42-015 (2) 242 WEST FARMS RD BP-2018-1083
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.Block:42-015 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catejamy: ROOF BUILDING PERMIT
Permit# BP-2018-1083
Proiect# JS-2018-001951
Est.Cost. 86500.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
UseGroun: JESSE BABCOCK 107350
Lot Suefsq. ft.): 59677.20 Owner. IYASTOUS GEORGE I&GERMAINE E
zommz� Applicant. JESSE BABCOCK
AT. 242 WEST FARMS RD
ApplicantAddress: Phone: Insurance:
77 OVERLOOK DR (413) 530-3680
FLORENCEMA01062 ISSUED ON.•4/25/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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:
FeeType: Date Paid: Amount:
Building 4/25/2018 0:00:00 540.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
i t23 I ' II APR
erkuse only
Curb CWDriwray Permit
�..A. 212 Main Street Sa ansePic Ava;pbiry
'! Room 100 WalsoVYe2 Avaibity
Northampton, MA 01060 Two Sens of Structural Plans
- _ phone413-587-1240 Fax 413-587-1272 PbusitPlane
Other specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION,-SITE INFORMI1T10N 6 - 1 .5 (0 8 a
nn
,., lonoixorth,Addresia,
CC�.TNa saction b W completed by office
Map�_ Lot Ure,
Daarby Ilfabict
Elm St."atria CB BfeWat
SECTION 2-PROPERTY OWNERSHIP/AURgRIZ AGENT
21 Owner of Record:
gAI'mL: 0ASTOa5 a/�s9 �+risll��/r��Qr �/�j�i7-
Telephone
Sgna[ure
22 Authorized AaeM:
�jGac� Z
Name(Prim) Cunem Mair,Adorese:
c
Signature TelelMerw
SECTON 3-ESTMATE0 CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
cornpletedb rnat applic,int
1. Building - / (a)Building Pennit Fee
So Od,aG
2. Electrical (b)Estin rte i Tall Costof
Construction from 6
3. Plumbing Building Permit Free
4. Mechanical(HVAC) / a
5.Fire Protection
6. Total=(1 +2+3+4+5) 60d .0d Check Number SJ
This Section For Official Use Only
Building Permit Number. Dab
Issued'
Slgrwture:
nuldtig o�wrnrepeG«a6afl� Date
JOSE�T(30P.-r,CY @ Gmg-IL
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING AIL Information Haat Be Completed.Permit Can Be Denied Dae To Incomplete Information
Existing Proposed Required by Zoning
This colvmv to M fium w by
Bwldw8Dvpanmmr
Lot Size
Frontage
Setbm:kv Front
Side L R L_R
Rear
Building Height
Bldg. Sq.Footage
Open Space 1-mlage %
(Int.miv.bldg a R'v
aro- )
#of Partatig Sp.
I ill_
rvl®ealncffioe
A. Has a Special Permit/Variance/Finning ever been issued for/on the site?
NO O DONTKNOW O YES O
IF YES,date issued:
IF YES: Was the pemnt 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 O
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 Wit the construction activity dishrrb(deanng,grading,excavation,or filling)over 1 acre or is it part of a common plan
thatwilldisairbooerlaae? YU0 NO O
IF YES,then a Nornampton Stmt Water Management Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORK(check all aoolice
Nev,Fblae ❑ Addition ❑ Rr acerrlrxlE![ndows I Alteration(s) ❑ Roofing -
Acceaeory Bldg_ ❑ Demolition ❑ New Signs 01 Deeks Cl Siding Opt ,[Other® )
Work ascription oT Proposed . �zG Cf/ �� G ✓ �Q I'LCuaCC Sk,��la✓1
Alteration of exstirg bedroom_Yes No Adding new bedroom YesNo
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
so If New house and or addition to eldsfllla housing.oomdete the following
a. Use of buildingOne Family Twa Faotlly Other
b. Number of rooms in each family unit Number of Bathrooms
c. Is there a garage attached'
J, Proposed Square footage of new construction. Dimensions
e. Numberofstones?
f. Method of heating? Fireplaces or Woodstoe Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of mrstruchon
i. Is constud.n within 108 R of wetlands? Yes No. Is construction within 108 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_ Pmata well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETEDWHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILODING PERMR
I, c2C o/q,Q N G 0 Ll J as Owner of the subject
property
herebyauthonze
to ad on my behalf,in all matters relaliv towork authorized by this Wpermit
building application.
Lil-ma �r° -k LZ trM-q
SignaWre mOnner pate
1• ;7LS 5' swye al- ,as O./Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the bear of my knowledge
and belief
Signed under the pains and penalties of perjury.
Kira Name
l
Sgrawre erlAgent
SECTION 8-CONSTRUCTION SERVICES
..aMC Fmou:tim S�llw: Not Applicable ❑
� s4e a /5-ov50
Nanr Gt 11�E01190_1101E9: _. lSefs4 Nut f
�� hadf D/fEtK j'G`rt�u' �/U(AG bjab'�` ,�S-L8 - 7r°( �
a�a TekplwrK
A RmLLlwad Moms b"P "W"Cooklo r: "Applicable ❑
S�ZIw t /3vr7s /��
17 ,V705
Re mftwE Numb°jW'
7? a4K+/r�.E �riti/ flcl�Lc 1'hfti bLrfv `�II�OiI
Add.,m Fxp rabon Date
Tet eptnre Yts.,53a�36a'a
SECTION lA WORKER5 COMPENSATION INSURANCE AFF7DAVrr(M.G.L.0.
V obkmCnTensafiontnsaa aflWavitnxestbecompletedar &ubvftdwM*mapp�.FaiWfeto-pmvi&fleaaffidav@vAHMs
in fha denial of the i55tlanw of the building
permR .,
Signed Affidavit Atteched Yee.._._ No...... ❑
City of Northampton
s -
r Massachusetts + y
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10edRDffiN1' QF 8[/ILDIIR; �rars �
212 191n atavP[ . Manic p 1 auildi J
NoriLa• ' ax 01060 S'f�F 3'-��•`
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to firm fancily homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the`reconstruction,adoration,renovation,repair,modernization,carversion,
improvement,ramova(damoldfari,or construction of an addition to any preexisting owrrer-occupied building containing
at least one but nU mora than/ora dwelling unds___or to structures which are ad(acert to such residence orbuftng?'be
done by resister ed contractors.
Nae:If the horneowse`has contracted with a emporatioa or LLC,that entity must be registered
Type of Work' ✓c14,h-5 4 p/J ,g� EsL Cost J g J'q 'I
Address of Work: rS/ �'qzs It // ;zwy'IKt'i,T 1,/ ,10
— /
Date of Permit Application:
1 hereby certify,that:
Registration is not required for the following reasom(s):
_Work excluded by law(explain):
Job under SI,000AII
_Owner obtaining own permit(explain):
_Building rmt owneroccupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A SUCH OWNERS ALSO ASSUME THE RESPONSIBEL TES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
Y/$/' /13 d?'Wwwt / 7 / 705
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
s .
Dlaaeaehus trs
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1
zaz �In sa . n. 0e ao e.iraanq c°
ewrUnaprm, ew so
Massachusetts Residential Building Code
Section 110.R5.1.2
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 farts structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section 110.115.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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 thejob 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 Commonweahh of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 027/4-20777
www.mass.g"Idla
Workers'Compeenatiou Insurance Affidavit.General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A�Dlicant Information Please Print Legibly
Business/Organization Name: .��s/�o,�t' //Ovl�f/S Z
Address: 77
City/State/Zip: /Z4irvna'c D y7L i. Phone#:
Are you an employer?Check the appropriate box: Business Type(required):
1_Q I am a employer with employees(full and/ 5. ❑Retail
or part-time).' 6. E]Restatmant/Bsr/Fsting Establishment
2.IL9.I am a sole proprietor or partnership and have no 7 ❑Office and/or Sales(inclreal estate,auto,etc.)
�� employees working for me in any capacity_
[No workers'comp_marauee requuedl 8. ❑Non-profit
3.0 We are a corpomtton and its officers have exercised 9. ❑Entertainment
Brew right of exemption per c. 152,§1(4),and we have 10[]Manufacttuing
no employees. [No workers'comp msmance required]'
4.C] We are a non-profit organization,staffed by volunteers, I101laidth Care
with m employees_[No workens'comp.insurance req.] 12[]Other
'Mya,laas Wan Aok haxbr vast also fflgun We x —Icbw Avoisia Warwo 'rmp®abn poik,ierosmatiou.
'•IfW mryorateod lova eoaPiai Wenselos,but We capaalbn ha oWa empbyeo,a aakas'asnpamon polity is na red and suchen
orgy tae shouldao*box M1.
lammsemp(oye "itpovidnrgworkers'mxgwxsaioninwrrunorformyemployeec Bebwirdaepoticywformadon
Insurance Company Name:
Insurer's Address:
City/Smte/Ltp:
Policy a or Self ins.Lie.4 Exphation Date:
Attach a copy of the workeni compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as regnrted under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500 00 ad/or ore-year impcisomnent,as well w civil perWties 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 imsumnee coverage venfication.
/da hereby c tlu alta ofpnd.7 decokehrfomratim parfded n bne and correct
Sim rare' � r( ?/ Dat yi v 0
Ph..4 ZYl3 � ✓/'�-36� /
WW141 use Doty. Do riotrwae in Air mea,m be complied by shy or maw ggiciaf
City or Town: Pernfluurense g
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/1'own Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone N:
.nw.mws.soaWa
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers compensation for their employees.
Pursuant W this statute,an employee is defined as"...every person in the service of another under my contract of lure,
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 of a deceased employer,or the
receiver or trustee of an individual,partnership,association cr other legal entity,employing employees. However,the
owner of a dwelling house baying not more thou tluee apartments and who resides therein,or the occupant ofthe
dwelling house of another who employs persons W 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 W be an employer"
MGL chapter 152,§25C(6)also stales that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit W 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 lire commonwealth nor any of its political subdivisions shall
enter MW airy contract for the performance of public work until acceptable evidence ofcompliance with the announce
unce
requirements of this chapter have been presented W the contracting au0rorim,"
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insumme company's name,address and phare number along with a certificate of insurance.
Limited Liability Companies(I,LC)or Limited Liability partnerships(LLP)with no employees other than the members
or per ora,are net required W carry workers'compensation insuunce. if an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be subrinned W the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit The affidavit should be retuned W We city or town
that the application for the permit or license is being requested,not the Department of IMusitial Accidents. Should you
have any questions regarding the law or if you are required W obtain a workers'compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance Boerne number on the
appropriate line.
City or Town Officials
Please be sue 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 W contact you regarding ilc applicant.
Please be sure W fill in the permit/lice im number which will be used as a reference number.In addition,an applicant that
roust submit multiple permit icesse applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proofthat a valid affidavit is on file for futire permits or licenses. A new affidavit
most be filled out each year.Where a tame owner or citizen is obtaining a license or permit net related to any tormisms
or commercial venture(i e.a dog license or permit W bun leaves eW.)said person is NOT required W complete this
affidavit
The DeparWent's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston,MA 02114-2017
Tel. #617-7274900 ext 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
FounR -ad02-11-15
City of Northampton
/ Massachuaetta ,f r�(`
D212 x 1S ar 'MnlT INS ldi,,
212 Nafn stxeec . , M 01 a�ai'a+^�
ao�tta.prm, w. ovoso
Debris 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
Z-'ZL lc&Jf i�r/ltS &
(Please print house number and street name) �T
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
f�ssb�, /3or/a�s�n tt,0�,Ab-1/3S z J4/,47 St.
(Company Name and Ad ass)
Signara Permit Applicant or Owner Date
If, for any reason,the debris will not be disposed of as indicated,the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.