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31B-105 (3) 33 BRIGHT ST BP-2018-1240 GIS#: COMMONWEALTH OF MASSACHUSETTS M"-.Block:3 1 B- 105 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Cateeom ROOF BUILDING PERMIT Permit# BP-2018-1240 Proicet# JS-2018-002213 Est Cost: $15200.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DICKY MATOS 105917 Lot Size(sq a.t 7492.32 Owner: CARSWELL CAMERON Zoning: URCH001/ Applicant: DICKY MATOS AT. 33 BRIGHT ST ApplieantAddress: Phone: Insurance: 3 GLEN ST (413) 530-5335 WC HOLYOKEMA01040 ISSUED OM5/23/2078 0:00:00 TOPERFORM 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 slmmmre: FeeTyoe: Date Paid: Amount: Building 5/23/20180:00:00 540.00 212 Main Street,Phone(413)587-1740,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Departmerd use only City of Northampton 'of " It r••. .µ ' ''i - Building Department " yPemit ' 212 Main Street SeweNSep(ic AwilatJ Room 100 waterANoil Northampton, MA 01060 Tvtoi� of Sbrr ralPt06s �,. phone 413-587-1240 Fax 413-587-1272 Plain 'r Ogler Spedfy APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I-SITE INFORMATION ECEIVED ISP 18- o-L!0 1.1 Property Address: This section to be completed by office 53 �Fjght �3fMAY 2 2 ma M P Lot 10,5 unit Z I Owrlay District DEPT OF BD UNNG INSPECTIONS NORTHAMPTON.MA010WF SL lama CBDIsIriQ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Owner of Rac rd: �m�rc�n Cfr�(, c,l ) 33 52ld,t Name(Print) Current Mail' A ress' v�Jn—nq Q Telephone Signature 2.2 Authorised Agent: arae(Pn I Curren)Mailin{g Atltlress: X13 J1) 533 � Signora Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by pemut 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 Official Use Ont Building Permit Number: DateIssued: Signalu Building Com ' sionedlnspector M Buildings Date EMAIL ADDRESS (REQUIR D; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ]EK] ZONING All Information Mout Be Completed. Permft Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be tilledin by Building Depmtrnent Lot Size .__ _.. ..... _. Frontage Setbacks Front Side L R.w L_R_ : l .._... Rear .... ... .... :.. Building Height Bldg. Square Footage "" % — -- _ Open Space Footage ,. % ... (Int area minus bids&paved _.. ,. arkiv #of Parkin Spaces --- volum<&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site. NO Q DON'T KNOW ® YES IF YES, date issued: -..._.... . __..__._. IF YES: Was the permit recorded at the Registry of Deeds? NO © 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 0 DONT KNOW ® YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained ® , 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 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? VES o NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing ID— r Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[C31 Other[pj Brief Descriptio of Proposea-fQGf C)If PrYII P-I� ROUFI(ISPCC�" WO (r i.ll' CCLW�f/15tLlf$�7I� C Work:unrl�W=in� at I� orl?ia Savant�inS4 Ild r>rrlc�e .r nr trSh8,1Lb6 unsIGI( Lcr,� Alteration of existing bedroom_Yes_No Adding new bedroom Yes No �'�"r'r7-sh�Mn Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Be.if New house and or addition to existina housing, complete the following. a. Use of building : One Family Two Family Other to 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 Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? in, Type of construction 16 Is construction within 100 ftof wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No I. 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 I, as Owner of the subject property hereby authorize —4ko CLZ}ii' r'+ to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date as OwnerlAuthorized Agent hereby tlecl re that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Sd under the pains andpenaltiespenalties of perjury r 7 `i Hr ,i I (enY3 Print N e e of Owner/ t ate ------------ SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construct Supervisor. �Not Applicable J of Name License Nolder'. I L'L F-�- License Numbs Atltlr Lxpla ion Date e j Telephone 10--1tseoHome Imorovemant Contrartor: Not Applicable ❑ � w F ((—,405 1( e( ill, — C�an N e Reg' tratio Number '� ylen Sfi AAlddrre s q Expiration ate r� W10 TelephanX �30 WS) SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,S 25C(8)) 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 ofthe building permit. Signed Affidavit Attached Yes....... No._... ❑ F } City of Northampton Massachusetts m -APARTMENT OF B. IDINCMu.i.i ZNSPBCdi.9 212 in atvaai