05-014 (2) 82 GROVE AVE BP-2016-1336
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05 -014 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-2016-1336
Project# JS-2016-002302
Est. Cost: $6255.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PHILIP W SHUMWAY 105743
Lot Size(sq. ft.): 9888.12 Owner: JACOBS DEBORAH L
toning: URA(90)/ Applicant. PHILIP W SHUMWAY
AT. 82 GROVE AVE
Applicant Address: Phone: Insurance:
P O BOX 522 (413) 687-9400
HADLEYMA01035 ISSUED ON.511712016 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 5/17/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
RE `Department use,only
City of Northampton StatusofPerrrt: .
uilding Department O 00tfDrivoway Permit
, 310;6
MA� 212 Main Street SewerlSepc"Ryeilaelllty
Room 100 WaterNVell Availebil: 77,
OF 5=1 MA N hampton, MA 01060 Two Sets of Structural'Plans,,
p one 413-587-1240 Fax 413-587-1272 PiotfSite Plans
Wit•5
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
MapLot Unit
Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
Name(Print) ^ Current ailing Addless:
�F Telephone
Signature
2.2 Authorized Agent:
Name(— Pr�— Currdint Mailing:A dress:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 74 (a)Building Permit Fee
2. Electrical d (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) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Comm issionerllnspector of Buildings Date
r.. ..,_,�,�
�:
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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 0 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
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
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO
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 Q
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Eff
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[O] Other[i:�
Brief Description of,P, oposgd �y
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 andor 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
as Owner of the subject
property ++''
hereo authorize
to at y behalf,in all mat rs relative to work aut orized by this building permit applicatign.
can m
Signature Owner Date
`' ) �6 ( "�' as Owner/Authorized
Agent hereby' eclare that the st tements and inform tion on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under thepd�j s d penalties of perjury.
Print Name
r
Signature of Owner/Age Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:— 15 YI W4�'Jt'l�J
105
7q
Licens umber
Address Ex iration ate
Sign re Telephone l �lrf J
9 Re lstered Home Improvement Contractor. Not Applicable ❑
a/A�q I -79 3 q o
Comg)anv
t�Name Registration Number,
Addres � � �
Expiration date
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 buil7g g permit.
Signed Affidavit Attached 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lep-ibly
Name (Business/Organization/Individual):_ c
Address:
City/State/Zip: Phone#: 0
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with_ 4. F-1 I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
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. F-1 Demolition
working for me in any capacity. employees and have workers' 9. F-1 Building addition
[No workers' comp, insurance nip. insurance.:
required.] 5. We are a corporation and its IO.F-1 Electrical repairs or additions
3.R I am a homeowner doing all work officers have exercised their 11.❑ P>lwbing 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' 13T1 Other_
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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:
Policy#or Self-ins. Lic. Expiration Date:_
Job Site Address: 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.
Ido hereby certify n ere pains andpenallies ofperjury that the information provided above is true and correct.
Signature: Date:
Phone
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 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: ra L/C v �-
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant VM r'U
Date (^ Signature of Permit Applicant
Shumway Services. Mass CSL#105743 General Contractor#22659
Shumway Services.
27 Huntington Rd
Hadley, MA 01035
(413) 687-9400
TO: Deb Jacobs
82 Grove Ave
Leeds, MA
Proposal (12/08/2015)
Description
• Reroofing of all roof sections will be completed except for porch roof
• Scaffolding and safety gear will be utilized
• Debris will be lowered in a controlled manner
• Existing shingles will be removed
• Ice Barrier will be applied at eaves,valleys,and junctions
• New rakes and drip edge will be installed
• Synthetic underlayment will be applied
• Certainteed 30 year architectural shingles will be installed(color to be determined by homeowner)
• New ridge vent(cap over type)will be installed
• Hip and ridge cap will be installed
• All debris will be recycled or taken to Valley Transfer Station
• Any nail debris will be cleared with magnetic sweeping
• Estimate is good for 30 days. Work cannot be completed until spring of 2016 and subject to change according to
material price fluctuations.
This estimate is going in under known conditions.Variables such as plywood and unforeseen items will be
additional charges to homeowner.
A 5 year written guarantee from Shumway Services is included
Pricing
Total: $6,255.00 in 3 payments of$2,085.00
Terms: 1/3 deposit, 1/3 on first day of project and 1/3 upon completion of project