r efii � �� a.... Not Applicable ❑
Company Na Registration Number
Ad ress r� Expiration Date
Telephone 1
SECTION 10- WORKERS COMPENSATION INSURANCE AFFIDAVIT (MG.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....... No...... ❑
The-current-exemption for "homeowners"wa ex tended_to nOude_ 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 co nsidere d 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 buildine 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 - f 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 tts fie�ra, aws- Annotated.
r tnanc a e
Homeowner Signature
e
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
APPUcant Information Please Print L � "blv
Name ( Business /Organization/Individual): .
Address:
City /State/Zip: Phone. #:
V I e ou an employer ?.Check the appropriate box: Type of project (required): am a employer with 4.. E] I am a general contractor and I
employees (full and/or part time).
: have hired the sub - contractors 6. ❑ New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet_ 7. Remodeling
ship and have no eaployees These sub - contractors have. .8. Demolition
working
or for me in an aci employees and have workers'
Y cap . 9. ❑Budding addition
[No wo rkers' co mp. insuran comp.. . ns urance .$ .
required] 5. E We are a corporation and its 10.0 Electrical repairs or additions
311 repairs or additions
myself o workers' co right of exemption per MGL
Y <N mp- 12. Roof repairs
c. 152, 1 (4), and we have no
insuran required.] t � § () 1 3.0 Other
employees. [No workers'
comp. insurance required.}.
'Any applicant that checks box #1- must also fill out the section below showing their work=* compensation policy information.
t Homeowners who submit this affidavit.indicatiag they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet shomn9 the name of the sub - contractors and state whether or not those entities have
employees. If the sub-contra h ave emp loyees, they must provide their worker comp. policy number.
I am an employer that is.providing workers' compensation insurance for any employees Below is the policy and job site
�ormati'on.
Insurance Company Name:
Policy # or Self -ins. Lic. #: o v f„(. -,�„� ( (� Expiration Date:
Job S ite Addr 7 Lin.. A sk AA � City /Sta&Zip:
Attach a copy of the workers" compensation policy declaration page'(showing the policy number and expiration date).
-_
Failure to secure coverage. as required under Section - 25'A of MGL 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 fi
of up to $250.00 a day against the violator, 1$e advised that a copy of this statement maybe forwarded to the Offf a of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of perjury that the information provided ahove_is_true_asdcorr�et__T
Signature' Date:
Phone #:
LOther e only. Do not wrr1e in this areas; to be comp eied by city or town afficiaL
To
PermiVUcense #
hority (circle one):
Health 2. Building Department 3. City/Town Cler k 4. Eiectrica Inspector 5. Plumbin Inspector - - - -- - - son: Phone #: