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25A-075 (9) 59 COOLIDGE AVE BP-2017-0798 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A-075 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-2017-0796 Project JS-2017-001326 Est.Cost:_$6000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group; BOB THIBODO ROOFING & SIDING 065699 Lot Size(sq.ft.): 5314.32 Owner: BRESNITZ VIVIAN Zoning:UR_Ei(I00N Applicant: BOB THIBODO ROOFING & SIDING AT: 59 COOLIDGE AVE Applicant Address: Phone: Insurance: P 0 BOX 201 (413)527-7663 O WC NORTHAMPTONMA01061 ISSUED ON:12/20/20I6 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF POST THIS CARD SO IT 1S 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: FeeType: Date Paid: Amount: Building 12/20/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240.Fax:(413)587-1272 Louis Hasbrouck-Building Commissioner -"� "r 4f •Depadmeo)=useunly_ ' City of Northampton Stewsg rermn I s +Iry s 512 h r� 5,y�t 9 Building Department c�r8�at/D`t�vewa�persn ` ,Ari , 4 \ 212 Main Street Sewer/Sep icAvairceatty ax i u- - *gfi tl 1 ROOm 100 Water''''&-- vadabutty + ''+ j Northampton, MA 01060 Twwffs-'e`tygfSti`yttuFAPraBg iik' r" ' '`��, M 'phone 413-587-1240 Fax 413-587-1272 PIaf gnIanses'4, _ T4 r.,acs —a. a dam- ti z4' v -; ' [ t,6 r- ' 'i • ••LICATICN TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH� A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION - /6P-/7- 7 6 d r 1s Tdie4 ction'fo be Andlefetl by orffice 1.1 Property Address: L s Ae"- �}ax s aMzp +,'DigDaaaras-4 r 4 3',7z.Gots s 4 Unit - 5 � = - t4 O ', 1 C �\ r f Zone mpdr Ov s-,Dl--nc£ b;'r r Ay=�V 1 3rr�i Trs'w r - r y w's'i. ElmSt D trct� _ fr)+rCB Dst ct '.T SECTION 2--PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: - :V 1n1VM 3 C-eSnv�Z Sri Coal : ' . -c 4‘.11(Name riot) Cu tMailin Address: \ 1.t+ Tele ane SignatuM 2.2 Authorized Agent 1 y Nam- (Print) C nent Mailing Address: L ed �� t Signature Telephone SECTION 3-ESTIMATED CONSTRUCT ION COSTS. Item Estimated Cast(Dollars)to be - Official Use Only completed by permit applicant 1. Building '(a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construdicn from(6)- 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 'c�6. Total =(I +2+3+4+5) 0 0 cD Check Number 4.14 /Qp7411 , This-Section For Official Use Only Date Building Permit Number: ',/(�/� Issued: Signature: ' / ✓ Pel la-a0 raJ/ Building Co Iss�spector of Buildings Date Section 4. ZONING AD Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This coi n to be flied in by Building Department H Lot Size i M 1 _ ; Frontage ) Setbacks Front I I I 1 F-1 Side 1.2r-1 Ry--1-1 L:t J R:I I I-1 Rear LJ L__ Building Height II 1 I 17-1 Bldg. Square Footage I 1 1 % 1-----: f L_J - Open Space Footage l i f (Int area minus bldg&paved ,J T I parking) T-1#of Parking Spaces C J %_ Fill: Wawa&Location) A. Has a Special Permit/Variance/Find©ever been issued©on the site? NO 0 DONT KNOW YES IF YES, date issued:] ___j IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW YES (3 • IF YES: enter Book 7 Pagel t# and/or Document B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O - Obtained Q , Date Issued: I C. Do any signs exist on the property? YES 0 NO 0 i IF YES, describe size,type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q IF YES, describe size, type and location: i 1 E. Will the construction activity disturb(clearing, grading, excavation,or filling)over 1 acre oris it part of a common plan that will disturb over 1 acre? YES Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. •• 1 SECTION S-DESCRIPTION OF PROPOSED WORK(cheek all applicable) —�' Naw House Addition Or Doors Windows Alteration(s) + Roofing F� rr—�� Or Doors O Accessory Bldg, Demolition Ell New Signs [p] Decks (q Siding[MI Other[DI Brief.- ptien of Proposed " Work: t t` •& • (\a , Sr. -_ . 0 _\ GV —vw; \ ' y Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 4If New hoD"saand'oraddition toexffiHq F ousinq,'compjdte the akiaria 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 Weedstoves 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 I. 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, V YNJ 1 Ar, 5 n Ai---C., as Owner of the subject 't property ��+�'� ` hereby authorize ______ >1%-,if"--7, 11 rC� ib fbrl to act on my behalf, in all mat rs alive to authorized by this building permit appl cation ,�C , �„ cation \ 1 C Signature of Owner Date I,— " `, 0 W ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief, Signedunderthe pains and penalties of perjury ed . ` K,� ''ONO Co U Prim,Noma 1p} 6 Signature of Owner/Agent Data r SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: N/ott�Ap�plicante F. Name of License Holder'. >: _ a � L../_d,. � y Licenseldumber Atl ress Evpiation Date Slgnatu e Telephone 8.pe e doomeirnprove @n»d actn _ ,,,_ .- .u..._ Not Applicable £ \ S 011 "1'1.— Com nY Name Registraho Number L y Addressc7 D e5 "3-0 1 f f1 �'d .^" , ._�� Exp ati r Dat S,. � Telephone S t Si] -‘ — 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 wilding permit. Signed Affidavit Attached Yes... £ No £ 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 108.35.1. . Definition of Homeowner:Person(s)who own a parcel of land an 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 ase and/or farm structures.A person who constructs more than oue 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 shell 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,von 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 .... cA The Commonwealth ofMassachusetts b• — Department of Industrial Accidents e. VW= Office of Investigations 600 Washington Street rrat -' net Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(EusinessiOrganfaaloolndividual)__. lob s 'a % a Address: US 'i i `II - City/State/Zip. ► _ *� \\} Phone#:. —! 1 ,•—•,Ar+ you an employer? Check the appropriate' ox: 4. I am a general contractor and S Type of project(required): I. I am a employees (fuer with 0 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [Remodeling ship and have no employees These sub-contractors have g, ❑Demolition world forment any capacity. employees and have workers' ? P '} 9. ❑Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions 3.[ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' camp. right of exemption per MGL 12. Roof repairs insurance required] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required."' �..'— 'Any applicant hat checks box#1 must also Lill out the section below showing thea workers'compensation policy information. TRo meowners who submit this affidavit indicating they are doing all work and thee hire outside contractors mast submit a new affidavit indicating such. eConnactors that check this box must attached ml.additional sheet ohowing the name of the;sub-contractors and state whether or not those entitles have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ,,, -{ \\ 1 Insurance Company Name-: \ F-('S k \,)1- Chi \ c.,v 1 .._.... Policy#or Self-ins. Lie. #:(--$ 6 C) \..)an—n— OCT SON kl1 Expiration Datt�e:' .. - '(� ���" Job Site Address: SC\ tp n \1 A t\^ MIA, City/State/Zrp: 1 I b�/ �\-'w Y vv' Attach a copy of the workers'compensation policy declaration page(showing the policy number and exptrarion date). Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.40 andfor one-year imprisonment, as well ascivil 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 DLA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above' is true and correct. S'...attire: .r . , e- Date: \a \, V\\ � , Phone#: GTh S t 9 6- \ _ 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 ' • IContact Person: Phone#: -,- • City of Northampton % a Massachusetts spa : iK. (� y . 54 DEPARTMENT OF BUILDING INSPECTIONS i, I - t + 212 Main Street • Municipal Building Ct . - a`7/ 4 rorthampton, MA 010600 - TNSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 908.3.4 to act as his/her construction supervisor. The state defines "Homeowners as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. if the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made !, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location 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: Cb 1 ; A (3Vg The debris will be transported by: 1?-, Q r) The debris will be received by: V $� L t 1 t\.\\\, Building permit number: Name of Permit Applicant pJ o ( -Nc\ Date Signature of Permit Applicant