17A-158 (7) 53 FOX FARMS RD BP-2016-1126
GIS#: COMMONWEALTH OF MASSACHUSETTS
N1ap:Block: 17A- 158 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-2016-1126
Project# JS-2016-001922
Est. Cost: $6000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 28793.16 Owner: RONDEAU PATRICK D&KRISTA S
zoning: URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 53 FOX FARMS RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.•3/22/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REROOF FRONT PORTION 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 Signature:
FeeType: Date Paid: Amount:
Building 3/22/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
e
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 WaterMell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-687-1240 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
- This section to be completed by office
1.1 Property.,Address:
5 O A-a 6-- Map Lot Unit
d rLtiC- t /✓� �- Q � Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY O6 NERSHIPIAUTHORIZED AGE14T
2.1 Owner of Record:
53 40n fia v--►mss
Name nt Current Mailing Address:
G y 1 '3 },�,�--f a t Cv
Telephone
Signature
2.2 Authorized Agent:
+ 0-i 11 1%,t. i Nl
Name(Print) Current Mailing Address:
Ar atm - s8 �c - � s�, Z
Signature Telephone
SECTIOry?.-ESTIMATED CONSTRUCTION C®?STS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 416, (a)Building Permit Fee
2. Electrical I (b)Estimated Total Cost of
I ( Construction from r61 I
13. Plumbing i Culldtna. C zrm t Fee
4. Mechanical (r vAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) eo, a-aY? Check Number
This Section For Official Use t3
Date
Building Permit NIlumber: Issued:
Signature: w [ FpNS
Building Co;nmissianerllnspe::tor of Buildings Lute
Section 4. ZONING All Information Must Be CompletL 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 Q DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was
V/y (�Wa(/ i s�t�'he permit recorded at the Registry of Deeds?
iD'ON"T KPI A1 (/
1 !- / YES 1 a
IF YES: enter Book Page and/or Document
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
6F YES, has a permit been or need to be obtained from the Conservation Commission',
Reeds to be obtained0 Obtained �1 ; Date issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there?ny proposed chargee to or addltiens cf sig rc intF'ndled for the pr`rn-e^ty 7 t"FSRill
IF YES, describe size, type and location:
l=. 1Nill the construction acttvtty oisium (clearing,arcing, excavation, or tilling)over 1 acre or is it pari of a con mon plan
that will disturb over i acre? YES 0 ISO
IF YES,then a Norihzmpton Sierm khfater Nfianagement Permit from the DP4&/is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK check alla licable
New Mouse F7 Addition Replacement Windows Alterations) E] Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[p] Other[E]
Brief Work Description of Proposed /� - Y-� oA �� /•n p W� h-0v
Alteration of existing bedroom �c- Yes—A- No Adding new bedroomo Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga.If New house and or ado Itdon to gx6eL g housing, can-inlets the foltoyAng:
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
i
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 Sev"ar Private well City water Supply
SECTION 7a-OVPVN?R AU'THOiR2ATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
ac llekmar of ih�c ,hie�t
j properly //
herebyauthorize �' '�'�� l4 "� r 1�"t ��"CJ��E�✓I F-�Jl
to on my half, in atte re to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Ag@tit hefeb��declare that the Stat�rnGntS and Snfcrmation on the foreoaing application are true and accurate,to the beat of my knourledae
Signed under the pains and penalties of perjury.
Sv s 1 Lv M
IPI-Int Nai-ne
i Cinnntrire of fl grnor,4,�_,t Dais i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: � �1`'(\ i����VV��l�tr1 C a`I
License Number
ak,
Address Expiration Date
Signat Telephone
9. Rgaaistered Borne Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
hr's� ,�j l �_ \C� _Telephone1t
SECTION 10-WORKERS' COMPERSATION 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...... ❑
11.
Home Owner Exe 2flan
Tlie Current exemption(ii'"'homeowners"was extended to includer�per�eo�-��C'�TM2e�1�?*'eE°PLt�S QT r to�:) or tvio(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,prok,;ded fhst Llse o-w er acts
as supervisar.CMR 78'9. Sia th Edition Sectiion
Definition of Homeowner:Pei-son(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..person who constructs more thzn one home fn a twu-year perfod shOl not be consfe-erect a homeowner.
Such"homeowner"shall submit to the Building Official, an a form acceptable to the Building Official,that he/she shall be
erSPnEpEYENkbbC por emp-Nuel mlong"erA_Ormee !_Vreei E ne rrnarPp-Jr-nv nermnr.
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 inay 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
Northam,pton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws annotated.
Hameawner Signature
City ofl�lorthampton 212 Main Street, 2\Torihampton, 1\iA 01060
Solid Waste?disposal A.fndavit
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:
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
3 z�
Date Signature of Permit Applicant
CS-077279
Su
263
Southampttm MA-01
06P4112016
m,Pc
I
l
i*- Office of Consumer Affairs and Business RCULI ati ion
T
10 Park Plaza, - Suite 5170
Boston, N'lassachusetts 02116
Home Improvement Contractor Registration
Reqlstratim 105543
Type'. Private corporation
VA! I EY HOME IMPROVEMENT !N,,-,,
S Expiration, 7/1712016 Tr# 254029
�)EN 'LVERMA"N
TE sl
P.O. Box 60627
FLORENCE, MA 01062
-r,dati:AdJ,-c,,,,s and return card.Mark reason for change.
I
AddressRenewtilEmplo,ment Ltist Card
,
The Commonwealth of Massachusetts
Department of Industrial Accidents
_ Office of Investigations
a r = 600 Washington Street
.' Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1,r l Please Print Legibly
Name (Business/Organization/Individual): V C't,�'�'i�� A( ; ,e 1 1i� f(}�` '�')�? T_n
Address: `ibQ,� �`j �;-
2-
City/State/Zip: (-ea« IPhone
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with I� 4. ❑ I am a general contractor and I
employees(full and/or part-time).
have hired the sub-contractors 6. E]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 for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9 E] Building addition
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 1 I.E]Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[✓�oof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 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: NVbg?Ma-
Policy#or Self-ins. Lic. 00 11-Yo- C .601 ° i Expiration Date: ah 6 l 7
Job Site Address:_ S3 r—o x �' 'U`s �• l-L�/ iv c , AA tC y/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 v rification.
I do hereby certify i the pains a`ld penalti 'perjury that the information provided above is true and correct
Si ature: � i�' ,J �� Date. 3 -I- ` / C,
Phone#: '"�� �y"�
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#: