37-079 48 PLATINUM CIR BP-2017-0468
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:37-079 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-2017-0468
Project# JS-2017-000778
Est.Cost: $13500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
useGroup: JARED LARAVEE 102286
Lot Size(so. ft.): 31842.36 Owner: SCHIPELLITE KAREN MARIE
Zoning; Applicant: JARED LARAVEE
AT: 48 PLATINUM CIR
Applicant Address: Phone: Insurance:
39 SWOL ST (413) 297-2259 WC
CH ICOPEEMA01013 ISSUED ON:10/13/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF -WHOLE HOUSE - 30
SQUARES
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 10/13/2016 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
r-° "- - - 212 Main Street Sewer/Septic Availability
OCT Room 100 Water/VVell Availability
OI I ' 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
.41 P i - ---- CC Map Lot Unit
T 1 0"'1 cc •^ Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Caren c � -pal , fe_ q z Nod- rloro.cc
Nam- (Pint) i Curren4tn�
/f oz�aiMg Address:
33%z
/.i✓ 'Z4 Telephone
Signature -
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building I07
3 5 O (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 �(d//
6. Total=(1 +2+3+4+5) b /3Sac Check Number d/fC 7 `>
This Section For Official Use Only
Building PermitNumber: Date
Issued: 9� /
Signature: , ' w //C
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
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 O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O 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 0
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. WII the construction activity disturb(clearing,grading,e cavation,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.
SECTION S-DESCRIPTION OF PROPOS D WORK(Check all appileable)
New House 0 Addttion 0 ._1IReplacementr inflows Aiteration(s} CDRoofingis
gr Doors (
Accessory Bldg. 0 Demolition ❑ New Signs DLJ Decks 1C Siding IQ) Other[CI
Brief Description of Proposedg,,
Work: t6� Sfr.p r �.sf..tr �.spt,. if sc,i t..J — 'SSr.rt(!✓{S /Wife&
Alteration of existing bedroom Yes No Adding new bedroom Yes No '-.):€'
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.It 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
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, .q'e'1. .ficin.nc lift ,as Owner of the subject
Property
hereby authorize TG,rt-4 Lcr cw'c C
to act on my behalf, in all matters relative to work authorized by this building permit application.
IK.-.- / • 0/ I to
Signature of Owner _' Date:
0 /2
I, tCeJ<.• SC L:1ve it it .as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and eon irate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
KC.i-« SC L..1ic./iJ
Pilo ame /1
...,,,Z....„--.7e lO/ld /2 olid
Sig ture of OwnerfAgent / Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
tlameot License Holder: ._..� ctr<d ( LAfo.vcs- c5 - (Ca2Zc6�
License Number
3� $„al 5fo(3 / & /z.c( -t _
Address - Expiration Date
-113- 2 `l7-2z '5-1
S=! ,•r Telephone
9,Registered Home Improvement Contractor: Not Applicable 0
I to 4r71
ComDanv Name Registration Number
39 S of s,t , t-v4 0(013 y(/12./2�fa
Address Expirat Date
Telephone '413_Z rl 7-22-s"
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8)l
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 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.CNH 788, Sixth Edition Section 1883$4.
Definition of Homepwner: 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 he,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 _ _......—
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: 'I7 It(4f•n- n ( r.
The debris will be transported by: LS,-4 12.«y Li?
The debris will be received by: vs.4 by 4- ,2ec/
Building permit number
Name of Permit Applicant g42c) Lc
io (o lc/ c
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
k.. 1—0
' Office of Investigations
',4
...,,
Congress Street,Suite 100
r�` Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le¢ibly
Name (Business/Organization/Individual): J CI rc, l_A rec.L,cn
Address: 39 S-,-o( 5} .
City/State/Zip: c icel c c* /4'in 0(443 _ Phone##: yr 3 - a e7 7 - 2:2 S ei
Are you an employer?Check the appropriate box: Type of project(required):
I.0 I am a employer with 4. 0 I am a general contractor and I
employees(full and/or part-time).
x have hired the sub-contractors b. ®New construction
2) i am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
insurances
9. ❑ Building addition
[No workers' comp. insurance comp.required] 5. 0 We are a corporation and its 10.E Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MOL 12,$Roof repairs
insurance required]' c. 152,¢1(4),and we have no
employees. [No workers' 13.❑Other - __,
comp.insurance required] _
`Any applicant that checks box NI 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 contactors 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 em an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: fcir r.,. �."" 1,15,--(‘'-""1; °^-
Policy or Self-ins.Lie. #: 2.n<4ttN 7143-- Expiration Date: (471/ 2.44 1-7
Job Site Address: e7*i c-0
cf f' V l_i-1-/1""t d1r- City/State/Zip: Y(arc-«G /i4-
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 DR for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature • _--� Date: 1a/t 0/zo i (e
phone ft; `{l3 - 2-er? - 2'z5-67
J 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
I.Board of Health 2.Building Department 3.Citytfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
iiR f rr /4 i Titi(f....0.4”..rt7,
�\ Office ofConsum Affairs&Business Regulation License or registration valid for individual use only
„a _J.NOME IMPROVEMENT CONTRACTOR
Vbefore the expiration date. If found return to:
- _ Registration: 165972 Type Office of Consumer Affairs and Business Regulation
Expiration: 4712/2018 DBA 10 Park Plaza-Suite 5170
`` '1 Boston,MA 02116
JL CONSTRUCTION
JARED LARAVEE
39 SWOL ST L._
CHICOPEE,MA 01013 �� —
Undersecretary Not valid without signature
CalMassachusetts-Department of Public Safety
Board of Building Regulations and Standards
Contra two Supenis tr
License: CS-1s0
• JARED A LARAVjZ -VIN 0
F
39 SWOL sr 5 1111-11111 (-
Chicopee MA 01443 ``,. ,
trim.-�j� , nvu's Expiration
Commissioner
01/062073 •
Oct. 11 .2016 10:50 Vales Agency - Farm Famil 14136658202 PAGE. 1
ACOROe CERTIFICATE OF LIABILITY INSURANCE 10/11/2016
1M5 GER-REIGATE IS ISSUED AS A RATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
ceawnCATE OCRS NWT MFQRNMI WLY OR NRGATRrtV ANGV, EXT N0 OR ALTER TRE COVI!MACE AFFON:EA BY ma POL/CMS
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ReStEMERNIXTBM ON PRODUCER MID:TUE CERTYICATE HOLDER I
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RK terms and condition d the NUN,certain WRNS may require an endorsement A atel¢ment on this *itIkate does not confer rgMs to O
certificate holder in lieu of such nldw,.meM e1.
PROD CER .W .CONTACT
NNE Amy Moray
WILES AGENCY FPZ) E ) (413)665-9200 jv°`c NPy5413)665-8202
1 Sugarloaf Street 'filet- ' nut
South Deerfield, MA 01373 ADD0r00amy.morey@Farm-£eerily.eom
41151.11551tM.555.55131116 sewers PAN
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MSVRE¢ )xSURER e. _ _ ,
Jared LaraveaIc.
1.
39 Seal Street nStwEna _�,...._
Chicopee, MA 01013 msypeu t.
INSORER F.
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Gone-CATE MKT RE ISSUED OR WF PERRTAW rW INSURANCE AFFORDED RT THE FMICIES O€Sf:NIBED RENEW IR 3OB$ CT TO AU FIE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POUCILS.LIMITS SHOWN MAY HAVE BEEN REOUC O By,WO Ct.AMS.
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CERTIFICATE HOLDER CANCELLATION
City of Northampton SHOJIS,ANY OF THE ABOVE DESCRIBED POLICIES aE CMNCEtIED SWOREi
Attn: Building Department s TOE EHYRATION DATE THEREOF NOTICE HILL OF FWNEREO .W
212 Main St. ACCORDANCE WT,{THE POLICY PROVASONS
Northampton, MA 01060 L_..
MRRUP REPRESENT w
FAX: 413-587-1272 Gn,ti ,F ,L114-€,(.61.,vv�i .1�JSS-2DICACORD CO RATION. Ail OEMs reserved.
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