11A-063 (2) 61 EVERGREEN RD BP-2017-0242
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao- Block: IIA-063 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category': ROOF BUILDING PERMIT
Permit# BP-2017-0242
Project# JS-2017-000401
Est. Cost: $9750.00
Fee:S40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: EUGENE BATTISTONI 003175
Lot Size(sq. ft.): 11543.40 Owner: MERRIAM MARTHA A
Zoning: URA(100)/ Applicant: EUGENE BATTISTONI
AT: 61 EVERGREEN RD
Applicant Address: Phone: Insurance:
534 Market Hill Rd (413) 549-2693
A M H E R S T M A 010 0 2 ISSUED ON:8/25/2016 0:00:00
TO PERFORM THE FOLLOWING WORK: Remove roofing and install drip edge I&W and 30 yr
Certainteed Landmark architectual shingles
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 8/25/2016 0:00:00 S40.00
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 Address: / This section to be completed by office
/ j , 2 Very tree N (? 1 Map Lot Unit
(y �r� 77�� 7 /C GL Zone Overlay District
(JCS' fly 14;* Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /;
Wig r /O /2..9e rn (1 A f 6 3 9IWre/w a ii 4r,-_--6 is /175f
Name(Print) Current Mailing Address"
Sed - 0 97a.
Telephone
Signature
2.2 A odzed Agent:
i Ili r74),)I ,,,,,70)-(yr.j L-7_,_ .r9y/2iedi A=ilr,49. 6/(, oz
Name( Current/
Signal Telephone
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 /
6. Total=(1 +2+3+4+5) 77sd oo Check Number 936�l
/ This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: aietX, 7 l/�Building Corn or
of Buildings Date
Proposal posa j Page No of Pages
BATTISTONIII CONTRACTING, INC.
534 Market Hill Road
AMHERST,MASSACHUSETTS 01002
(413)549-2693
PROPOSar SUBMITTED TO: PHONE DATE
Ms.Martha Merriam 413-586-0972 April 4,2016
STREET JOB NAME
63 Evergreen Road 63 Evergreen Road
CITY,STATE AND ZIP CODE JOB LOCATION
Leeds,MA 01053 Leeds,MA 01053
ARCHITECT I DATE OF PUNS CSL License 8003175 WC License #104608 JOB PHONE
We hereby submit specifications and wawa for
Removal of existing roofing materials from all roof areas of main house_
Installation of Ceitainteed Winterguard snow and ice shield on bottom 6'of all roof areas and in all _
Installation of Palisades synthetic polymer underlaymeut on all remaining roof areas.
Installation of 8"aiuminam drip edge and rake edge.
hnstrillation Of Certainteed t andmark thatyyear architectural shingles.
Installation of I.omeneo kiwgpafile ridge vent on all mof pea}a._
Clean T and d1sp9sal.of11!b related debris.
Price: $9,750.00
. .. Buildin�Permit Fee: 40.00
Note: If plywood decay is found,replacement will be at an additional charge with a rate of$2.40 per square foot,materials and labov
We propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
dollars($
Parma to be made as follows:
One half deposit,remainder due upon completion
^y A
All materials guaranteed to be a specified All work to be completed in a wukamlike Authorized e,„,„1--45-....
mama according to nwadxd teachers. Amy dtaatiw or devalue form above specifc8i' is signature Z 4 /
mvolvmg area Costs win be exemaed only Wa wrmm siders, and wra become an aNs //— ..
charge over and above the estimate. All agrarnls contingent upon strikes,accidents or lite.Thus proposal may be
delays beyond aur control. Owcer to a+.,fee.tornado end mho neausay inanrarce. lhr Withdrawn b}r/s if not nccryted within 15 days.
workers are fully covered by Workman's Compensation Insurance.
Acceptance of Proposal -he above prises,specifications �}q
and conditions are satisfactory and are hereby accepted. You are Signature /z lr ze�,yq/7.. ' ,
authorized to do the work as specified. Paymaot will be made as outlined
DateofAcceptance 11- 1J / Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs ]O] Decks [❑ Siding[❑] Other[co
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
5a. If New house and or addition to existing housing. complete the followino:
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 / 7
hereby authorize /y5J/F i/7].s -x77 Ni Bd Y in-
to act on my behalf,in all matters relative to work authorized by h /sris building p r it appIfcatioa
Signature of Owner Date
474.94/,- 7q/9 & c?'- " ,as Owne uthorized -
('Agent-hereby declar@lhat the statements and information the foregoing application are true and accurate,to the best o edge
and-belief.
Signed under the pains and penalties of perjury.
t,✓, je 1L,4S,�N/•
PnM Name /
2I -/6
Signa de• '% er/Agent O Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ///1 / Not Applicable ❑
Name of License Holder: gl<4 er-r- 1 a �S., v /
Qt7 ?/7r
�q� -1.714/-(8/1412 License�Number
Ad s Arii -0/66 1 Expiration Date
Sign T�Al!��..� '41.-- ., Telephone _.
9.Registered Home lm rovement Contractor: Not Applicable 0
e- � C tiCompany / nRegistration
Number
_</ i1ce_ 7- /Y —/ 7
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 buildin permit
Signed Affidavit Attached Yes No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 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
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 1.: 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 DON'T KNOW lEY YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW Cr YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW laYES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO l7
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,excava ,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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: /4 5 /e q,r"ee,t /nA M,"
The debris will be transported by: ,wt.t Aloft t
The debris will be received by: .5 /
Building permit number:
Name of Permit Applicant ��,few i P % cZ- d42,- 11416 Neerlyugt
Dat- Signature of Permit Applicant
The Commonwealth of Massachusetts
_ — Department of Industrial Accidents
P . 1
B= lir,- Office of Investigations
a1=^-4 1 Congress Street,Suite 100
'��1— Boston,MA 02114-2017
C www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print I.e¢ibly
Name (Business/OrganizafiM
(Business/Organization/Individual): Y"41-b Sio-v; (omiTRe'/ Z� e
Address: y 3 t J41,- i-- 4411
/O
City/State/Zip: Mt , /On Z Phone 4: 4/3-r- 2-6 7 '�
Are you an employer?Check the appropriate box: Type of project(required):
1.Tam a employer with `, 4. ❑ 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P ty 9. [' Building addition
[No workers' comp. insurance comp-insurance.:
corporation 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.p Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL I2 trs
insurance required.]t c. 152,§1(4),and we have no Pa
employees. [No workers' 13.0 Other
comp. insurance required.]
'Any applicant that checks box dl 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.
7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 7?friJs Lei' y- , r. Cc .. _ _ _
(olicy)or Self-ins. Lic.X: 1 Su a /p Q, i 7F-gy_-,/-/Z Expiation Date: t.-23 '/ 7
Job Site Address: L G.-- r /. f_ _ - City/State/Zip: 0/ 0,41,
Attach a copy of the workers'compensatio 1 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 urtfri-
he pains and penalties of perjury that the information provided above is true and correct.
Si nature: '- - Date: Y 17- /6
Phone N: el/3 4Y9 .-26,p 7
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License k
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: Phone4:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"_.every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives ofa deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemrit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax# 617-727-7749
www.mass.govidia