35-245 (Complete Asphalt, Slate, and Dubber Rool ili _!. and
Repairs, Sidin Chiulnev I'ointin;! and (inners
Customer:
Jon Western (roof quota)
27 Ladyslipper Lane
Northampton, MA 01062
586-3917 p I -°°1 Work to be done: �yl 3 t 41 f
Complete main house roof only: V� fl
Remove and dispose of existing layer of roofing shingles. � t, �� ,� Q6
Install new white aluminum rake and drip edge. g
Install "famko ice and water shield on eaves_
Re -roof over 151b base sheet with Tamko Heritage 30 -year architectural shingles.
Re -flash and /or re -seal along all protrusions.
Jon - ,Anti' questionv, fuel fete to call. We are hooking for early to mid October..
Total Cost $ 6,940
(Labor and material)
Deposit required of: $ 2,200 Homeowner: » Z GR� la
Payment when V2 complete of: $ 2,200
Balance upon Completion: $ 2,540 Contractor,'" .
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 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
— pets- in-- con}unct on._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
1, 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 roe.
Address of work
location
, e.rell■ .
The Commonwealth oplassachusetts
Department of Industrial Accidents
I / ......4.... ii
R ....1,4111 r Office of Investigations
k == a1 - _ — , 600 Washing,ton Street
• --_1...if----1
Boston, MA 02111
www.mass.gov/dia •
WO
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician.s/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ri g)‘ 70n
• Address: f:5 ..- - --- (cle,/ -57 .--
City/State/Zip: 6iet(-42(P /0 0/ 3.0/ Phone #: '77S
Are you an employer? Check the appropriate box: Type of project (required): l '
1. D I am a employer with 4• D I am a general contractor and I
6. 0 New constniction
have hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet. 7• 0 Remodeling
2. I am a sole proprietor or partner-
These sub-contractors have
shin and have. no , --nployees 8. 0 Demolition
employees and haN workers' . . .
working for me in any capacity. 9. Q Bung addition
[No workers' comp. insurance c° ins 131.233 e ,I - . . _
required.] 5. 0 We are a corporation and its
3 0 10.0 Electrical repairs or additions
. 0 I am a hom.eo-wner-doing-all-work — _o_eficar,s l asdst_d_thir____
ave tx_e
1 - I - . 0 Plumbing repairs or additions
. .
right Of exemption per MGL
myself [No workers' comp. 12.N Roof repairs
insurance required.] t • C. 152, § 1(4), and we have no
employees. [No workers' 13. Other
comp. insurance required./
*Any applicant that checks box #1 must also fill out the section below showing their workers compensation policy information.
t Homeowners who submit this affidavit indicating they are doingall 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 number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
_information. _. _
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date: -
Job Site Address: City/State/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 25A 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 TIF:
of up to $250.00 a day against the violator. Ile advised that a copy of tbic statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
_ I do hereby certify under the pains tuld penalties of perjury that the information provided_rzbove_is_true azuleorrect_ ___ _
._... i
Signature: 44/10 11111v- < Date: / /
Phone #: 9/3– 77-C 77Z5 -
Official use only. Do not write in this area, to be iiiilitid by city or town official
City or Town: Permit/License # -
Issuing Authority (circle one):
• I. 1 Board of Health 2. Builtling Department 3. City/Town Clerk 4- Eiectrical Inspector 5. Plumbing Inspector _
6. Other
Contact Person:
Phone #:
1
• .
s
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : a) K Y�� / 7 /
License Number
Y -5 . '' 7 / frel 1
Address Expiration Dat
6 /-'
i /114- c' /3411
Signature ,.J n -, Telephone
-- 77< — _'
9.. Retifstered. Home im / p � rovementCon nt ti l acto � `r• Y ,:',04,2i / __ . .�., . ,.. . Not Applicable Q ❑
� 'j']
Companv Name Registration r
mb
AIL, Si -7' Ri� /v
■ Address, �f Expiration ate
( 4 ` t 05 Telephone ?
_ 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
i a ou ex` - X fi , en
The_current_exemption for "homeowners" was extended to include Owner- occupied DwellinEs 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 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
- , . .: il _ • , , , • - e
_r-al�L-aws-Annotated.
o amp i5 i r • mane , "� a em • _ o
Homeowner Signature
1
t f-
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition El Replacement Windows Alteration(s) ❑ Roofing 4i{
Or Doors E 7`C'
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [p] Other [ID]
Brief Description of Proposed ,,
Work: jet s lat APV- Fest( ,
Alteration of existing bedroom ` Yes `• No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓No
Plans Attached Roll - Sheet
.1f NewbotAe4ncroi4dditibrtio :'existtini tiousing oinptete thelottoviing
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 C ® MPLETED 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, � � C17 ���) a s Owner/ uth orized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best o my kno dge
and belief.
Signed under the pains and penalties of perjury.
1 0 0 )} ' `
Print Name
/Ammar i
Signature of s ; ner /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
Frontage- - ...__._, - ._-.. __. _..____....__..x.__._. ...... _..
Setbacks Front
Side L :_... -.-_ _ R.- -_ L::____ ___ R:L... -_._,
Rear
Building Height ` " ---
Bldg. Square Footage __ % ._
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces -- ---- -- - -- - - --
Fill:
(volume & Location) .._.m..__ _..-
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW to YES 0
IF YES, date issued: _I
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 DONT KNOW 0 YES
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 (3 NO ,,10 .
IF YES, describe size, type and - location: -
" -.`- --- — D: - Are tie any propo c !tinges to or a itloris o signs intenaed the property ? YES 0 NO fill
�
IF YES, describe size, type and location: :4
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 /A!
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
i" -
0 Deparent<P�onlr
�` f Northampton Stat P e
-° Bu�dg Department Ct Dri �errt�tt
212jMain Street
2 (3 t- ,`'' . Room 100 w va 2 ? � `�f r � '' ■ C; 4 ` Nortbim t MA 01060 p � ` A a rf x f a rt y , � ` � � >„ 3
p
pho .3 '7 -124 Fax 413- 587 -1272 I� a s ,F _ § :
— ..r c , 1.',1", `C� ., er , 9: , - � ' � ,- -, r 4 k
, APPLIC
0,-,,, ION 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
-- ; , ,7 L1' 14,-pe Map Lot Unit
Zone Overlay District
Elm St >' District GB - District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Recor0:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
5 taY % S. 4 / 51 eenf /i pi 30
Name (Print) Current Mailing Address:
�' ( 43 - 775 R 77
Signature ` Telephone
SECTION 3 IMATED 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) /l/9 Check Number ��/ 0 5
This Section For Official Use Only
Building Permit Number. IIsssued:
Signature:
BuHding - Commissinner/Inspector of Buildings Date
r �,.
to,Y 4 r BP- 2010 -0446
GIS #: COMMONWEALTH OF MASSACHUSETTS
;. �.. CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catego BUILDING PERMIT
Permit # BP- 2010 -0446
Project # JS- 2010 - 000603
Est. Cost: $6940.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TODD BOYNTON 079221
Lot Size(sq. ft.): 38202.12 Owner: WESTERN JON W & JENIFER E URFF
Zoning: SR(100) //WSP II Applicant: TODD BOYNTON
AT: 27 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
83 SILVER ST (413) 772 -8829
GREENFIELDMA01301 ISSUED ON:10/21/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:1NSTALL NEW 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 10/21/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo