31A-257 City /State/Zi • : • i - C . / 1 hone. #: c .._( € 7 (3 S L'
Are ou an employer? Check the appropriate'box: Type of project (required) 1
1. I 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 colistztiction
2_ ❑ I am a sole proprietor or partner listed on- the:attached sheet 7. ❑ Remodeling
ship have no employees These sub - contractors leave. g.Ii$on •
working for -me ui any c l oyees and 3zave workers'
' iT/CiTrant'C - . Cn np. n 9 . 13ii11 AdY ; .
required 5. 0. We are a corporation and its 10.0 Electrical repairs or add'iti'on
Officers have their ❑ nng repairs or additions
3. [] I am a homeowner doiag all work , 11 PInmb r
myself [No workms' comp_ • right of exemption per MGL
12.0 Roof repairs
insurance required.] t : .c. 152, § 1 (4), a nd we have no •
h`I.
employees: o workers'' 13_❑ Other r
Y
• • comp. insirance regtr ed.j. '
`Any applicant that checks box #1coust .also fill out the section belowshowing t aworke s'..compeasatian policy information:
t Homeowner' who submit this affidivitingriewt4ai they are doing all work and then hire outside contraetols nmst subnut a new affidavit indicating such.'
that check this box must attached an additional sheet showing the name of the sub contractors and state whetheror notthose'entities have -
employees_ If the sub - contractors save employers, they must provide their workers' comp. pa Hey number_
lam an employer that isp.roviding workers' compensation insurance for my employees Below is the policy and job site
information. -
Insurance Company Name: . j j r... ./' dl 7i,e ✓, .L
Policy # or Self-Ens. Lic. # v) . .'� °. _ j �/ 71 v J I s / — 1 I ton Date � C • X27— - 3 f
Job Site Address: 3), iki'°"i � t • f City/State/Zip :`. d . `� `11.1p, ' / y► . . // G,
Attach a copy of the workers'' compensation policy declaration page the policy number.. and expiration date).
Failure to secure coverage as required under Secttoa25A ofMGL c: 152' can lead the imposiition' cnmiu I penalties of a
fine up to $1,500.00 and/or one -year imprisonment; as well as civil .penalties in the form Oa STOP 'FOAL-ORDER and a fine
• of up to 5250 00 a_ day against the violator Be advised tliat a copy of this statement may be forwarded:to the •Off`ee of
1"nvestigations ofthe DIA for msurance` coverage verification: .' :_. .,.. , .; _, ,._
I do hereby cerh, fy _ �thep� p ' ofpe j y that the ucfonn ation pro w deilb ls trur a n Lcb rr,a�f '
'.J
Signattr • ate ` 1 �O — t t • .
i /�
P h o n e #: 3 � �3' "- (' e 731 � Cam- ._ . _ _ ..
Official use only. Do not write in this area, to be completed by city di- tow offccdaL
' City or Town: Perndt/License # •
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town CIerk .4. Electrical,Iiispector 5. Plumbing Inspector
6. Other F
•
Contact Person: Phone #:
um WVIII IV Ui aWVt, DIJ�,vuivuuvia� ...... ....... - .E -.
$5250.00
$ - 2000.00 down payment amount
$3,250.00 balance due upon completion
Authorized signature: j ��` J J_ .-.._ y date y 4 j i
Customers signature:
date
Please make check payable to N.R.B. Exteriors, Inc. and mail to N.R.B. Exteriors,
Inc. 7 Philip Cir Granby Ma 01033
SECTION 8- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( Not Applicable ❑
Name of License Holder : tP a `r1) t l./L ` ( Cl t C A C S
License Number
7 : 1 1( r (�
P ✓ 1 v4 fiA_L ( / t C 3.-0V--- ) 3
Address' Expiration Date
_r. 2
1/ 5t. ?-4 -3 1
Signature Telephone
9 Reai i otne r nrofiiiiient nfth o ~ MEZ , ; E " -Z-, _ Not Applicable ❑
Co p a n g Name l Regi Number
c / . / GL
Addr1ss 7110,/f77L. I i t f i V b,/,,, } L Expiration " Date I
T elephone 51 , j .l .1
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 ❑
1i . m �€ erJ i p
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 1083.5.1.
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
SECTION 5- DESCRIPTION OF PROPOSED WORkjcheck all applicable)
Y ` '-Cz t /^
New House [l Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [0] Other [o]
Brief Description of Proposed 0 gto + 66r ` ` 4./ 4 ,
WOrlu� ,��� `.r �.. K X��'1 l�ti � "- J� 61
Alteration of existing bedroom Yes _ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a ItiVe .hOti 'iiilt C ttdi d ri iiditltlq 'tO iiiii 1 ooR1C Etethe:fai]O'' fQ:
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
1, a ✓r 1/'C f , 'Cl 4 /11 4- , as Owner of the subject
property ,'
hereby authorize !lM 6 -04/.--v i L / A. (
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date Li -- c '--- 1 1
I, l U t j? -6(-1-(4'0,-" l k C. , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signe under the pains and p nalties of perjury.
rint Name _ (, r L t
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Info(�rt f`ttpn -...
Existing Proposed Required y Zoning
This col Iv i
a,
Building D artment 1i 10 cl ,�
Lot Size t f or :;
. .
i
Frontage l ._..._
Setbacks Front ; i 1
Side L: . R: t L: R:1 i I
Rear ,
Building Height i [
Bldg. Square Footage 1 1"" - ' - 1 % I I 1 I
Open Space Footage , %
(Lot area minus bldg & paved E
parking)
# of Parking Spaces 1 ,
Fill: _... ... ,.� . .,.-- ----1 r' , — ...,. -
(volume & Location) I k ` i
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
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 s Pag and /or Document # N
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
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
IF YES, describe size, type and location: E .
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 . f
D ity of Northam LT ° ' a
• - ?.uilding Department a b _ -'E 4�x
212 Main Street ' m ix
pis „ 6 2011 Room 100 - p ° !�
o ampton, MA 01060 ff P
,:r1: 3 -' :7 -1240 Fax 413- 587 -1272
DEPT. of Bu--- ;MO, ?:
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
{�
3 �- d'ci�` Map` Lot Unit
A! V /� 4
Zone Overlay District
' EIm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
-1° ( ti l .e .. ,): (1 f\)0..' 4 r „ - it./ /IA du 3 d led,.
Ne (Print) Current Maili Address:
� ..l 1 Z.,. t l e . q ��-e e� .n.,-i, 1 Telephone v y ,,,s.,,._ 0
Signature
2.2 Authorized Agent:
N I'S ,� r s � �9 (l ' o ✓ � 5� ti el.
Name Print Curre t Mailing Ad re
Sig ature 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
' 5
6. Total = (1 +2+3 + 4 +5) ) S C) . Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
32 PARADISE RD BP- 2011 -0804
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 257 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2011 -0804
Project # JS- 2011- 001324
Est. Cost: $5250.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NRB EXTERIORS INC 99565
Lot Size(sq. ft.): 82328.40 Owner: SMITH COLLEGE OFFICE OF TREASURER
Zoning: RR(56)/URC(44) / /EU /WP Applicant: NRB EXTERIORS INC
AT: 32 PARADISE RD
Applicant Address: Phone: Insurance:
7 PHILIP CIRCLE (413) 563 -6354 WC
G RAN BYMA01 033 ISSUED ON:4/7/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR REAR SECTION OF 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 4/7/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner