49-018 340 GLENDALE RD BP- 2010 -0591
GIS /: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 49 - 018 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit i BP- 2010 -0591
Project to JS- 2010 - 000863
Est. Cost: $9000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 40597.92 Owner: PION MARK S & KATHLEEN D
Zoning: SR(100) / /WSP 11 Applicant: BOB THIBODO ROOFING & SIDING
AT: 340 GLENDALE RD
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527 -7663 0 WC
NORTHAMPTONMA01061 ISSUED ON:12/11/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & 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:
FeeTvpe: Date Paid: Amount:
Building 12/11/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
Department pse only
City of Northampton Status of Permit:
Building Department Curb GutiDnvevvay Perrn
it
212 Main Street .
Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Twb Sets •of StrUctural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site P!ans
Other Specify
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
Zo ne Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OVVNERSHIP/AUTHOFZIZED AGENT
2.1 Owner of Record:
'
Name (Print - Current Address:
l /
e-
[qt." Telephone
Signature
2.2 Authorized Agent:
.,
't ) A '
Name (Print) Current Mailing Address:
2 — 1
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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) (71- r C heck Number /
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING Alt 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
Side
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# 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 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES (2)
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained
Obtained
0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any to or additions of signs intended for the property ? YES 0 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.
'
SECTION 5- DESCRIPTION OF PROPOSED WORK (check aU applicable)
�~/
New House El Addition [l Replacement Windows Alteration(s) } ! Roofing |—!
Or Doors El
Accessory Bldg. E �-| DemDemolition F—1
nn �-� New Signs [[]] Decks [[l Siding[[]] Other [DI
fP d ~—'T�—~
Brief
*n�c��wovnm°vvouoo'� -t � � � ' �� _� __� ��-��\\ �lr'�� ,--::;‘,1-,,,,c,1„.1 \��
\
mueradonofex��ngbedmom Yes No Add�gnewbodmom Y�u mo
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rol! - Sheet
s== 1 '~-^~~~-�°
_-_- house and or ---'-_ to existing h cornglete the following:
a. Use of building : One Family Two Family Other
u. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Froposed Square footage of new construction. Dimensions
__. /
e. Number of stories? -���_-_�__-
f. Method of heating? Fireplaces or Woodstoves Number of each
S. Energy Conservation CompUance. 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 ceflar floor below flnished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Suppty
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
.
c'
I, \^ ) ^
|. .. ��~_y— ~� ` \��—~ . ao Owner of�eou�e�
property'
4- \
hereby authorize \ �\ 1 %� �
to act on my behalf, || ative to work authorized by this building permit a |ivadon
~ ` / _J � ��
=— �\ / /, L.,, \ ^.�m �� /- �� `
u/onamreu/ - wn , Date
-. .~~~
I. . anOwner/Authorized
Agent hereb declare 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 and penalties of perjury
' '(l '\
\ � ��D \ �� `1) (-'. ��
Print Name
^ � \ ) ' - � � � � � {�` i� _ ___
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o�na��mnw^cnwoom oa�
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: $ _ � " 1
License Number
w '
Address t Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor:. Not Applicable ❑
Company Name Registration Number
Asa" d
Address Expiration Date
' Y r Telephone 3,4,
—
SECTION 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 building permit.
Signed Affidavit Attached Yes No ❑
11.y Home Owner.. Exemption
The_current_e emption for "homeowners" was extended to include owner- nceupied 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
T\T - i arrpton Ordinances, state and - local - Laws ng Laws &ad- State - of Massachusetts Laws Annotated.
Homeowner Signature
\ The Commonwealth ofMassac/uisetts
5 lw - - , Department of Industrial Accidents
'''7 --- i' + Office of Investigations
(= � 600 Washington Street
P
,. , / Boston, 11//1 02111
' www.mass.gov /dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name Business /Organintion/IndividuaI): ,., I t,. , , 4._-
Address:
N AT'
A- , i�`'°��°" � `�\ .c'� \-4, ')
4 .
City/State/Zip: m;, w -� Phone T:
Are you an employer? Check the appropriate box: Type of project (required):
4_ I am a general coast actor and I 6. ❑New construction
I. I am a employer with . ❑
employees (full and/or part-time).* have hired the sub- contractors
2. 11 I am a sole proprietor or partner- fisted on the attached sheet. 7. ❑ Remodeling
ship and have. no e_vioy ees These sub contractors have 8. ❑ Demolition
I working for me in an capacity. e , 1 loyees and have workers' ❑
Y P tY 9. Building addition
[_No workers' comp. insurance _ comp. ;assurance.-
5. We are a corporation and its 10.❑ Electrical repairs or additions
required ] ❑ P
3. El am a- homeowner - doing-all work
m officers have xeTCSed their Jl.�Blumbing repairs or additions
self o workers' co right of exemption per MGL
Y comp.
12. [,00f repairs
insurance required_] t c. 152, §1(4), and we have no
employees. [No workers' 13.111 Other
corns. insurance required.)
"Any applicant that checks box #I must also fill out the section below showing their workers' coropensa ion policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afiZdavit indicating such.
- Contractors that check this box must attached an additional sheet 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' cour_ 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: ' �'� i.. ^..v " B , - I (
Policy # or Self-ins. Lic. #: " \ "'
'; 'e" _ Expiration Date:
Job Site Address: 11 ,1 L, w k° ,:-... (.' .. _ I'*- - q1 r , 1 '% c (", 1 -'� 1„
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 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51500.00 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. Ise advised that 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 pains and penalties of pezjury that the information provided above is_true.artd correct__
Signature: r , -- ,-- r ° Date: ._. .
-
Phone #: '` ; (7) , - - " ... -,
Official use only. Do not write in this area; to be completed by city or [own offzciaL
City or Town: Permit/License # II
issuing Authority (circle one):
L Board of fiealth 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Ins _
6. Other
Contact Person: Phone #:
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations_The inspection_process requires that the building department be called to
inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour). a rough building inspection (before work is
concealed). insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the buikling_permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
- -Date--
Address of work
location