31A-209 4 T
BAYSTATE RESTORATION
87 SHATTUCK RD
HADLEY MA 01035
(413) 549 -6824
CS 89485 / HIC 165549
vt17/ CIA
DATE:10
PROJECT: DEENA SARVET
#25 HARRISON AVE.,NORTHAMPTON
SCOPE OF WORK
REPAIR ROOF ON FRONT PORCH $1000.00
STRIP OFF EXISTING SHINGLES
INSPECT STRUCTURE FOR DAMAGE*
COVER ENTIRE DECK WITH ICE& WATER BARRIER
INSTALL NEW DRIP EDGE
RESHINGLE W /30YR ARCHITECTURAL ASHALT
SHINGLES FROM CERTAINTEED
SEAL FLASHING ALONG EDGE OF WALL
*IF PLYWOOD IS NEEDED OVER DECK $200.00
RE- SHINGLE GARAGE $4400.00
STRIP OFF ALL ROOFING
REPAIR DAMAGED AREAS IN DECK
ICE & WATER BOTTOM EDGE OF ROOF DECK
FELT REMAINDER OF SURFACE
INSTALL WHITE DRIP EDGE
LAY 30YR ARCHITECTURAL SHINGLES
OPTION
CUT IN RIDGE VENT �' 0 1
PERMIT FEE $80.00
c(frO
ail
/ a kit Io
CAL _ _ + -•rr
� � f
w ,
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
iermits 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
I, 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
...... ,..
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations •
600 Washington Street
Boston, MA 02111
,_........,...
www.mass gov/a'uz
. -
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizatim/Individual): r eAq sAi-L-5 EiLk.42-itpx. Pcs-Rs2A-1:2 .
• Address: 2? skct au ck--- 4( . •
City/State/Zip: ( 1 _ /44— &all Phone #:
ppropriate box: •
Are you an employer? Chec . . .
4 Type of project (required): I
4. 0 I am a general contractor and I
f3Ecri a employer with 2 - 6. 0 New coistruction
have hired the sub-contractors
employees (full ancVor part-time).*
listed on the attached sheet. 7. 0 Rtmodeling
2. 0 I am a sole proprietor or partner-
These sub-contractors have
ship and have no .e,loyees 8. 0 Demolition
working for me in any capacity employees and have workers'
9. ErBuilding additiOn
[No workers' comp: insurance
i
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers havetxercised their 11. il Plumbing repairs or additions
3-
myself [No workers' comp. right of exemption per MGL tr.
1 . 4 ,1 • . d repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance require4.1.1
*Any applicant.that checks box #1 must also fill out the section beloW showing their woricers 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 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' comp policy amber.
/am an employer that is providin g workers' compensation insurance for my employees. Below is the policy and job site
information. / / 1
Insurance Company Name: C4fa 1- 4-Cililpe...11
Policy # or Self-ins. Lic. #: OC...-- //, 37 13 Expiration Date: - 2r/77)_0, if
,,.,
Job Site Address: A gilf irtSo Alit' . fqz-iha,,,,k, City/State/Zap: . 6(c)&13
Attach a copy of the workers' compensation policy declaration pag,e (showing the pplicy naiaber and eaRiration date).
Failure to secure coverage. as required rind& Sectinii bfMGI, c. 15Z can lead to the irapositiOn of Ciimhial Penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil - penalties in the form of a STOP woRK QRDER. and a ate
of up to $250 00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Inireitiatiolis Of the DIA foi insurance coverize verification. _ . ... _ .
fdd hereby .:67 lilt t 1 e pains and penal.ties of perjury that the informationprovk I e d Abov ' _antLcorrect _
• 1 0 .
Si- . .ture: .' . irite- / ..tai 0
Phone #: 5T, - - 1617 - 4 - -
• - Official aye only. Do not write in this area, to be complet.ed by city Or townOfficiaL
• 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 . fr• .
■
Contact Person: Phone #:
a,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
b - Q
Name of License Holder : �C
&r) Fi fc
�] License Number
S. tnt cck- P . 3 /C iao l Z
Addr ss Expiration Date
' �•g��
Signature Telephone
9, Reaisterezl titn ilntpro� ert ent daiiiiit*A4ccamieutaigt i agMeAMV Not Applicable ❑
Company Name Registration Num er
Fig. ' 3/1 �►�-
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152; § 25C
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 Ro ❑
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
r
as
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition [] Replacement Windows Alteration(s) ❑ Roofing -- - --
Or Doors CI
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [01 Other [0]
Work: k: Description of Proposed r I I + r
wor �� ,)- 5 of I�t l(r✓U ,
Alteration of existing bedroom Yes Le° No Adding new bedroom u Yes No
Attached Narrative Renovating unfinished basement Yes 10 No
Plans Attached Roll - Sheet
ii.irtreiiiietielifiti, ..aaditlarios kr ina + this raiiii e�the feArCtwihq:
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
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, q lSOi' as Owner /Authorized
Agen herebyby declare a that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sign under the pai nd penalties of perjury.
IN
LW 4 s
AAA JAA,_ 11 Iasi /10
Pri N me
Signature of Owner /Agent 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 i I i 1 —.'
Frontage ` i i I
Setbacks Front ( 1 E i
Side 1..:1----i R: f L: .Y._.= R: : L..„_i 1 J
Rear
Building Height i
Bldg. Square Footage 3___.____, I 1 % "' rnsi L 1"
b
Open Space Footage t %
(Lot area minus bldg & paved G r 1 .
parkin
# of Parking Spaces € i -
Fill: - _ — _ -.,..._ , .,..��..n..._..,��... �. ; < ...... _ _ ,_. ,-.. II (volume & Location) - -- ,
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW e- YES 0
IF YES, date issued:! 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I ! Pages and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
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. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 58--
IF YES, describe size, type and location: 1 .
E. Will the construction activity disturb (clearing, gradin• -xcavati•n, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO re/
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton "' �F ,
Building Department '° b 2 . 2r
-trams P 11 ,E 3
212 Main Street t t
LU
\O Room 100
I `' -} Northampton, MA 01060 , . , , '
phone 413 -587 -1240 Fax 413 - 587 -1272 w gyp"
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map Lot Unit
} -
Zone Overlay', District
/"
Elm St Distrlet CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owne
1O_ t/,E�l 1
r of Record: L L d ' / I
�e a4 5 f�t (Yl3c,,, ! ' _ / 'vCic`I-KA.,.,P -P,-,
Name (Print) Current Mailing Address: a0 _ D-g644
Telephone '1
Signature
2.2 Authorized ent:
(C14-49-0 , r44KiSc‘isc
`Z gitaTitick-- 12cL- lt
Nop- r t) Current Mailing Address: ( f
Si 'nature Telephone
SECTION 3 - !ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 54/ (a) Building Permit Fee
7
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) >"(32), (45 Check Number 3J
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings, Date
-imp •
BP- 2011 -0490
GIS #: COMMONWEALTH OF MASSACHUSETTS
4 _ atA4209 ' 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- 2011 -0490
Project # JS- 2011- 000803
Est. Cost: $5480.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD PALMISANO 89485
Lot Size(sq. ft.): 12371 .04 Owner: SARVET BARRY D & DEENA E
Zoning: URB(100)/ Applicant: RICHARD PALMISANO
AT: 25 HARRISON AVE
Applicant Address: Phone: Insurance:
87 SHATTUCK RD (413) 549 -6824 WC
HADLEYMA01035 ISSUED ON:11/29/2010 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:
FeeType: Date Paid: Amount:
Building 11/29/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner