35-093 (5) 6 CAHILLANE TER BP-2016-1422
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-093 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 x BP-2016-1422
Project= JS-2016-002447
Est. Cost: $3100.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAMELA LEBEAU 064756
Lot Size(sq. ft.): 9888.12 Owner: LANGLOIS JACQUELINE D
Zoning: Applicant: PAMELA LEBEAU
AT: 6 CAHILLANE TER
Applicant Address: Phone: Insurance:
248 Bryant St (413) 296-4506
CHESTERFIELDMA01012 ISSUED ON:6/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP & SHINGLE ROOF ON GARAGE
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 II 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 6/1/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
- ., "�` - .• Department use only.
City of Northampton sratus'o(PermlL
rm
j
Building Department Clrtt Cutmnveway permit pkc
ECEIVED 212 Main Street Sewer/Sephc AvatlaMfitle
Room 100 Wafermelt Availability-"
MAY 31 _ Northampton, MA 01060 Two Sets of Structural Pians =
1-13Zphbne 412-587-1240 Fax 413-587-1272 'PIot/Site Frans- t-"'-.
���� -Ether Speofy
o7tAP4UCA;1 1QitjONS-RUCT,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
/ Cfl Ili LLi4N&E -feec'nc(/-. Map Lot Unit
1�Fc 2e-f-4 •T�- Zone Overlay District
!-( r!}. O 1062
Elm St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C A CIL( e`%--N 6-Iro k s (-, e R 14, LL#p reee. Flo
Name(Print) Current Mailing Atldress'
VI W. 01ok.
� \IIYV.j Telephone
Blgnure ( 3 — Ski — -7k7-7
2.2 Authorized Agent: ,.L,1 I ,-,y.�,�+
T k �Z-14- ( e= `�rN cKCJttAeg gum
Ij —14 �� 7 Ma �lr E S .
Na�(Print) Current Mailing Address:
HOo , . .40 . t_ 4l � S ^ iCc() R(3 —S75- 458)
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS it 3 I Oe
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit 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 ] p
6. Total=(1 +2+3+4+5j Check Number •7gj0 �ci(�
This Section For Official Use Only
Building Permit Number. Date
Issued
Signature.
Building Commrssioner/Inspector of Buildings Date
Section 4. ZONING AU Information Must Be Compteted. 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 Heigh[
Bldg.Square Footage --
Open Space Footage _ -- --
(Lot area minusbldg&paved _
paddne)
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 O DONT KNOW 0 YES 0 _
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 516._ DONT KNOW O YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ® , Date Issued ,. ...
C. Do any signs exist on the property? YES Q NO 0--
IF
—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, excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre, YES O NO }(CST
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 D Replacement Windows Alteration(s) n Roofing X,
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding[O] Other[DI
Brief Description of Proposed
Work. St2_p V} nct, ,c- Pt •-i-in rr-V2 f'F e-r^- o F k tv b r2#fisk7NKk, .
Alteration of existing bedroom Yes y— No Adding new bedroom Yes /-4410
_e.
Narrative Renovating unfinished basement Yes �-No
Plans Attached Roll -Sheet
Ga. 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
OWNERSNAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
f )A C4 h ktatek&CCJic-, as Owner of the subject
property
hereby authorize .-----Pa- a-vhA I. i t, '3
to act on my behalf, in all matters relative to work authorized by this building permit application.
Jr- •• j .-I.1%..._,,,,
Sign lure of Owner . Date i 4
----pA--f-1.al,t'k (Xrej G* ) 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.
eA-f-t i{LH- (a--Re h)pPrint me
Oz-e._Q9 .r 0I/20i.. ,
Signature of Owner/Agent Date I
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 1_,U-res _,� l Not Applicable 0
Name of License Halder: ( �t''��'= �-1� �, GKV C-5 oh - r5-lo
/�
License Numbers f�
t'ts 13 Qy f} mi
��. e-� -Pi t� R� -7 LLJ/ ZOI
Address 1 oto 17 Expiration Date
Sign r Telephone
(Le 4 %lFP,m LOS —ZCi6 - tcot
9.Registered Home Improvement Contractor. 1-t,.;. .;, ", ,_ ';. Not Applicable ❑
/ 30/o
Company Name Registration Number
Cu, zia
Address 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 building permit.
Signed Affidavit Attached Yes No 0
11.- Home Owner Exeinpfion
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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,von 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 Anno'ated
Homeowner Signature
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: (�, dAAlI CLAWC
The debris will be transported by: 711344e2,ra- (---g1S 211-0
The debris will be received by: Vo n, �2 ct J �p<
Building permit number:
Name of Permit Applicant 7 E-L,� LeB6-mf� �X vies-e-$ l /7-6/C1
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
„Thr ic_ Department of Industrial Accidents
131- —"♦t Office of Investigations
[!;1;. ,, 1 Congress Street,Suite 100
�\-!,�ay.j ' Boston,MA 02114-2017
k ,-;i'
K www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name Business/OrganirationAndividuap: Pamela R. LeBeau
Address:248 Bryant St.
City/State/Zip:Chesterfield, Ma.01012 phone#:413-296-4506 cell:413-5754581
Are you an employer?Check the appropriate box:
contractor and 1 6. of project(required):
1.ID 4.I am a employer with ❑ I am a general
employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2.0 I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
rant ty = 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing 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' 13n Other
comp.insurance required.]
*Any applicant that checks box#1 must also till 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'cmnp_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 IS or Self-ins.Lic. #: Expiration Date:
lob 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.
I do hereby certify under the
nn pains and allies of perjury that the information provided above is true and correct
Signature: //()moo , 4 S� nzea .4_Y Date: iii/Z6/,‘,w.
Phone#: 413-296-45Cra
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#: