17C-265 (6) 104 NORTH MAIN ST BP-2018-1175
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 17C-265 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-2018-1175
Proiectk JS-2018-002106
Est.Cost:$12000.00
Fee $70.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sa. R.): 15071.76 Owner: COE NORMAN A&3ACKLYN A
Zoning:URB(100 Applicant, BOB THIBODO ROOFING & SIDING
AT: 104 NORTH MAIN ST
Applicant Address: Phone., Insurance:
P O BOX 201 (413) 527-7663 O WC
NORTHAMPTONMA01061 ISSUED ON:5/9/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE SLATE ROOF, PLWOOD, RESHINGLE
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:
FeeTvne: Date Paid: Amount:
Building 5/92018 0:00:00 $70.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
h
Department use only
City of Northampton Status Of Permit
�. Building Department Curb Cut/Drive"Permit
212 Main Street Sewer/Septic Avallablity
1 • ')��� Room 100 WatertWell Availability
Northampton, MA 01060 Two Sets of Structural Plans
\;. phone 413-587-1240 Fax 413-587-1272 Plot/Ste Flans
Other Speafy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Prooertv Address'. This section to be completed by office
Map- Lot �i a,,'5— Unit
1 O L ( 1�1 •-�A p 1 T. I � l _ Zone Overlay District
OL— (
1 '\ 1� 1` �" Elm SL District CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam Pdn) cument Mailing A dress:5� S S
Telephone �1
Signature
2.2 Authorized Agent:
� ossok CA,24
Name(Pring Cument Mailing Address: 1
� U S-15 1Gtil
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by eermit 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)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Oficial Use Only
Date
Building Permit Numb Issued {
Signa re: J
B Acting C issionecinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled m by
Bonding Department
Lot Size
Frontage
Setbacks Front
Side L: It U R
Rear
Building Height
Bldg.Square Footage -" % - -
Open Space Footage
(Lot.vee minus bldg&pevN _..
rkin
#of Parki ng S paces
Fill:
(volume&Lacetion)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T 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 Q , 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 ® NO O
IF YES, describe size, type and location:
E. Wil 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 O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r
SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all applicable)
New House ❑ Addition ❑ Replacement Windows Ali lon(s) ❑ Rooting
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[Ell Other IpJ
Brief L�s�nption of Proposed \ ` O sl -
Work- �l =oVC ] IA 6 �S�L. %0 eo d Air
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes -No
Plans Attached Roll - Sheet
Ba. If New house and or addition to existing housing, complete the following'.
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?
J. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservallon Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
i. Is construction within 100 R. 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_No.
I. Septic Tank_ City Sewer Private well_ City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize O
to act o half, in alla relative to work authorized by this building permit applicatio .
Signature of 04ner Date
as Owner/Authorized
Agent h reby d clave 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 perjury.
Print Na e
5 �
Signature of Owner/Agent Da
1
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: C�\) ( •\! i 4r Cj
1LICen 2 N
Address Expishoh Dale
Signature Telephone
S.Re istered Home Improveontractor, Not Applicable ❑
Company Name
�l\ \ Registration Number
A�e. t V� �-1D. N
A,�"d�res�s ��(� Expna bn Da
Ra l � Telephone5l S CI (e1
SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6()
Workers Compensation Insurance affd vit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil Ing permit.
Signed Affidavit Attached Yes....... d No...... ❑
_ City of Northampton
( Massachusetts
DEPARTMENT OF BUILDINGi INSPECTIONS
St
212 nein reet eMun010 Building
Northamptoo !A 010n, 60
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 four family 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, alteration, renovation,repair, modernization, conversion,
improvement, removal, demolition, or construction otan addition to any pre-existing owner-occupied building containing
at least one but not more than tour dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered.
Type of Work: Est Cost:
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under S 1,000.00
_Owner obtaining own permit (explain):
_Building not owner-occupied
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 RESPONSIBILITES 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:
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 4
Massachusetts
�• s
DEPMTMENT OF BUILDING INSPECTIONS
212 Bain _the • Mup 010 Building y CD
NortAamp[on, MA 01060
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 farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section i 1025.1.3.1
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 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 permit.
City of Northampton
6
Massachusetts
._A L
I DEPARTMENT OF BUILDING INSPECTIONS 3
212 Main Street •Municipal Building n„ 4
Northampton, MA 01060 hiy �1
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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
I bt-1 Irl �� S4' yor "
(Please print house number and street name)
Is to be disposed of at
V A\1 - ) �cC� C��
(Please prini name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
. o-\� ) '1�: 10 a 1&, —Z- s�.4 w. wIx S)�" 6sf y
(Company Name and Address)
�..� 1
Signature of 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.
r�
The Commonwealth ol"Massachusetts
Department oflndustrial Accidents
1 Congress Street,Suite
Boston,MA 02114-2017
www.mass.goeldia
US- Workers'Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
2 licant Information Please Print Leltibly
Business/Organization Natal
Address: -ND�ENS
City/State/Zip: Phone#: y �� s1� f C7 6---N
At u an employer?Check the appropr'ate box: Business Type(required):
I.u I am a employer with employees(full and/ 5. ❑Retail
or Part-time).* 6. QRestaurantBar�Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 71 ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] S. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right ofeeca ption per c. 152,$1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp.insurance required]*' 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp. insurance req.] 12.❑Other
"Any applicant that cheeks box#I most also fill can the section below showing Meir workercompensation policy Intortmtlore
"Ifthe cotpomm officers have exempaN themselves,bat the conmmtion has othm employees,a workers'compensation policy is required and such an
mgamvation should check box#1.
I am an employer that is providing,-workers'compensation Tsurance far my employees Below is the policy immamofion.
Insurance Company Name: ham( �p���` � OY(1U
Insurer's Address:
City/State,'Zip:
Policy#or Self-ins. Lic. O U 1j), —0 a SO N ]y �Lf—I L Expiration DOlt
ater ��
Attach a copy of the workers' compensation policy declaration page(showing the policy number a d expir tion date).
Failure to secure coverage as required under Section 25A ofMGL c. t52 can lead to the imposition of criminal penalties of a
fine op 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
Investigations of the DIA for insurance coverage verification.
Ido hereby certify,, under thepains and penalties u perjury that the information proval d above is true and correct
Signatumd L=4_(-, Date: SA 9A\
Phone# LF 1"ll, S1S 1 CI L, ,,
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):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www mass.goddla
/ Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
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 or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, constmetion or repair work on such dwelling house
or an the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer"
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to 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 the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be are to fill in the permit license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license 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 proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form aevieed 02-13-15