42-109 1023 WESTHAMPTON RD BP-2017-0077
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 42- 109 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-2017-0077
Project# JS-2017-000139
Est. Cost: $16000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
!toil U S METAL ROOFING DISTRIBUTORS, INC 031003
Lot size(sa.ft.): 19994.04 Owner: FRUGE JON&SHELLY LAVALLEY-FRUGE
zoning: Applicant: U S METAL ROOFING DISTRIBUTORS. INC
AT: 1023 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
740 HIGH ST, SUITE 2 (413) 536-5474 WC
H O L Y O K E M A 0104 0 ISSUED ON:7/21/2 016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & INSTALL NEW METAL 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 7/21/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
i' Department use only
F' City of Northampton Status of Permit
a 2 1 2016 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
wsv
i,tons Room 100 Water/Well Availatupty
-tr'g •cs'r"'0-0
cs
�pr. Northampton, MA 01060 Two Sets of SWctural 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 Address: / n This section to be completed by office
/0013 Lti s/Ainpoi) oa-- i Map Lot Unit
/Oran C.0 in4. 0 / 0 fr 0 Zone Overlay astda
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: VIE
� ' '/ f J /
/J h -12il c ViElyA .Yi,/AL -yrte-r /mai -3 /J "in/Act--'nr%n22.C./
Name(Print) U / / / / Current Mailing Address:
�� /j vl✓ 1� 96 SFJ/
Pure SP(', Cal ✓9.C�J Te phone
gnature
2.2 Authorized Aoem: r)
_O • ,A4e/la or li0 / s1 �tl KJ� r
1
CennAUre14 Sill
Ctrr(Pd ) � ,
tin %LP.-P, ) -S 3 5+7Vf
Signatu T le one
SECTION 3-ESTIMATED ONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /� ) oG (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
6. Total =(1 +2+3+4+5) l�^/ ar 6 - UL Check Number /.,1 els-c,2 4'92
7 This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:Signature:
Building Commissioner/Inspector of Buildings Date
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 , •
A\ \ Frontage
'ii Setbacks Front •
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage °o
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volumes Location) j
A. Has a Special Permit/Variance/Fi ding ever been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW ® YES O
IF YES: enter Book Page and/or Document s
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW VD 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
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 O
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 lip
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) n Roofing
Or Doors 0
Accessory Bldg. 0 Demolition 0 New Signs [CI Decks [q Siding IpI Other[co
Brief De ription of Prpposed //r / / / f t / /
Work:/5/11— l4- at(O01a. O P ij ilir''.1I r00 =I:hif N +-i n pike) /71 t✓SonnalfrGe nC.,'Yt ftle
Alteration of existing bedroomrYes y NO Adding new bedroom Yes g No1/ 41u-Y/
Attached Narrative el Renovating unfinished basement 'Yes d No
Plans Attached Roll -Sheet
'\
5a. 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. Masschedc 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, / 1OnLlr)eil 34441 /!✓de day' U�{ �� , as Owner of the subject
property / / rf/ U
hereby authorize (x( / ) rs Mein_/ ouoy/i✓1 - ) -477,,,✓. g permit Mica ion.
to ac on my behalf, in a111YYI matters relative to work authoriz y is wilding permit gppllii-cation.
/Gill.e. ,50._..e, con /l LI 7/I"eco
gnature of Owner Date
[ L/ / Date
1,/I (S irk/P 7G(.l d10i/�/ �/f 7Yi 4U-YOr3 filo �^ as Owner/Authorized
Agent hereby declare that the s .ements an f (nation on the foregoindapplication are true and accurate,to the best of my knowledge
and belief.
Signed under the pai d penalties of perjury.
MPPPnai' e.,-)n1 1\NAlb62.41
. i /CPe "�'Q`"P 7-77 ��
ure of••
edAgert Date
J
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction^ Supervisor:^ -- �, Not Applicable 0
Name of License Holder S 7 ( _ (per/Il /04 )9 A e_3- 03P-z)
License Number
_
Ad c ��
„ t . .Frim , P 5- i /g moi
Address e Expiration Date
a _i Z
Signa.-- elephone
B.Registered Home lmprowe Co ':etor: Not Applicable 0
• an me ' RegistNbon r mber
�Isw �(4 . 771/7 .174 flu/ a t tr740/by!a , _ //—d°/�
Address / / " Expiration Date
(/ Telephoriffr3-5 R)-51117
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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 oft budding permit.
Signed Affidavit Attached Yes No C
11. — Home Owner Exemption
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,you maybe 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 _ _
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: /02 3 �,�,�,tiLip-mClon� l�ooa�/
The debris will be transported by: rt(, `i. Ma 1 x4 7�i. Gfr <✓{ 2n c/
The debris will be received byr'�mf�e��i )iipo.r, , Ly�xe 444. °/
Building permit number: / //
Name of Permit Applicant (,r„5.A41,,/
6
(_2(:),_tait,_ a
Date 7 4C, ; Sign ture of Permit Applicant
The Commonwealth of Massachusetts
n; — / Department of Industrial Accidents
evp
e: Office of Investigations
_ie 1 Congress Street, Suite 100
1i`— Boston,MA 02114-2017�� www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 5 r�/, / ,,l/.� !� 1 [Please Print Legibly
Name Business/Organiation/mdividuap/,(. //j' kJ / (PUVA //�/;1144,,,QtiJorJ Inc
Address: 740 1-11r4 .3/ie ems _ >tilee,d— ,� OFe 4/IL
l
City/State/Zip: got. e /f,. Phone #: 3- 2y
reou an employer?Ch: k the :ppropriate box:
I. 1 am a employer with 4. ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).' have hired the subcontractors 6. ❑ New construction
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
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.
t 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.E I am a homeowner doing all work officers have exercised their ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 Roof repairs
insurance required.] t c. 152,§I(4),and we have no
employees. [No workers' • 13.0 Other
comp. insurance required.]
*Any applicant that checks box M I must also fill out section below showing their workers'compensation policy information.
f llomeowmers 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'comppolicy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. nYr [ n
Insurance Company Name:372(N �JuCn nC� CP'
Policy#or Self-ins. Lie.#:/,(/k/t.OG„/8#f c y,0 _ Expiration Date: 7-1-C.-4W'/,(4. �nj
/aa31� 1
----/
t 'l
Job Site Address: PJ �79/p,(/'la?�0�w City/State/Zip:f"�UYF�IICQ/ MOM-6
Attach a copy of the workers' compensatio 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.
1 do her., -' •er the pains a allies of perjury that the information provided above is true and correct
Sign..ur:. / / .. ,1P 2 Le --J Date: 7- /'s-''4
Phone#: ()( t _ 5,54- 7,4
Official use only. Do not write in this area,a, 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 It;
- a
US. METAL ROOFING
7411 High Street•Suite 2•Holyoke,MA 01040 ,5 7
1-810-232-0399•1-413-536-5474•Fax 1-413-533-8166 „n ,o.„„„,,„
www.usmetalroofing.net i2,-,a7-a,
j y 3 (267-43/2/5-/-4-55- rf. c
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We will furnishand*bossiest
nw Engler,Standing SeamMechanicallyisetanae lal.asystem.24 deluge az listed below
raIS,rrw a lie high u.wmaa ass yeah
-,'^P e- ^ yearsane SPECIAL INSTRUCTIONS/COMENTS
sorrlt. _ 1>--..-- G I L, -e 5-, h -,6rrT ^�
FASCIAAi,. / a, r--- w _v i, r=„34.- a3 Pe c.
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f C�e7_C L pip to.Os...,,dapp.duped by dr. e as ocyontl cp....,peon.. the
roofing panerls am cuMcm labncateaon site wall stale ofAre.rt mlllerming egulpment.
ray become eider s ollhe day w
.The' interne al he mem! tr t ho limes
as a product
defect and hall not be cause ler mlmfon�
Cmlmrior does not perform or assume any wvinslbluy in:any pasting,staining or weed or wall finishing on interior or Edens
The or does arms agree with lid owner teat f 1 he will begin work within a reneonshe time alter the emcMnn t ereol.and will
prosecute it diligently and with due m
and In a goon and workmanlike enu q ldl lu s. r doing the Wash he will comply w all stele .
,
regnN sardrmdetarussepincaNethereto-
Connnctnrtoprocureallpermitsr coed by law Contract,shalt pmwde pupilI.„Nile,Inserenecn
o,,,,..,,,,Thi.,ills nu lr aµoryny ra wlrh�he work is tobe peroirved ni Opal ire is oNerwme nntharraa no hn4olt rueu
We Propose her zmpleen n..
,n ,a.ra -„ a„ „, bait
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Payment Si he metie as.0 l..
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IS—''_ I nm ROOFING osrF9UID]n5 INC
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upon eel Sine alan
',�' ^is 6'Pro l up.,'/2F own //
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Acceptance of Proposal I m read both si 01 arts document and accept the prices,speMrcel.ons and conemns sly.
understand cat upen signing,nils proposal becomes a binding coMad You are apnmzed to M me work as car/damns slated
I
as ourrred above. spetlnerl.Famrenr will be
You,the Buyer,may cancel this transaction tany time priortomidnight o fuse third business day afterthe date of
thist tttt n.C be done writing.SeeaccompanyingBcancellation.
GN THIS CONTRACT IFTMEHEq TE BL