17C-092 (5) ' R ;y� ' � 40
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APR 1 14
INSULATION � zo
& �`
SIDING CO., INC. i S`
EASTHAiMPTON OFFICE 413527-0044 CSC, License #CS SL 99739 WESTFIELD 0!~FICE 4 P
56 FRANKLIN STREET • EASTHAMPTON, MASSACHUSETTS O 1027 • FAX: 413-527-1222
Propoeal Submitted to Phone Date
Tok�ln & Laura Ritt "PurGh er" 413-586-5664 March 28, 2014
stloal Job Name
122 Chestnut Street
City,Mate end Zip Code Job Location Job Phone
Florence, MA 01062
o::i w'*ui homby submits to P:icd c ipc,dfi ations and estimates for: INSTALL UION OF A NEW ROOF
HOUSE
:1,1G1(U Wi ' - Qt III a dUl:jp5ter sUWWIiQd by Us.
2-We will 11-04
u -i u
,s
We Will w5tall ijQV alUi2jimim drip QdUQ ou all eyea atid ije)&aluil3inui2i rake udge on rake areas,
We�sill kistall QW�)mximately(30)' c)f roll Vent m I)eak uf�QQf fQr additional vent'latim-
install W We bnots where needed,
r
PRICE $ 2, 53.00
** S DATF WIL L UE ABEBOXIMAJELY 8 WEEKS FROM THE �TF WE RECEIVE THE 500Q DEPOSITALONQ WITH THE
SIGNFQ CONTRACI LESS ANY r
kiF.2jk{M"NFFDFD THFRF WILL QE AN 16R.R.111QHA Q1MQE9E$38 PER SHEET TO REMOVE.-_
DDS F OF-AND INSTALL _ m
k
ATTIC.AS NF.LQLD: B0 1 QQ. l& ULBRIS FROM ROOF REMOVAL ._
ALL STAR IS NQJ R45PQN,-2lQLE EQB ANY LEAKS THAT OQQQB IN EXIST EYLIGHT,$(IE APELIQABLL).
*1-ALL STAR WILL SECURE BUILDING E NEEDED. HOMW)IYNER iYILL BE RE,aPQNSIBLE FOR ANY&ALL FEES
BEQUIRED
*hA _ _
DALEY INSUR6 QE&GENS.X9F WEST Se IINNGFIELD M 15 QUR 6QENT,
P
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): !/ V� I� �clli9f�j� r�i'(4C I _
Address: .5w �►�l /U
City/State/Zip: Phone #
Are you an employer? Check the appropriate box: Type of project(required):
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 construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working or me in an capacity. employees and have workers'
g y p m'•
[No workers' comp. insurance comp. insurance.. 9. ❑ Building addition*
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right ofexemption per MGL 12.❑ Roofrepairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.UOther
cornp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name ofthe 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:
Policy or SeIf-ins. Lic. #: L66ig � (It cf Expiration Date:
Job Site Address=fimom - sr wn Cjn City/State/Zip: /./-/A
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 ofMGL c. 152 can lead to the imposition ofcriminal penalties ofa
fine up to$1,500.00 and/or ore-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine
ofup to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
Investigations ofthe 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.
S igwture: C�".�.A,l,l}-�L'"�nn(1 C�.N.1'��� Date: �
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
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
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor: Not Applicable ❑
ti
Name of License Holder: 24 u 7)0 `-,Q tom'd'0 essz-— 09Y722
License Number
LArn
Address [ Expirat�ate'
��� o►�vvte� ��3�5`2��'�Y�
Signature Telephone
9.Reaistered Home Improvement Contractor: Not Applicable ❑
All aors.�nscI1&6w Ao/gsIF
CornDany Name Registration Number
Address f ExpiratioK Dat
Telephone Y
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....... 151 No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(1) or two(2)families
and to allow such horneowner to engage an individual far 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 ye Hod 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 ofthe work for which this pen-nit 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)ofthe Massachusetts General Laws Annotated,you may be liable far persons)
you hire to perform work for you under this pen-nit.
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 ofMassachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] ecks [ iding [❑] Other[o]
Brief Description of Proposed � �j
'�4VA -0
Work: C/
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
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
now—
I, � � ,� 1 J 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.
)
Print Name ,f
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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus b ldg&paved
parking)
#ofParking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW (2�/ YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 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 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excaysiton, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only ANON
112 0'4 i y of Northampton Status of Permit:
ilding Department Curb Cut/Driveway Permit
An
12 Main Street Sewer/Septic Availability
Electric,Plumbing&Gas Ins
pectlons Room 100 Water/Well Availability
Northampton, MA 01060
hampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
�� /") (,�r -p�,..t- ` Map Lot Unit
�( O
can ez>� i M A Zone Overlay District
T� l Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
--r—b o-k aLU
Name(Print) Curren Mailing Address: _
�-t! �3—5 [,,
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
4113 25� -Qi1 �
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (rl`$5 J 01 .pd (a) Building Permit Fee
2. Electrical O( (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
122 CHESTNUT ST BP-2014-1078
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 17C-092 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-2014-1078
Project# JS-2014-001849
Est. Cost: $2853.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALL STAR INSULATION & SIDING CO INC 99739
Lot Size(sq. ft.): 7013.16 Owner: RITT TOBIN C&LAURA A ST PIERRE
Zonine: URB(100)/ Applicant: ALL STAR INSULATION & SIDING CO INC
AT. 122 CHESTNUT ST
Applicant Address: Phone: Insurance:
56 Franklin Street (413) 527-0044 Workers Compensation
EASTHAMPTONMA01027 ISSUED ON:411812014 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE LEFT SIDE OF HOUSE 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 Siiinature:
FeeType: Date Paid: Amount:
Building 4/18/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner