24C-170 (3) 67 FRANKLIN ST BP-2017-0008
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C- 170 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-2017-0008
Project# JS-2017-000016
Est. Cost: $11201.75
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DICKY MATOS 105917
Lot Size(sq. ft.): 6011.28 Owner: KETAY SARAH
Zoning:URB(I00)/ Applicant: DICKY MATOS
AT: 67 FRANKLIN ST
Applicant Address: Phone: Insurance:
3 GLEN ST (413) 530-5335 WC
HOLYOKEMA01040 ISSUED ON:7/7/2016 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:
FeeTvpe: Date Paid: Amount:
Building 7/7/2016 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 Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 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
1.1 Property-Adddress07 Ertl ic/iri This section to be completed by office
(p4 7/Qn kiln 5'f, 1I� Map Lot Unit
Jo I
rlhany�fun, Pin Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Sarah k'fay la- *anklin Sa- Mithamef✓n /CII
Name(Print) Cure ailin d re
L.Qan� . IL Telephone
Signature
2.2 Authorized Agent:
N ktdafos 1 CiLen Sf fftlwb�i , "In
Name(PP Current Mailing Address:
(al3)530 -5335
Signature Teephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
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 7(�
6. Total=(1 +2+3+4+5) $((, a,0/.q.c Check Number 87p o
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Date
RF_C
JUL — 8
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %n
(lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding e er been issued for/on the site?
NO O DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regis of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document it
B. Does the site contain a brook, body of water or wetlands? NO GC DONT 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 er
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 d
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 pad 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.
SECTION 5-DESCRIPTION OF PROPOSED WORK{check all aeblicabiej
New House ❑ Addition ❑ Dnt�4 Indows Alteraeen{s) Roofing ff
Or
Or Doorsoors ll��
Accessory Bldg. ❑ Demolition ❑ New Signs ID) Decks C Siding fl J] Other[CI
Brief Des tian ofcps fti `ckl2 E and Yt1 bd { z�Q.j lik of �! andtit !
Work: tq/ d Tl ✓s1 to t}
Alteration of existing bedroom Yes No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement _ Yes ✓ No
Plans Attached Roll -Sheet
Be,if New house and or addition to existing housing, complete the following:
a. Use of building : One Family f" 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 farm 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�JAPPLIES FOR BUILDING PERMIT
Sciatic- {[ Lf as Owner of the subject
property J
hereby authorize ) A . Lr 5 1
to act on my behalf, in all matters dative to work authorized by this buildin. permit application.
Sig : are orilta. bate
me /1.i.I /
I, ./)lHurl ,as Owner/Authorized
Agent hereby de re that the stateinmrds and information on the foregoing application are true and a n rate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
� , s
Print Na
De /i(a
Signature of Owner/Ager Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction$upervisov Not Applicable ❑
Name of License Holder:_____________.__1,� Y`-f U C,•;- I t6.91 v-
, JJ License Number
� . /f0 . 0 re 03136//9
Addres- Expiration ate
� 3 o-5-33C
S'- eiephons
9,Registered Home Improvement Contractor: Not Applicable 0
4.62.11C mpanv N § Regis on Nu ber
C.'? S{-, I-/o/Juke k/g osin ?
Address ff Expiratio Dat
_... _Tetephonel4133)5-39 -S335
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c,152,§25C(69
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 Exemption
The current exemption for"homeowners"was extended to include Owner-occupied thweltings 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 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-near 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 persons)
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 _,,,
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 150k
Address of the work: C,r4 7anklin Sf. nt jfkrvL HR
The debris will be transported by: 71 is kali) ) I
The debris will be received by: LI F--1 F4 1C/(js Mc• 161Uo /1.Th
Building permit number: J
Name of Permit Applicant I ckij $RJ- j
olioasitu
Date Signature of Permit Applicant
2 The Commonwealth of Massachusetts
��,;�/� Department of Industrial Accidents
rs0!'j=17 Dice of Investigations
,� 1 Congress Street,Suite 100
' Boston,MA 02114-201Z
k" www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information j� d Please Print Legibly
Name (BusinessJOrganizatioMndividual):ThiL/LU itledbj
Address: R (-1(Ln SF ./
Cit /StatelZip: K8 ,i — _jt i 1d _ Phone#: 3 530 -53_
�___.
Are y an employer? eck the appropriate box: Type of project.(required):
I. 1 am a employer with S 4. 0 1 am a general contractor and I
employees(full and/or parttime)." have hired the sub-contractors 6. []New construction
2.0 i am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees these sub-contractors have S. ® Demolition
working for me in any capacity, employees and have workers'
comp. insurance.: 9. 0 Building addition
[Noeqworkers' comp. insurance cIOU Electrical repairs or additions
required.) -. ® We are a corporation and its
3.0 1 am a homeowner doing all work officers have exercised their I t.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
Y12.0 Roof repairs
insurance required.] ' c.152, §1(4),and we have no 111tu RoJ
employees. [No workers' 13.�Other KAT
comp.insurance required.] _
*Any applicant that checks has k I must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicatingthey are doingall work and then hire outside contractors must suhwit 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.
7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. / ,11
Insurance Company Name: ►Inlor]w&Aan QJ11SW1anP,f. _
Policy#or Self-ins. Lig.-: �W/3- Ori f i5*/:4 - p -15 _ Expiration Date: t 1 i j �I
Job Site Address: tori f ani<-,1 n S . City/State/Zip: u -,2 A/ Ill t-1
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 2SA of MGL.c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 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 DR for insurance coverage verification.
Signature.:
ig erode/I do by certify ryo[kS ain3 y� Wallies of perjury that the informationDate:provided/ t/(40 aiuf correct._
Ph
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 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
aaaa: 08r07!20te 14:49 9002 P.001/001
-tauCERTIFICATE OF LIABILITY INSURANCE aasaaaw+
/011
Nana ha macaw wb01aam0a0wnsasepsaOl✓a
aMOMOMI OMtI
Mal Ma
aao� 0111111111/L a lligrwa•oISM ar mrao•oaiawiwmpliaWpm*
lbSal riOin•1a• My iMplimialmommi AiMatual•wdnr•liOl laaar+rbbS
a�aaaaarl•aIbutapY ,
Iaa•awar La•aaaaw yew sae te. aa•t a-- -0a 1agm. el aw-•s
100 itlLa lea at
1SiOaer r 01040 SIBaeea_•eaaa Ile_
axe keta s•
mum tea.
Diem ins eon
l Me e6. aaaw•. • '
Wan, la 01040 r_u
eel
r • MI • `I.ea �,rj:, , • WEIS •row �' r aor
i ,, � Mu .. arca: 1)1! ,J, Oaf :m 1� T
.. _ . talo' . �:a. _ ,n aau�r iu.aa
is
Serf ,
.
■■ waw• No oaae N. • awwaarrat p
IN - taa•utar0aa•a •
• Iaaga-. - -- a
a•alppaaaOwl I
_ minterne • aav�iitss a
atw.w _ ••••• -•-••
a
•aw aal0aaaaaa 'r
a
• ssi f-■rte rMINIM a
■
• --1.---•—• -08-O111107-0-15 TAWS Vale=la*ai 1l`
.l . talo LL•aesew• • 100.000 r
n. a��Maa
. •. . . , JLaat-aosa a a00 000
• t I ! .
as rownalala ofaalieal a•aiMaSSir1- t -'---p -.
•
rads 1fYlII Iw.r .
cowsQ^rrayauaaa0.ain Oaalallaaaa
01001• 11•1011 Aaal� �111., t- a r & w al a
INCous
Swan
l Me as •waaaat&iiirowoht
' aalgehm, la 03.040
1�MSS The tern awaaad as 611arUA00110001M11 at MaMaalsa/.
iota a�Yaaaaab afA00p
®. Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-105917
OREMATOS
HGLEN REET
HOLYOKE
STSTKE MA OtWO
Mitt ` A. . Expiration:
Co inmiseioner 03/30l18
,ax
, ,r___= QXlee ipv,ndnwea/t4 oig aoAecoetty
PI
r _'■ . Office of Consumer Affairs and Business Regulation
)711.-,=‘ 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 166207
Type: Individual
Expiration: 5/72048 Tr# 288608
DICKY MATOS
DICKY MATOS
3 GLEN ST. —.
HOLYOKE, MA 01040 — --
Update Address and return card.Mart reason for change.
U Address l Renewal 0 Employment I-] Lost Card
scn+ o 20u-05n+
r:i2.'I9r.nurznr+vwe///,, H//-.,r/rruiG Licenseorregistration valid for individualux only
Office of Consumer Again&Bud Regulatio.
Otot.*IOME IMPROVEMENT CONTRACTOR before the expiration date. Mound return to:
. f
Registration: 166207 Typo: Office of Consumer Affairs and Business Regulation
Expiration: 517/2018 Individual
Park Plazs-Suite 5170
„y^' Boston,MA 02116
DICKY MATOS
DICKY MATOS
3 GLEN ST.
HOLYOKE,MA 01040 Undersecretary- Not valid without signature