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17A-039 (4)
200 BRIDGE RD BP-2017-0743 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 17A-039 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS jTTOTTHE TGU'/A'�RAANTY/FUND D((MMOLL c.142A) Category:window replan ed BUILDING ILDING r 1'lRMI 1 Permit# BP-2017-0743 Project# JS-2017-001237 Est.Cost: $40.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RANDALL ROBERTS 042573 Lot Size(sq.fl.): 11717.64 Owner: BERTRAM PAUL Zoning:RI(100)/URA(100){ Applicant: RANDALL ROBERTS AT: 200 BRIDGE RD Applicant Address: Phone: Insurance: 41 HEMENWAY RD (413) 530-2703 O Workers Compensation LEVERETTMA01054 ISSUED ON::12/2/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE 7 WINDOWS, U VALUE - .27 OR LESS 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 12/2/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner `` Department use only -1 /'z/ City of Northampton Status of Permit: / i Building Department Curb CuUDrlvewayPermit 1 / ti / 212 Main Street SeweriSepacAvaluability / /! 45j r / Room 100 Water/Wel AvailabilityAvailability,� Sl e- / Northampton, MA 01060 Two Sats of Structurai Piens� jtphone 413-587-1240 Fax 413-587-1272 Plot/Sits Plans ' ' '" d Other Specify -'CATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE � /OORR,/DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 89- /1-' / 3 1.1 Prro�perty Adtlresg: This section to be completed by office x(06 -B r i rias Rd Map Lot Unit ._._ Florence J Zone Overlay District _^ Elm St.District CS District _ SECTION 2-PROPERTY OWNERSHIPtAUTHORIZED AGENT 2,1 Owner of Record: iinti_ l -- )Prfrain aoo r�d� R l orer,ce (M ola, a NarnglPr-4 Curren n?ring rens' / �'YJ� i 7a7 - a3s a Telephone Signature Z2 Authorized Agent. 1 1044 R. -ri-ss of tieirenun,}/ Rd, i_eueref, mit 0/(0/ ._ Name ' Int / Current Mur athro,ccaS leos 4ti s s. iVG TeWphmne CTI 1. 3-E'TIMA DC! ST-.. CTION CO TS :tern Estimated Cost(Dollars)to be Official Use Onty .p�A.ompleted by permit applicant t. Building Irl 11°00 t 9 9 (a)Building Permit Fee -- 2. Electrical (5)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee I I 4, Mechanical(HVAC) I 5.Are Protection _ 'f� e 6. Total=(1 +2+3+4+5) iy oo©O , Check Number a iv All '' This Section For Official Use Only Building Permit Number t-ta Signature: , .../' /7� 2.'/t} 11111111=- Building Commissioner/Inspector of Buildings Date ko C - s �C7 Section 4. ZONING AU Information Must Be Completed.Permit Can Be Oen' D�e I pq piete trf rmation Existing Pr sed Re tired b i e N O/ y edfy 1J ing Department i Lot Size Frontage ... . Setbacks Front Side L:_. R: L R: Rear Building Height Bldg Square Footage Open Space Footage _. .. . . o {Wt arta minus trtdg&paved parking) Ss of Parking Spaces Fill: t'&ume&tncws,mi A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DONT KNOW tfYES 0 IF YES, date issued: IF YES: Was the permit recorded at theRegistryof Deeds? NO 0 DONT KNOW fk YES 0 IF YES: enter Book Page and/or Document N B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? \\\ Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: p,Q D. Are there any proposed changes to or additions of signs intended for the property? YES a NO -'4�(Tf# IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or tilling)over I acre or is it part of a common plan that will disturb over I acre? YES O NO a IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check all apmlfeeble) / } _ 41C)G • oie' New House ❑ Addition ❑ Replacementjdows Alteration(s) ❑ Rooting 0 Or Doors Accessory Bldg. C Demolition 0 New Signs i1J] Decks Ip Siding 5C31 Other[m WorkBrief Descriptigrsyf P sled (- a ., dot,* • 'Mri dote)// c /meq Alteration of existing bedroom Yes 7 No Addingdingnew bedroom Yes f, ` No -Y-C�n� V 5" "ta r Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and oraddition to existing housing,complete the following: Y-- a. Use of building:One Family Two Family Other_„_„ b. Number of rooms in each family unit: Number of Bathrooms /` rr h c. Is there a garage attached? t---4.C> G e---- di ^-- 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? In. Type of construction i. Is construction within 100 ft.of wetlands?„ , ,Yes _ No. Is construction within 100 yr. floodplain YesNo I. Depth of basement or cellar floor below finished grade S. W0 building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private welt City water Supply SECTION 7a•OWNER AUTHORIZATION-TO BE COMPLETED WHEN • NERS AGENTORCONTRACTOR APPLIES FOR BUILDING PERMIT I, ?Qu / �? ('f2LL "as Owner of the subject property + ' 1 Q('^/� iF,� hereby authorize 1s4z+4_ II ) T'�t, �j ex---k to act o my bppehalf in all matters relative to work authorized by this building permit apcation. Signature of Owner Date +y I, Q ccvaatm U ` ' D V e.,,,C4 ___ as Owner Authorized A.ent hereby declare Nat the statements and infomlatio on a foe foregoing application are true and accurate,to the best of my know ge an• •eief. Sigd Cunder the pal s and nalties of.1.).- ury. N� e li� 45P a ar 1E"-- Print Name 1 Signature of Owner/ enl Date 1/Z-57771g • SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /� ' " Y Not Applicable ❑ Nome of License Holder: rv{a I I eaf 2O1'LIt_`T'5 o4 5 /bl3 License Number i Hernen.ot& Rd Le kJ-ere-Ft rnA oio;3(,— t1$ t g Addre s Expiration Dat LS*, 1113-530-x703 dna ir- ` Telephone 9.Registered Horne Improvement Contractor: Not Applicable Cl R1 . 4. , • s :ra 1 e•nett /098? Company Name Registration Number 41 Ne i R _ Leser i . oto`� ?1/.542x1 Address - Expiation ate Telephone 413 .5.31; -2703 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8)) 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 H No ❑ 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,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 he 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 peimit. 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: ;Roo &ri d3e Pvl Aorence The debris will be transported by: Ru.rvlall Rol rks The debris will be received by: I fpi,thl tc, .evince S Building permit number: Name of Permit Applicant TI ar.tt 13er-From 76L Date Signature of Permit Applicant i t/a 5 .6 • • The Commonwealth of Massachusetts Department oflndustrialAccidents -m'Nu'5' 1 Congress Street,Suite 100 "- 1= Boston,MA 02114-2017 wll www.mass.gav/dia t1'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumoers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly • Name(Business/Organization/Individual):Randall E Roberts DBA Window Works Address:321 Russell ST City/State/Zip:Hadley, MA 01035 Phone#:413-530'2703 — — a Are you an employer?Check the appropriate tor: Type of project(required): I.0 I am a employer with 5 employees(full and/or part-time). 7. Q New construction 2.0'am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.(No workers'comp insurance required] ] 9. Demolition 3 I am a homeowner doing all work myself(Noworkers'comp insurance required]' 10©Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all convenors either have workers'compensation insurance or are sate 11.0 Electrical repairs or additions proprietors with no employees, 12.0 Plumbing repairs or additions 50 I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.DRcwfrepairs These sub-contractors have employees and have workers'comp.insurance) 6.0 We are a corporation and its officers have exercised their rightof exemption pr.MGL u. 14.['Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inibrmation. '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 fox must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp_policy number. I am an employer that is providing workers'compensation insurance for ny employees. Below is the polity and job site information, • Insurance Company Name:Wesco Insurance Company Policy#or Seif-ins.Lie.*W WC323t 176 Expiration Date:1 011 91201 7 Job Site Address: All Locations 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 MGL e. 152,§25A Is a criminal violation punishable by 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$230.00 a day against the violator.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 pains and penalties of perjury that the information provided above Is true and correct igtature: pate: Phone SP 413-530-2703 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#: 'S''' o tm,n*n eellho� Ors ofCaonmar Atter' et } Rebdadm License or rebtrnWaa wad for tad/Maid at out R HOW IMPItOVIBIENTCOBIRACTOR edam the espinYm data. Ttbnd retsina On e ^ Raaab/Jo; men 1YPa; Office ofCao uaeARan add Badness ArSehibn Expiration. )11&2018 OSA 10 Park Pleat•Sake 3170 RANDALL E,ROSEitriSGENERA4COMM Boston.MA 02116 Randall Roberts 41 Hememvay Road o-r-s-w .-- Lotted MA 01064 Cd oy sigasiare • Massachusetts Department of Public Safety \ Board of Building Regulations and Standards License: CS4/425T3 Construction Supervisor _ V 'eEid i 41lr11 AY.7. 1 awawrr MA4 1 NCS ,: