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23C-010
• / ./ }� r , f• -: Massachusetts - Department ut Put)lie S:ttrt. ee, . th cl• ,. 1 •'La uaC/ LS� vet ` \ _ Bt an 01 ls lte:utdus and St: nth rds p Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR ''`z.-'' C ;onstru lot! Su .c -: isc ._ . c,_ { c = _ Registration_ 104873 License: CS 42573 I t r C Re stricted to: 00 Ex 7/15/2010 Tr# 277373 ;j c t ��. Type: DBA RANDALL E ROBERTS :13 - a : r 4 - 1 : RANDALL E. ROBERTS GENERAL CONTR 41 HEMEMWAY ! _ i Randall Roberts LEVERE I I , MA 01054 - ',_ .i 41 Hemenway Road .4CLc .— Leverctt, MA 01054 Administrator .. . t "InRitSfrittted to: 00 T r -: 1117 . License or registration valid for individul use :only 00 - Unrestricted before the expiration date_ If found return to: 1G -1 2 Family Homes Board of Building Regulations and Standards One Ashburton Place Rm 1301 ' oston Ma, 02108 �� - �` 3 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license_ ` " ? Lift Refer to: WWW.Mass.GovfDPS Not valid without signatur R f _. • • • 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 jermits in conjunction to the building 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 Date Address of work location , * , - • The Commonwealth of Massachusetts •■■•■■■ mmll■ Department of Industrial Accidents jilk ==f== in Z " =S" -1 I IV I 7■''''''. e Office of Investigations .. 7 i 600 Washington Street saw= * Boston, MA 02111 t..,, - , www.mass.gov/dia • • • ... -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name pusineseorganizationandivith.D: Address: ,- • City/State/Zip: - Phone.#: Are you an employer? Check the appropriate box: ' •Type of project (required): / LA I am a employer with -6 4. 0 I am a general contractor and I 6. D New construction have hired the sub-contractors employees (full and/or part-time).* listed on the attached sheet. 7• 0 RemodeJitif,r 2.0 I am a sole proprietor or partner- ship and have no :iloyees These sub-contractors have .8. 0 Demolidon employees and have workers' working for me m eny capacity. 9. El Building additiOn [No workers' comp. insurance 100 Electrical repairs or adclitions required.] .. 5. 0 We are a corporation and its 3. 0 I am a homeowner doing all work officers have4xercised their . 11.0 Plumbing repairs or additions myse]f [No workers' comp. right of exemption per MGL 12.0 Roof repair' s . • insurance required.] t c. 152, § 1(4), and we have no 13.0 o th e r employees. [No workers' comp. insurance required.] *Any applicant -that checks box #1 must also fill out the section below showing their companation policy information. — . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors 'mist submit anew affidavit 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-ccatractorshave employees; they must provide their woricers' comp. policy number. . . lam an employer that is providing workers' compensation insurance for my ethployees. Below is the policy and job site information. . Insurance Company Name: Ac Li 5 A • - • • . • Policy # or Self-ins. Lic. #: C. LI5S )07 A7 g Expiration Date: - /0:119 1 ' d ,„ L i- Job Sim Address:n i arLdit. iii-e-- City/StafriZip:'Nerfltarry-tem ) 144- 4 7 iz . L Attach a copy of the workers' compensation policy declaration page the policy number and expiration date). Failure to secure coverage as required under Sectiai'25A OfNIGL c 152 can lead to the imposition of Ciimin41 penalties of a fine up to S1,500.00 and/or one-year imprisonmen.t as well as civil penalties in the form of a STOP WOil.K-ORDER. and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offfce of , , _ ..,, _____ areitiziitioni of the DIA for insurance 60yirazi I do hereby certz;fr under the pains and penalties of perjury that the information providedaboveittrue_andiorrect._______ _ __ _ _ . . . Signature: ' . Daft: • Phone 4: 1 113 - 53o 03 Yee-(1) 1 -/1 3 - 75 - i?d- - 6 1 -14 6 - to F f7C&) • Official use on.ly. Do not write in this area, to be completed by city or town official City or Town: ". Permit/License # Issuing Authority (circle one): :1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other , Contact Person: Phone #: j . SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construc on Superviso . l Not Applicable ❑ Name of License Holder : N t l e� '`' Liz 7 3 II( 4 Q 7 License Number 25 G 0 Address / Expire Date ft s ?i e . ‘?.7 7 �� Signatur Telephone fi s`_.. 4 ,l w . ; i = w . a a1 .:.J ; . a .:,71 ax " ;.. ® w.. ; ;, m Not Applicable ❑ Company Name R Number r t°!� 4/, ' g / / {'✓'e -9tG /..L 7--LJ -- / � Address Expiration Date Telephone ii? - 5 ^,Z ? j,y y — 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 ❑ The current exemption for "homeowners" was extended 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 Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature s SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacemen ndows Alteration(s) • ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [0] Other [0] Brief Description of Proposed J (bci-("r2a r a Stc1�r Work: Ke P I ct (-)L tsF-r rbj 10 10 i rl�(c%t3.s (Ike 40 . -cc(l n -I-rt'e Alteration of existing bedroom Yes J X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet y ita a. Use of buildinC One Far:Lilly, . Two Famjly Other b. Number of rooms in each family unit: Number of Bathrooms Z- 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 4( I, � r - Yrl a ( p t2 d ne S , as Owner of the subject property �, r / � G r `J t► her - authorize ...1 I A . IA to i on my behalf, in a matt - - ive to work authorized by this building permit application. 04,_ 1 A S Si•naureo Owner . Date IP • A ` l C> ltt 'al , as Own /Authorize Agent -reby declare that the statements and information on the foregoing application are true and accurate, to the best o ge •elief. Sign der the pinsr penaltie perjury. Print Name / ;r 6 -- `l ' Signature, . • gent 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 1 ._j Frontage Setbacks Front j = Side L:; # R: _' L:I I R:` I , Rear = = i i Building Height = 1 i 7 Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved 1 1 77 1 . 1 i parking) # of Parking Spaces •° ---- Fill: - - . ...,.� - ,.�,.. . _ (volume & Location) 1 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: 1 . IP YES: • Was the permit recorded at theRegi try of Deeds? NO 0 DONT KNOW C.' YES 0 IF YES: enter Book € P age [ and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® ,Date Issued: C. Do any signs exist on the property? YES 0 NO 0- I 1 IF YES, describe size, type and location: P D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO drs IF YES, describe size, type and location: 1 E. Will the construction activity disturb (clearing, grading, e vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. L � , City of Northampton g , Building Department Main Street = = i , Room 100 , " � ray Northampton, MA 01060 phone 413- 587 -1240 Fax 413-587-1272 TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A 0 i , R I LO ILY DWELLING SECTION 1 -SITE INFORMATION p tu , ; P 1.1 Property Address: is se tt ip, qirt►plls llY office Map Lot - Unit I 'zone Overlay district BIM St District.:' CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Pa fnet f ee :Tones 6A. m& Na a (Print) Curren Mailing Address: Telephone Signature 2.2 Authorized Agent: 5-4 Pea r o 6 �3z/ p t�6 4 c- Z l / gal(.-1, N. e (Print) Current Mailing Address: ?'" 5 9d - 2 . 7 6 3 Vi 3 ",fgZ oi" Signature f / Telephone �� SECTION 3 - 'ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building te,e,© ` x � (a) Building Permit Fee 2. Electrical ( ` a (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection ri 6. Total (1 + 2 + 3 + 4 + 5) Ch ec k N umber $ ej Z �` 7 , Ali This Section For Official Use Only Date Building Permit Number: Issued: t i Signature: LL-^- T /�11d Building Commissioner /Inspector of Buildings;. Date i4 UMW AVE , BP- 2010 -1150 GIS #: COMMONWEALTH OF MASSACHUSETTS p: c c, c: 23C - 010 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 # BP- 2010 -1150 Project # JS- 2010- 001686 Est. Cost: $13000.00 Fee: $78.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RANDALL ROBERTS 042573 Lot Size(sq. ft.): 4704.48 Owner: JONES MICHAEL D & PARMALEE J Zoning: URB(100)/ Applicant: RANDALL ROBERTS AT: 54 LANDY AVE Applicant Address: Phone: Insurance: 321 RUSSELL ST (413) 530 -2703 () WC HADLEYMA01035 ISSUED ON :6/17/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK: REPAIR ROOF & SIDING FROM FALLEN TREE, INSTALL REPLACEMENT WINDOWS 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 6/17/2010 0:00:00 $78.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo