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24D-129 ��/1eo�itrrrniirnea/!/r c�C'lcr��frrlrr�r//t Office of Consumer Affairs&Business Regulation License or registration valid for individul use only kW .ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: 104873 Type: Office of Consumer Affairs and Business Regulation piration7/15/2016 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 RANDALL E.ROBERTS GENERAL CONTR Randall Roberts 41 Hemenway Road Leverett,MA 01054 Undersecretary Not valid without signature v u Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Super%isor License: CS-042573 \``.Y 1 1� RANDALL E ROI$R 41 HEMEMWAY a Io LEVERETT MA;b1 Expiration Commissioner 0812512016 Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991M )of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPs 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 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 Names (Business/Organization/Individual): Randall E Roberts DBA/Window Works Address:321 Russell St City/State/Zip: Hadley, MA 01035 Phone#:413-530-2703 Are you an employer? Check the appropriate bog: Type of project(required): 1.❑■ I am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ 1 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 for me in any capacity. employees and have workers' insurance. 9. E] Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 131-1 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 doing all 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. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Wesco Insurance Company Policy#or Self-ins. Lic. #: WWC3104432 Expiration Date: 10/19/2015 Job Site Address: All Locations 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 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: Phone#. 413-530-270 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' 8.1 Licensed Construction u ervisor: Not Applicable ❑y C Name of License Holder: I t 0 b e-r— O 1 `v License Number Lf Address ^ e� � Expiration Date Signaftv Telephone 9:°=.a �s'tered,,, meb�m rove "tkCon'actort1". ; '`` Not Applicable ❑ � o c 000� Com an ame Registration Number�I Address Expiration Date Telephone a C-3567> SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L 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...... ❑ wher WREe , Ee>lnpt><.O.n 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 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 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 £ i J SECTIONS--DESCRIPTION OF.PROPOSED]WORK(check all applicable) r New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[O] Other[0] Brief Description of Proposed 1► 4% kl Fee 5 �. Work: ��'�G► t Alteration of existing bedroom Yes No Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basement Yes _JC_ No Plans Attached Roll -Sheet saROW house.~andJIGaddit on.to`exisfin'g} Qusl'ng comp[e#61hildli wing: 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 SECTIC)N 7a OWNER AUTHORIZATION„.TO,BE CQMPLETEDa WHEN , OWNERS AGENT OR CONTRACTORvAPPL1ES F4R aUILDN PERMIT p V �� 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, �� ��'� as Owner utho [Y Agent her by declare that the statements and information on the foregoing application are true and accurate, to the best of my Fnowledge and belief. Signed_u r the pain and GKlties of 'ury.�r C Print Name Sianature o Owne gent Date f , Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required bytning This column to be filled in by Building Department Lot Size i Frontage Setbacks Front E Side L: R:'' L Rn € _ Rear ° Building Height Bldg.Square Footage i % p Open Space Footage �-- % ----7 (Lot area minus bldg&paved parking) i I t t #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding eve 1pd for/on the site? NO DONT KNOW 0 YES 0 IF YES, date issued:' 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# t B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 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 NO 0 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,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. R .f `'ad nrx?, Departriret use`orlprk �� of Northampton Status o Rerrr�it � �� ' u ling Department �rb�GutlD�veway •: r � � dam. �� '� 2 Main Street SewerSep IC aIla6iflty� � �� ! DEC a 2014 �, Room 100 w #eNelCfi�aila T. Rs � r-- rth mpton, MA 01060 Two els E ec t . F l r i. ti � r p&hptq # - -1240 Fax 413-587-1272 PIQ SI ePlan APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1;-SITE.[INFORMATION �This section to be completed byoffce 1.1 Property Address: 3r 4 5 x 1 tt2 p Lot v Un x ✓ .i a.L k si giros § S"' S• �kZone � ""� 4 t Et1 St.�l7istr�ct�`'"� SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner}of Recrcord: Name(Print) Current Mailing Address: Tel p ature uthorized Anent- cc Name(P ) Current Mailing Addr s �, � Si re Telephone ad SE~N 3:ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to beOfrical Use Oniy completed b permit applicant 1. Building ©� (a):Bmldmg"Permit Fee r 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Builiing Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) % Check Number ' This Section For Ofriciaf Use Onl' Building Permit Number IIssued: Signature: Building Commissioner/Inspectorof Builiiings Date 237 STATE ST BP-2015-0628 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D- 129 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-2015-0628 Project# JS-2015-001209 Est. Cost: $2500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RANDALL ROBERTS 042573 Lot Size(sq. ft.): 6534.00 Owner: STEIN JUDITH Zoning: URC(loo) Applicant: RANDALL ROBERTS AT. 237 STATE ST Applicant Address: Phone: Insurance: 321 RUSSELL ST (413) 530-2703 O WC HADLEYMA01035 ISSUED ON.121512014 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 Sisnature: FeeType: Date Paid: Amount: Building 12/5/2014 0:00:00 $35.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner