36-181 Cc.SF:
1Th)iJ D
CITY OF
BUILDING INSPECTION DEPARTMENT
Construction Debris Affidavit
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work covered by a
Building Permit shall be disposed of in a properly licensed disposal facility, as defined by M.G.L. c.
111 § 150A.
DC ,,fk --
Address of Work: �CS(T 7�� b�� f1 I
The debris will be transported by: LLD r 7-=
The debris will be received at: z)/ L2 a S.-'_"7-L.1 ,cam ��' lei` ' ° ` '''''/'. "' �`;
I AM FAMILIAR WITH THE REQUIREMENTS OF 310 CMR
7.09, AND I HAVE MADE PROPER NOTIFICATION TO ALL
FEDERAL, STATE, AND MUNICIPAL AUTHORITIES
HAVING JURISDICTION.
Signature of Permit Applicant
1n --- I1
Date
Building Permit Number:
CITY HALL, 70 ALLEN STREET, PITTSFIELD, MA 01201
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.aov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual) VAN itt off
Address: 'a. 1A/0;,c6.5\--NA tz.i v
City/State/Zip: /116-N c.,w'\-b�J . {1A A D►oL,n Phone#
Are you an employer? Check the appropriate box: Type of project(required):
1. am an employer with ) 4. I am a general contractor and I 6. _New Construction
employees(full and/or part-time)* have hired the sub-contractors Remodeling
2.—I am a sole proprietor or partner- listed on the attached sheet. I —
ship and have no employees These sub-contractors have 8. —Demolition
working for me in any capacity. employees and have workers' 9. Building Addition
[No workers' comp.insurance comp_insurance. 10. _Electrical repairs or additions
required.] 5. .- We are a corporation and its 11. Plumbing repairs or additions
3. —I am a homeowner doing all work officers have exercised their
myself. [No workers'comp. right of exemption per MGL 12. —Roof repairs
insurance required.]t C. 152, ' 1(4),and we have no 13. —Other_
employees.[No workers'
comp.insurance required.]
*Any applicant that checks box I must also fill out the section below showing their workers'compensation policy information.
F. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
I Contractors that check this box must attach 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.
Insurance Company Name: /,I.cu u 4 C)-.14.-5L A�u 1,74 c.,�
Policy#or Self-ins.Lic. #: 4 5b1 •5112 Expiration Date: 1 '
Job Site Address: I/l p f e! 7� City/State/Zip:W6124-4 i p 7 6A 1fl&
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
S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a fine 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 Investigations of the DIA for insurance
coverage verification_
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature:<: Date: / 3
Phone#: G/i.3 --3(j I 5„..).5- eft
Official use only. Do not write in this area,to be completed by city of town official.
City or Town: Permit/License#:
Issuing Authority(circle one):
I_ Board of Health 2. Building Department 3_City Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
,� f
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS 89ch 2 3-/9--2014
G RA/'D n7q.l At License Number Expiration Date
Name of CSL Holder
*12. 2A/.DGJ5 TRIAL :D/i-ivC List CSL Type(see below) L�
No.and Street Type Description
KI Unrestricted(Buildings up to 35,000 cu.ft.)OR T HA fr 1 F'7-6 A/ /ti7AS5 O/C2O
C�,C�l2Y OIZ City/Town State,ZIP Restricted 1&2 Family Dwelling
IVAttiC �S M Masonry
Y
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
4/3-34/-5259 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
_ /6oS8r f 8-7-2.6 lc/-
YANKEE' A�A9E"2"/.41 =MEN r HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
82-MA/DUE 7x'1.4L.. 2.7/2.1t 1C-*
No.and Street Email address
NOI TH AM PTDAJ MASS D/O6L3 4113.3e//-5 59
City/Town,State,ZIP Telephone
SECTION 6: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 .❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize YA N( NOME X-MiReDVE-A4Eki T
to act on my behalf,in all matte relative to work authorized by this building permit application.
oN - CT _ _ , 3
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
Eg 'Y OR contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass_aov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
sEP 1 z 2013 ,-..1 ,
--":�' as inspections The Commonwealth of Massachusetts
Electric,Plu'nbr, a�A oioco Board of Building Regulations and Standards FOR
Northa ;S'6`�• MUNICIPALITY
�•�� Massachusetts State Building Code, 780 CMR USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 P rt ddress: el-zI-en Ce-- 1.2 Assessors Map& Parcel Numbers
1.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ,
Ail e-LA -A(lan.S_Olii/0 czo,:„...,,,, ,.,, voi,,, ,..,1 0 a_
Name( rint) City,State,ZIP
--W—D u ,.2 p / I) R_ 9.3'3 -2/e3,8
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building V Owner-Occupied ®- Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other illt Specify: R.66•-'(11 Ci
Brief Description of Proposed Work2: re_4(1 0 i'Q4- p-0001t1... G.ti b 5
ti e_,.,) 5k ,`vi 9Le-5 4- Gt, trees
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I.Building $ t 7( ) 9( 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All F s:
Check No. Check Amount: ✓� Cash Amount:
6.Total Project Cost: $ 3/ / q' ❑Paid in u ❑Outstanding Balance Due:
111 DUNPHY DR BP-2014-0310
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 181 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-0310
Project# JS-2014-000527
Est. Cost: $13199.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: YANKEE HOME IMPROVEMENT INC 89442
Lot Size(sq. ft.): 14984.64 Owner: MANSOLILLO ANGELA
Zoning: Applicant: YANKEE HOME IMPROVEMENT INC
AT: 111 DUNPHY DR
Applicant Address: Phone: Insurance:
82 INDUSTRIAL DR, UNIT 2 (413) 341-5259 Q WC
NORTHAMPTONMA01060 ISSUED ON:9/12/2013 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 9/12/2013 0:00:00 $35.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner