10B-031 (3) a y
'
177 Pair -St
* f 01027 (413)-527-2443 tx
Complete Asphalt, Slate, and Rtibher Rooting S sterns and
din hininc\
Customer:
Shawn Gunderen
253 Wendell Rd.
Shutesbury, MA 01072
253-1478
Property 1 Evergreen Rd,, Leeds
Work to be done:
Complete house roofs NOT including garage:
Remove exterior layer of existing roofing material, where necessary.
Install white aluminum rake and drip edge.
Install Tamko ice and water shield on all cave edges.
Re-roof with Tamko Heritage 30-year designer architectural shingles, color to be chosen
by customer at a later date.
5-year guaranty on labor. 30-year Manufacturer's Warranty on material.
Shawn — We are currently scheduling for late March. Any questions, feel free to call
or e-mail. Todd
T otal Cost $ 6,515
(Labor and material)
Deposit required of: $ 2,100 I lomeowner:
Payment when 1/2 complete: $ 2,100 7
Balance upon Completion: $ 2,315 Contractor:
(Sign and return one copy with required deposit)
Make checks payable to: George Thibodo
Only top quality materials used — complete insurance coverage
References available upon request. All trash removed by
contractor. MA HIC# 107483
Service charge of 1.5% per month equivalent to an APR of 18% per annum applied to over 30 day balances.
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DEPARTMENT O BUILDING INSPECTIONS _. _ /_
INSPECTOR
212 Main Street • Municipal Building
Northampton, MA 01060 ,~ s`'`.
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction sups: :. isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he /she resides or intends to be, a one or two
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 any 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 fegulations. 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 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
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-- DEPARTMENT OP BUILDI INSPECTIONS • -
1 212 Main Street ' hMunicipal Building
i . Northampton, Macs. 01060 tr'
WORKER'S COM:PENSATTON C\ISURANCE AIFF1J)fi. \'1T
I 6ettlegi ,-,--,(„w, __.__.
• (Iicr is dpermittcc)
with a principal place of business/residence at: --
(77 � ( �_ fi /14( c7i6 .7 • (phone ) S�7- 4'yy.-�'
(strc iJdty /staicfrip)
do hereby certify, under thc.pa_ins and penalties of thal .
.
( ) I a an employer providing the followin'
m t
, worker's compensation coverage for my
• •
employees working on this job:
(L^s ran= Conccn) (PcLic: Nu.nDCr) (r : Dales)
( ) I am a sole proprietor, general contractor or homeowner (c tie one) and have hired
the coon listed below who have the following workers comoensahon policies:
(Name of Contncior) (lnRlrancz CoIApany /Policy Nand - Kr) (_ :pirauon Datc)
(Namc of Contrnor) (lns - nec. Comoan-y Po!icy Nunc_r) (E ). Date) ,
(Name of Conn (insuranc: Company/Policy Nusbu) (1=xpimtion Date)
(Name of Contractor) (Lasuraaca Company/Policy Numbs) (Ex Date) .
(attach _d i oo! bcct.ifnoocru.1 to fnc!u& inform.tioo portaiains to .11 coca - _coral .
1 am a sole proprietor and have no one working for me-
( ) I am.a home owner performing all the work myself.
NOTE: plese be ""2.m du! gal )e hemen.voc:s .a ho ccoplay prom to do mcr cr.:uao cr repair wont co a d of
not mote do= Clive tmitt is which the boo rtsida or co the c ouac„s+ zppurtensl tber -o car o% G-=, --.11y xcscd. —cd to be
l
caipoyca untie the ..a-S es e np�- -.+ Act GL1 Sts l 5
( ( )).:.pplinhon by . bomcnoac far: lieer� __ a permit rr:y cvidmx the
losof eta.'ua or an ccpIoyor uodrr die Woricola Coospomijioa. Act
1 uadaoand thud a Dopy of Chi. mtcmant m,.y be foro.nrded to the Do ...mm.0r of 1 , id Reckon tY OfLoe of t+a✓•nco for the
cova vcif atioo szvi this E itac to sa - uc'eovrrozo ttodct veeiioo 25 A of MOL 151 da lu.d to the is oraioo of criminal pm, trio
coosairs of a f °C up to s l SOO.00 ■ndfor isrprisoccolcact ()Cup to Doc yr r sad civil pw.hic is tic form of a Stop Work. Ordc acrd •
fin= of S 100.00 t thy aEatinA
'� jjj For dcgvtmY� ux only
,i " / / I�CTIII1f Nl1IDtX7
Sigtiatun of LiansaJPcrrniticc 'Date - - -
•
SECTION 8 CONSTRUCTION SERVICES +
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
- r - - � Not Applicable ❑
: fie :"fet`ome�m = ravem �� � " ;
Company Name
Registration Number __
/7 A4 .57 Z<A /ate
Address Expiration Expiration Date
G ; 5719k/ �`�vl f* 0;,' Telephone /3
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 ll
The current exemption for "homeowners" was extended to include Owner occupied Dwellings of one (1) or two(2) families
and to allow such homeowiiei 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 - vear 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
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) n Roofing KJ
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [►J Siding [O] Other [In]
Brief Description of Proposed
Work: f p
—1 `h( over Ce
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
-Fsn� `- .
sa:-Tf vewhousean r. ddi o d,,:extstinc 1. i t stnq comptetethe fotlowinq:
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 stones?
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: BUILDIING ;PERMIT
, 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
D , 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.
Signed under the pains and penalties of perjury.
V&
Print ame
Signatur ibf Owner /Agent Date
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Section 4. ZONING All Informatibh 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
i i'
Lot Size i '
Frontage
Setbacks Front I I I
Side L:' + R: La I R: 3
Rear I I
Building Height I 1 •- �
I _ i
Bldg. Square Footage ! I E (% I
Open Space Footage %
(Lot area minus bldg & paved i 1 I i I I =
parking)
# of Parking Spaces [ I
Fill: , 3 I { -
(volume& Location) 11 i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW ;gli 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 j I Page; 1 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained ® Date Issued:
C. Do any signs exist on the property? YES 0 NO ip
IF YES, describe size, type and location: I
l
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO k ilif
IF YES, describe size, type and location: z
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 r NO
i
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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City of Norti�;�mpton .
Building Department �P
212 Main Street F �°
Room 100
Northampton;MA 01060 e ' °+ phone 413- 587 -1240 Fax 413- 587 -1272
try & e 4 4, , . t.;.. t, --; :.. ...,... , n.. m`I£ .. r _^ » a
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
Th se ction t b coronleted by9ffice
1.1 Property Address: h 1 _
4 '$ ! _fl t k t 1 nt#
Zone Ouerla y y D tstri c t
1 +
',• EImSt. Distract CB Dis��c
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AG
2.1 Owner of Record: /� ' A! � /
gi,4'1 6/ s, „-, �S ✓Vt°9 1L PS j
Name (Print) Current Mailing Addre s:
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollars) toc be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical ( b} Estim Construct ated i on Total Cost m (6) of
fro
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection 77
6. Total = (1 + 2 + 3 + 4 + 5) Check Number ad a7,2_ OrS-
, This Section For Official Use Only
Date
Building PermTNumber Issued:
I
Signature:
Building Commissioner /Inspector of Buildings Date
BP- 2007 -0956
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -061 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2007 -0956
Proiect # JS- 2007 - 001557
Est. Cost: $6575.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: George Thibodo 107483
Lot Size(sq. ft.): 25221.24 Owner: GUNDUSEN SHAWN
Zoning: URA Applicant: George Thibodo
AT: 1 EVERGREEN RD
Applicant Address: Phone: Insurance:
177 Park Street (413) 527- 2443 ()
EASTHAMPTONMA ISSUED ON:4/11/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER 1 LAYER
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 4/11/2007 0:00:00 $25.002222
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo