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23A-052 (3) City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: Ig, u-)z,,�f C -• St The debris will be transported by: 7 Trt�,�.•e etl�, c.�ks.sfi� The debris will be received by: Building permit number: Name of Permit Applicant -- ? 10 Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): PC",,U --ts 2,00 S Address: QO ?� t3 City/State/Zip: Phone #: ct:Sq S Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. KI am a general contractor and I 6 ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 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 for me in any capacity. employees and have workers'comp. ❑ Building addition [No workers' comp. insurance comp. insurance. 5. F-1 We are a corporation and its 10.❑ Electrical repairs or additions required.] 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.[R 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. tHo meowners 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: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: 0 Uj e «- CV O City/State/Zip: VC-1 " nk 01069 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. Sip-nature _...___. Date: _b k) / Phone# �3— 4 3�S 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 Supervisor: Not Applicable £ Name of License Holder: 1 " /oC,33i License Number ED Q--czn ►,-c?5,1;. t t ?� 6 MUD Address Expiration Date 3_ Ci S Sig ure Telephone 9.Registered Home Improvement Contractor: Not Applicable £ Company Name Registration Number Address Expiration Date Telephone OA5 3`4 S 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 Attach Yes....... No...... £ 11. - Home Owner Exemption 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) 7 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 1:1 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [[31 Other[0] Brief Description of Proposed Work: Remove&replace existing shingle roof with new architectural shingle roofing complete with all associated flashing details Alteration of existing bedroom Yes x No Adding new bedroom Yes x No Attached Narrative Renovating unfinished basement Yes x _No Plans Attached Roll -Sheet 6a, If New house and or addition to existing housing, complete the fallowing: 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, Kerry Raivel as Owner of the subject property hereby authorize Roberts Roofs to act on rpy behalf,in all ma rs relative to work authorized by this building permit application. jtJ l� S signatu ° er Date' I, Kerry Raivel 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. C� 9AIVE-(-- Print Na I-61b Sign ture of Owner/Agent Dat ` REVEL --D Depart ttent use only ity of Northampton StattaaFf rmlt 'j `z ilding Department Cerro GutJaivawy Ise it ',T ? 212 Main Street serlSt►cAyat1611tty Room 100 Water/WellAitabll�ty DEPT.OF BUILDING INSPECT?oNSNo hampton, MA 01060 �,�t>5ets of Structural Plan NORTHAMPTON M o, 87_1240 Fax 413-587-1272 Plt1t/ tta`1�ianS Cutter Sperrlfy , ., APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: 18 West Center Street Map Lot Unit Florence, MA 01062 zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Kerry Raivel 18 West Center Street,Florence,MA 01062 Name(Print) Current Mailing Address: 413-570-3121 Telephone Signature' 2.2 Authorized Agent: 9'�j ,Al ` y t�CJ A 1131' -- F,�r� Ctl c ti�� /'w Ot GOB Name(Print) Current Mailing Address: S' nat Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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=0 +2+3+4,5) 12,500 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 18 WEST CENTER ST BP-2016-0540 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A-052 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-2016-0540 Project# JS-2016-000897 Est.Cost: $12500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ROBERTS ROOFS CO INC 100333 Lot Size(sq. ft.): 10759.32 Owner: RAIVEL KERRY F&PATRICIA M MALONE Zoning:URB(100) Applicant: ROBERTS ROOFS CO INC AT. 18 WEST CENTER ST Applicant Address: Phone: Insurance: P O BOX 1312 (413) 283-4395 Workers Compensation BONDSVILLEMA01009 ISSUED ON:1012012015 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 10/20/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner