23B-008 (10) 15 STRAW AVE BP-2017-0770
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23B-008 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-0770
Project# JS-2017-001281
Est.Cost: $5000.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq.f): Owner: PERMAN GARY
Zoning SI(I001/ Applicant: JAMES ROBERTS
AT: 15 STRAW AVE
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
W ESTHAM PTO N MA01027 ISSUED ON::I/5/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR SMALL SECTIONS OF ROOF 8
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 rt Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: OI: 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 1/5/20170:00:00 SI00.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Version1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Status of Permit:.
Building Department Curb Cutf06veway Permit
�� 212 Main Street SeweoSeptic Availability
Room 100 Water/Well Availabltfy
\ Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLI •TION TO CONSTRUCT,REPAIR,RENOVATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address' This section to be completed by office
Map Lot Unit
Zone Overlay District
-- -- - - Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Re/co}rd�:
f(� /�
eet
Name(Print) / f Current MailingAddress
Signature .41,....€4-dor ,,,/// 1 Telephone
2.2 Authorized Age /'
Name(P(nt) f Current Mailing Address
4.
Signature T.. Tom/ 7 /
/C2 ear Telephone � 7 v t/
SECTION 3-E 1fIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
col deted b •ermit applicant
1. Banding f� (e)Building Permit Fee
2. Eledncai
(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) Check Number jr�j '��
This Section For Official Use Only
Building Permit Number Date
Issued
Sig ���/ r /7
. !
SNltlln:om iss• ernspecturni6uldtngs I ate
/36 _dot
Version].7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs 0 Additions 0 Accessary Building 0
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use Other 101
Brief Description Enter a brief description here.
Of Proposed Work: f mauu o /;n(( 01 yVi py... / _.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ Al- 0 A-2 0 A3 0 IA 0
A-A ❑ A-5 0 1B 0
e Business ❑ 2A ❑
E Education! 0 2E I 0
F Factory 0 F-I 0 F-2 0 2C i ❑
H High Hazard ❑ 3A 0
Institutional ❑ 1.1 0 1-2 ❑ 1-3 ❑ 3B r ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 0 R-2 0 R-3 0 5A ❑
S Storage ❑ s-1 ❑ S-2 ❑ 5B ❑ 'I
u Utility ❑ Specify _... . .. .... . _ ._ .... .
M Mixed Use ❑ Specif".
S Special Use _...p Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS.ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: _ ..... Proposed Use Group: __....
Existing Hazard Index 780 CMR 34) _._ __. - ._ Proposed Hazard Index 780 CMR 34)SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
2"
aro _...
Total Area(sr) sets!Proposed New Constructionist)
Totsl Height(ft) _
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7A Flood Zone Information: 17.3 Sewage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone❑ i Municipal ❑ On site disposal system❑
Versionl.7 Conumeicilal Building Permit May 15, 000
fi. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This stluv:n tete filled m by
Building Department
Lot Size _
Frontage . .. .. _.
Setbacks Front -
Side I R-_. _ - L: R
pni
Building Height
Bldg Square Footage
Open Space Footage - .... % _._. ........
(leg area minus bldg&paved
'laking)
P of Parking Spaces ----
hell.
,volume&tocabon) _ .. ..._ _.
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page and/or Document k
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and tocat ion:
D, Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0
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 ofa common plan
that will disturb over 1 acre, YES Q NO Q
IF YES,then a Northampton Storm Water Manageme_Permit from the DPW is required.
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
_. ..__., _.... _.,. Not Applicable 0
Name(Reoistrani):
R9 trabon Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineers):
Name Area of ResponMbl ty
Address Registration Number
Signature Telephone expiration Date
Name. __. _. _... _. Area of ResponsibilN
Address Rey mrat on NumGe'
Signature Telephone Expiration Date
Name _.. Area p£RaspCnSibitity
Address _.._. ...._.. Registration Number __...
Signature Telephone Expiration Date
Name Area of Responsibility
Ndtlress _. _. _... _
Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Nut Applicable
Company Name
Responsible In Charge of Construction
4drl rebs _.. .. _.
Signature Telephone
Version'7 Commercial Building Permit May 15, 2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) /`�
YIndependent Structural Engineering Structural Peer Review Required Yes 0 N U
SECTION 11 .OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, _5. i 'as Owner of the subject property
hereby authorize i� . ;l/. --- // .. air_. _ _. _ .. . to
act on my behalf, in all ma relative to w�orpk authorized by this building permit application
Spate of Owner / Date
i _ ,as Owner/Authorized
Agent here. de •re that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of permi
rf fi %AP -, -_
Prim Name _.
/
signature of Cwmxiaaent.-...... Cate / / - ....-...-
SECTION 12-CONSTRUCTION SERVICES
10,1 Licensed Construction Supervisor: Not Applicable LI
Name of License Holder , if......... „a., ? !�i. '” -
D 4 t-
ee- r License Number
,_, Expiration Date
/ ..� ,� - .(17 6_____Address /9/5d
&gnats i Telephone
SECTION 13-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 building permit. _
Signed Affidavit Attached Yes 0 Na 0 ---
The Commonwealth of Massachusetts
Department of Industrial Accidents
- Office of Investigations
=r '--t ; 600 Was/Sown Street
Boston, MA 02111
www.in ass,govkfia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(3151ess/OS nstion.andivid.at): y,y dA i/ 'ale
..da ss 3 ; c� -•
� ir 1 i
City/State/Zip: ,/� Phone:i: .e; — .I
Are you an employer" Check the ..proprlate box: Type of project(required):
1.C._ Iamaployer with 4. I I am a general contactor and I
�x 5. ❑New construction
emnt nes(Pali andtor part-time,).' have hired the sub cnnvacmrs
2. am a sole proprietor or gamier. listed on the attached sheet. 1 7. 0 Remodeling
ship and have no employees These sub-comractors have 8. 1 Demolition
workingfor me in anycapacity. employees and.have workers'
[No 9. 1_ Building addition
workers' comp.insurance Wecoarp.e
La corporation required.]
5. I I W e area corporation and its 10.0 Elec ical repairs or additions
officershave11 rPlumbing repairs or ations
3.� I am a homeowner doing all work exercised their =-� ddi '
myself [No workers' comp. right of exemption per MGL 12.1 Roof repairs
insurance required] t c. 152, §1(4), and we have no
employees. [No workers' 13.: ] Other
comp. insurance required.]
Any applicant the:checks box pl must also fill out the section below showing thew workers'compensation Policy inita:manon.
f'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 nano of the sub-contractors and state whether or not those entities have
e mployees. If the sub-contmcters have employers,they must provide their wodtrs'comp.poly number
I inn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: �J/
(✓' ,,._ _
Policy 11 or Self-ins.Lic.fir Expiration Date:
Job Site Address: 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 Station 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
Investigattions of the DLA for insurance coverage verification.
I do hereby certify under II • Joins and penalties of pedal),that the information provided above is true and correct
Siengeme: Date:
Phone r:
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Permit/License d
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. CitvlTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 4:
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: /517-C4-010/79---.
The debris will be transported by:
The debris will be received by:0, ` -4? r
Building permit number:
Name of Permit Applicant / 714 40P"
C -j
Date V/ Signature of Permit Applicant