12C-038 T' P- 110 N III-: U i UP 0 V EIN i EIN,-1, INN C.
5-5 Granby Road*Sou nh A,01 15
CSSUI IMME I Of Ho-e-.41 3-532-76011 fax:
IVA%to.j43099 NPHKi Vt;rzcpn.n:,,
CT P=pOAS73197 IB Memb--T
Name: a t
Street A dress:
2:,,P
71 utter
Telephone: 'Uell:
e,m a I:
PROPOSAL F*
OTHE
R
RE-ROGF 7
iers: od: Yes orNc#—
COMPLETE ROOF J'3RC7EC7t0KI SYSTEIVS':
MAII proper permits shaU be obtaiied.
Cardiftates 9,7 Insurance provided
1,5DOIT',
;yProper Measurements Wil!bataven,ic Dro"Iec,helme
-7
and property
tR-NIPP.,S its remo%--CI�re-l-,Sysiev'r.ic vwocd;de:,*,ing
SProvide ho-ne mvner with full ex-mrior inaneation
-S Any unsafe or decaped deck boa-ds or wiNt�,
replaced at$3.25 per sq.foct(vtfth cust^mer zpprova�)
-M.-fqP,Ht will leave the horneowner wit
-h a sz-'✓and Clean
enwiron-nern a.the end of each work-dal!
4,qPLH?I will perforrin a final clean up-with a rail mag-ne,",w rcemicvs-any nails.ieft be'n"rIc
Ad"Project waste shall be removed
ty dum,.�pst-r k"dumps"'er for contractor use
0 0 F S 11s 7TEfe,
install Ice and water shie;.Id 3" 1! -0 2 accardin,-tc- :-eq i-q,
lnStaL40e 1R ter shield around pemetrations,chimneys, F.Id in at:vall°-vs
Maftejor bravm drip edge will be ins.ajje7>.ol).
eaves bib underlavrne n-' f c�t )jLzcl,
Inst"O Precut starter strip shingle or,rajes am-�
insta,?i-1doevent - in-t7y -7 M
Step flashing will be installed in call ne areas
tnstai4 t-ead counter fiasning on chimney
SHINGLES z
Lifetime Ultra Lifletirne GAF Ridge Car 'M
- Si mqla C,r-,:o i—
trVARRANTY:NP HVMe
9r4 i7 'he ab--,,--
%
wa--ani)t. -his estmaie is vajij,C,-15 days.
13 Extended vva7i2n,'-$275. DGr year 3Y
W Popose berebv to.firrfth m nd a=;,^Qan:e k,,,fthi above I
e r
specifications for the sum of: ban
Dowr. Pavrren,Z,,
Acceptance: T he above price,spe�.fications and conci;,Oon ars �,nci are ilerevx,. aocented,
Paent MR be V
pm S dawn upon signing, anid balancs. lue y?
o^. U-nai-baian
n -i , C�--S Shall 2C.^(:c
v"rith. Mterest a f^304Z o, -=,annam- Pum-laser(S'l I-ViN Da",f.lr sE expensas ain� asonable a,txnev's
h =�siz
'fees Incurred by N.P Lj -e C �A-cSVS7 artv Su."t5 du
-Sir
g iai r--
7
zft
o�
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: 2T�, Qo& Kitole C 2 1- . K EAlicinipkr)
The debris will be transported by: &)1-Y10e4
The debris will be received by: Cc ll V(e it hL 1-1�A
Building permit number:
Name of Permit Applicant Wnq E' 1 "Y)OMIDIIE'1
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(B usiness/Orgmiaation/Individual): � � �OME ID -MD r
Address: 515 Q Mnbu Rd -
City/State/Zip: �h Phone.#: y�V 552-71kO
Are you an employer? Check the appropriate box: Type of project(required):
1 .I am a employer with 4. Q I am a general contractor and I
6. New construction
employees(full and/or part-time).* have hired the sub-contractors ❑
2.[1 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, Q Demolition
working for me in any capacity. employees and have workers' 9. Q Building addition
[No workers'comp. insurance comp. insurance.$
required] 5. Q We are a corporation and its 10.E]Electrical repairs or additions
3.Q I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.Q 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.
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: A-_ P1101.r Irmo ante. -TYlr —
Policy#or Self-ins.Lic.#: a Expiration Date:
Job Site Address: City/State/Zip: h(JMOtm M,4.Gin
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 certi er the pains and penalties of perjury that the information provided above is true and correct.
Si tore: Date: Il _
Phone#: y I?�-
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):
I.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 0
Name of License Holder: i ����� E�� `'�J�, 1 Wi l
License Number
917) G RCS �• I�ar�le� HA oacq<3 q1 1 I DO("
Addr s Expiration Date
R
yl3 a IPA
Signat re Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
N .P - +lo rn C m p(Dut�r=:n+ Inc 14309`1
Company Name I Registration Number
_�`�5 C,V-ranb�� �d NadVLJ , IWA ni g (L� [(d I(,
Address Expiration Date
Telephone Li I b3
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....... )I 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 10835.1.
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)
New House ❑ Addition ❑ Replacement Windows Alteration(s) El Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding M] Other[Q
Brief Description of Proposed mrm Cwrrta+ Sky i$V�t3
Work: f I� �t � P I C! I n`4011 �) <,�Cta6'W'S ail li'1` a 11 Q ffLJ r'ty� Sy,je yj
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
l NAL k as Owner of the subject
property
hereby authorize �1'.P• HomE :1.-T�rnP(n nm+
to act on my behalf, in all matters relative tow rk authorized by this building permit application.
�
��4t
Signature&Owner Date
I, ►V N(�Yl'] �t !��( i,1�1P��}'l i �l7 C 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 Nam
ig at 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 bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW 0 YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,ex vation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YEE O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
,City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
_- - 212 Main Street Sewer/Septic Availability
Room 100 Water/Weil Availability
NOV N rthampton, MA 01060 Two Sets of Structural Plans
phone 13 587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
VTC
ppGiTHA
ATION 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
2 Sd KfOr-41n HAple 54 - Map Lot Unit
M0 rt-1 ko ry0m , N1 A 0106-0
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MARY SIR 6 2$B ►y6etln Pl"lc , MDdf)arn03n
Name(Print) Current Mailin Address:
H11 - 70%
G1 w E—a C-A,+rnc� Telephone
Signature
2.2 Authorized Aaent:
KI-P� Q M AIL 11)C , b l,5 010
Name(Print) Current Mailing Addr s:
Signature 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) Or)O . Check Number
This Section For Official Use Only
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
288 NORTH MAPLE ST BP-2016-0668
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-038 CITY OF NORTHAMPTON
Lot: -00 L PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2016-0668
Project# JS-2016-001118
Est.Cost: $10000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: N P HOME IMPROVEMENTS INC 100481
Lot Size(sq. ft.): 30012.84 Owner: BERUBE MARK
Zoning: RI(100)/URA(100)/WSP(100)/ Applicant. N P HOME IMPROVEMENTS INC
AT. 288 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
575 GRANBY RD (413) 532-7603 WC
SOUTH HADLEYMA01075 ISSUED ON.11/12/2015 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF & REPLACE SKY
LIGHTS
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 11/12/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner