31B-045 (3) 17 SUMMER ST BP-2016-1254
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-045 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-2016-1254
Project# JS-2016-002157
Est. Cost: $4500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MATTHEW BEAUDRY 108605
Lot Size(sq. ft.): 5706.36 Owner: KAHN ALEXANDER&ESTHER WHITE
Zoning: URC(100)/ Applicant: MATTHEW BEAUDRY
AT. 17 SUMMER ST
Applicant Address: Phone: Insurance:
117 FERRY ST (413) 320-1348 WC
EASTAMPTONMA01027 ISSUED ON:4/27/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE GARAGE 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 4/27/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
a
�—jr, G Department use only
R1 `' ity of Northampton Status of Permit.
uilding Department Curb Cut/Drivevvay Permit
APR 2 7 2016 212 Main Street Swe
er/SepticAvailability
Room 100 WaterNVell Availability
No hampton, MA 01060 Two Sets of Structural Plans
NORM r+n...--rensm. 13-587-1240 Fau 4'13-587-1272 Plot/Site Plans'
Other Specify c.
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
Map Lot Unit
�Colhn fi CSS 11 0 Zone Overlay District
timr St.:District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
f�l�x Y.UI�n � ��r �l�►ti� 17 ��vn�r ��
Name(Print) r Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. BuildingcJ (a) Building Permit Fee
2. Electrical / vV (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number O
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Informatiqn
Existing Proposed Required by Zoning
This column to be tilled 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 0 DONT KNOW 0 YES 0
IF YES, date issued:;
i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES 0
IF YES: enter Book Page and/or Document#':
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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 NO 0
..........-.1--.1--.1-11 .....__ .. _..._...
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
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 Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
C-UyD
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Rooting
Or Doors E-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [0] Other[O]
Brief Description of Proposed `
Work: cx►O e ybof Sylp GhI YT-ru)r I t
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 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. A )\61 as Owner of the subject
property
hereby authorizeC*2nudt,
to act on my behalf, in�ifl ma ers rel�tiv to work a thorized y this building permit applic ion.
A. '' a /J(0
Signature of Owne Date
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 /
1
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor- Not Applicable E
Name of License Holder: C5^i V t`—
License Nu ler
U 001
Address Expirati Date
Signature Telephone
9:Registered Horne Improvement Contractor: Not Applicable £
CompanyNNAM-0 Regijs79q5o,
tioner
(�Vbol,qr--� /
Address Expi ation D e
E /P/4 Telephone
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... . . £ No...... £
H. 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 faun
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
I
The Commonwealth alth ofAfassaachus,eas
®fJj c ®fInvestigations
600 �V ashington Street
x
Boston, MA 02111
www.mass.g®y/disu
Workers' Compensation Insurance Affidavit: Buuilclers/Contracto rs/IElectiricians/Plun>I beers
Applicant Informatio><n Please Print Legibly
Name (Business/Organization/Individual):
Address: �-�—
City/State/Zip: V_ Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with 1 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
2.F_] I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
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.E] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.lRrRoof repairs
insurance required.] t c. 152, §1(4), and we have no 13.❑ Other
employees. [No workers'
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: d,
��
revazw5
Policy#or Self-ins. Lie. #: 1( �;k5(��lJ(�W I S Expiration Date: t�*t
Job Site Address: City/State/Zip: NA ` ,jM o i( u
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 all ve is trate and correct.
Signature: Date:
Phone#: 9/ 1/ 1
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#:
City of Northampton .
- r ° MassachuS2ttS - f
DEPE3RTMZTT OF BUX-T DING INSP.uCTX01VS
212 Main Street o Municipal Building 5Ji L�
Northampton, MA 01060 s�r� r_x1 '
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
I
it
t y
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: 1r1 5U,\Vy "Y -5 �>
The debris will be transported by: ►-
The debris will be received by:
Building permit number:
Name of Permit Applicant 1' �U ►
r,
U
Date Signature of Permit Applicant
VDAC
WORKERS COMPENSATION
AND
` 7 EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S60US-2ESS300-0-15)
NEW-15
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
1. NCCI CO CODE: 10466
INSURED: PRODUCER:
BEAUDRY, MATTHEW FINCK & PERRAS INS AGCY
117 FERRY STREET 6 CAMPUS LANE
EASTHAMPTON MA 01027 EASTHAMPTON MA 01027
Insured is AN INDIVIDUAL.
Other work places and Identlflcatlon numbers are shown In the schedule(s) attached.
2. The policy period is from 05-04-16 to 06-04-16 12:01 A.M.at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s)listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In
Item 3.A. The limb of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 600000 policy Limit
e Bodlly Injury by Disease: $ 100000 Each Employee
JO C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, 0 any,listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GB
j
D. This policy Includes these endorsements and schedules:
o SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
. 4. The premium for this policy will be determined by our Manuals of Rules,Classilications, Rates and Rating
JO Plans. All required Information Is sugect to verification and change by audit to be made ANNUALLY.
r�
CY 1,-,< - ///,,- C,,;,-v, . -
DATE OF ISSUE: 04-30-16 JS ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 060
PRODUCER: FINCK & PERRAS INS AGCY 28NOK
008140