17C-159 (6) 78 CHESTNUT ST BP-2018-1163
cls 9. COMMONWEALTH OF MASSACHUSETTS
Map'Block: 17C- 159 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:ROOF BUILDING PERMIT
Permit4 BP-2018-1163
Protect JS-2018-002090
Est Cost,$12000.00
Fee,$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sp.ft.): 9801.00 Owner: CORBETT ANNEKE S
Zoning,URB(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT. 78 CHESTNUT ST
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527-7663 O WC
NORTHAMPTONMA01061 ISSUED ON:5/8/2018 0:00:00
TO PERFORM THE FOLLOWING WORKSTRIP & 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 4 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:
FeeTWoe: Date Paid: Amount:
Building 5/8/20180:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
_ _. . Department use only
C ty of Northampton Status of Parmn
VAY - 4 2018 l3ilding Department Curb Cut/Driveway Permit
j 212 Main Street Sewer/Septic Availability
LI Room 100 Water/Well Availability
DF=r o=BUILDING INSPECTIONsNor hampton, MA 01060 Two Sets of Structural Plans
r<0:Ill A PIONM $7.1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIONI -SITE INFORMATION
1.1 Property Address This section to be completed by office
Map L rC Lot .Unit
q1C C 1�5 U y Zone Overlay District
Q r 1 111 Elm St District ` CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: �
n r e 1
Name( t) Curren)Mailing Address'. s O O L
�( t n Telephone
Signature
2.�2 Authorized Agent:
[ \
C, S1 �t1b0 awl Qb rS)t ri.4'� 1 �1M�1 dNw�VTd'
Name(Print) Current Mailing Address: �T
�TGti L--._�,tr� `I 12> S 1 . f t
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed bpermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 'f /J0
5. Fire Protection —I V
6. Total=(1 +2+3+4+5) 1 TUU ,Check Number .9057
This Section For Official Use 0
Date
Building Permit Numb Issued: { /�
Signal re:
Buildin mmissioner/Inspector of Buildings Data
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Ironinn b¢rII
Existing Proposed Acquired by Zoning
This column to be filled in by
Building Depertmem
Lot Side
Frontage
Setbacks Front
Side L,'. R ___. L ..__ R
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&pavedi.
Banking)
H fPa,kii,g Spaces -
Fill:
(volume&Coonan) -- —
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW Q YES O
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 8';
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
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 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO O
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 of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
Mew House ❑ Addition ❑ Replacement Windows Alterations) ❑ Rooting
0r Doors D
Accessory Bldg. E] Demolition ❑ New Signs [OI Decks [M Siding[0] Other[01
Brief cripticnof Proposed \ 1 �// (\may (�
Work <'MpJ[ eXrST lI r ' sr�A6� –lt xr � W 00
Alteration of existing bedroom Yes_No Adding new bedroom Vis No
Attached Narrative Renovating unfinished basement _Yes _No
Plans Attached Roll -Sheet
its. If New house and or addition to existing housing complete the followings
a. Use cf building Orel'anall Two Family 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. Number of stories
f Method of heating? Firepleres or Woodstoves Number of each
g, Energy Conservation Compliance. Masscheck Energy Compliance farm attached?
h. Type of construction
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
1. Septic Tank_ City Sewer_ Privatewell_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CCONTRA(CCTOR APPLIES FOR BUILDING PERMIT
1 ( l 7�q \y r–OQ as Owner of the subject
property
hereby authorize ' ✓ t/
to a runy eha f,In matt rs relati e k authorized by this building permit application,
Signature of Owuv ,.�� Oate
1 \1 /.n c \ H H Cl as bestOwner/Authorizedomyol
Agent ereby decl—are 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 antl penalties of perjury.
Print Name
Signature of OwnerlAgah Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suoerviser: Not Applicable E
Name of License Holder`�O\R, t z G g Q
License Number I
f� Tna i7
Atldress p
Expiration Date
1LCQa �1 ) 11 �`l
Signature Telephone
9.Registered Home lmpravement Contractor _. Not Applicable E
R? 6; :: a . \sa.t�'1-
Company Name t Registration Number
3a �A�� plc s � �A �.IR
Address p Expiation Date
e-o--A Telephone
SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurani,p affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of t e building permit.
Signed Affidavit Attached Yes....... £ No...... £
11. -Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(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. Shtli 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 care or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one loonue' two,,year period shall not be 'd J a 1
Such"homeowner"shall submit to the Building Official,eu a form acceptable to the Building Official,that he/she shall be
res '11 t 11 such work performed under the building 't
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 ofEmployers to
Employees for injuries not resulting in Death)ofthe Massachusetts General Laws Annotated,you may he liable for persons)
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.
Hmncowner Signature
The Commonwealth of Massachusetts
Department ofIAadusdrlal Accidents
d � Office Of Investigations
y 600 Washington Street
Boston,NIA 02111
www.me ss gow/rdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informations Please Print Legibly
Name (Business/Organization/Individoal): b Y\tt (f �7 C�
Address: _�-ck)? �< 4
City/State/Zip: Phone#:
Are ou an employer? Check the appropriatebox: Type of project(required):
1. I am a employer with 1 — 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. El New construction
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
wonting for me in any capacity. employees and have workers9. ❑ Building addition -
[No workers' comp. insurance comp. insural l
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L❑] umbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.L•-J,(Roof repairs
insurance required.] t e. 152, §1(4),and we have no
employees. [No workers' 131-1 Other
comp, insurance required.]
'Any applicant that checks box#1 must also frit out the section below showing their workers'compensation policy occultation.
tHo meowners who submit this affidavit indicating they are doing all work and thea hire outside connactma must submit anew affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-conhactors and state whether or at those entities have
emplaysce, If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information. 1
Insurance Company Name: I f\-( \��n Vi-� o r` \
Policy#or Self-ins.Lic. #: 6 S (a J)V ?> ^O� S 6 N 1 tl- 6 Expiration Date:( AZ_ 1 °t
Job Site Address: � 'r 0 \N<�J[ Sk City/State/Zip: V) kx y-e. r-_,
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
hivesfigations 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.
mi
Siat m R ML. 11Date:
Phon #� L( ) 3 ' 5-15'' 1 C1 fob
=Other
only. Do not write in this area,to be completed by city or town official
n: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
son: Phone#:
City of Northampton
;(+ Massachusetts �.
a
D212 Mains=XT OF BUSLDTYG ZITal Building w
212 Main Street o Municipal Building D�
.p NOlthamptoe, Mel 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" 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
I, understand the above.
(Homeowner/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
I
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: �) �: ���s }h J� S+
The debris will be transported by: 3 013 —TJK,b o
The debris will be received by: V,.\1e�,A �} e c r h
Building permit number: \
Name of Permit Applicant 61
Date Signature of Permit Applicant