o lWnicipal Building Noithamp[on, !p 01060 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 of an addition to any pr"xisfing owner-occupied building containing at least one but not more than four 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: �,�(�00 Address of Work: Date of Permit Application: , f 1 hereby certify that Registration is not required for the following reason(s): _Work excluded by law(explain): —Job under$1,0K00 _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: �dbl8 )irf( / Mr I( o( pLa: Date Contractor- ame 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 Signarme City of Northampton Massachusetts DEPANTAffiNT OF BUILDING INSPECTIONS 212 Main Street a Municipal Building \_ Nor Hampton, He 01060 SYjy'yllJ Massachusetts Residential Building Code Section 11O.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 I O R5.1.3.1 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 persons) 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. 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: 33 bk-�Qrrt' ,�f- The debris will be transported by: The debris will be received by: l af�'e 1 IG 0-t l Building permit number: Name of Permit Applicant Date Signature of Permit Applicant The Commonwealth ofMassachusens Department of Industrial Accidents I Congress Street' Suite 100 Boston,MA 01114-2017 www.mass.gov/dia uffi Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Ipformation Please Print Legibly Business/Organization Name�I].J�l�r \ / Address: �� cIkn City/State/Zip: Ci Phone#: (JR `73Q' 03 Are you employer?Check a appropriate box: Business Type(required): 1.Erlarnitmpfl.ycrwith employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurent/BadEating Establishment 2.❑ 1 am a sole proprietor or partnership and have no y [36ffice and/or Sales(incl, real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] S. ❑Non-profit 3.❑ Weare a corporation and its officers have exercised 9. ❑Entertainment then right of exemption per c. 152,ys 1(4),and we have l0.❑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.] 12.0 Other 'Any applicant that cheeks box#1 m t alsofill out section below shoalhittheirnvrkeri compassatlon pefc,information '9f the corporate officers have exempted themseh'cs,but the coRoration has he,employees,a workers'compensation policyis ho mcd and such an nrganizatinn should check box#I. I am an employer that is providing workers'campensalion insurance for my emplovees. Below is the policy information. Insurance Company Name: ]' Insurer's Address: City/State/Zip: (( Policy#or Self-ins.Lia# I I'Y"I Pp 3a ,,h��- Expiration Date: t1 �I r�IIG 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 time up to S 1,500.00 and/or one-year imprisonment,as u ell 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. I do hereby cerci under the pains a d p hies of perjury that the infonnatientire vlded above is trMe and correct. Si nature: Date: 3 Phone#: Official use only. Do not write in this area,to be completed by city or town oJfcia7 City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.BuBding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: wvv.m ss gavidia 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 a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or vustee ofan 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,construction or repair work on such dwelling house or on 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 of public work until acceptable evidence of compliance with the insurance requirements of this 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 ofinsurance. 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. Iran 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 workerscompensation 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 sure 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 affldavit indicating current policy information(if necessary). Acopy 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 burn leaves etc.)said person is NOT required to complete this affidavit. 'f he 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 Farm Rcviecd 02-23-15 d VjLjM, 1 Date May 11,2018 P.O. Terms BiH To Cameron Carswell Ship Via 33 Bright St Northampton Me 01010 Ship Date ee5fnpllan UN EA NEW ROOF 380.00 9,500.00 Tear off entire roof Inspect plywood(if any damage will be and additional cost of 60.00 per sheet 112 inch and 75.00 314 plywood Install ice water barrier 6 ft and valleys Install syntectic underlayment to rest of the roof Install limited lifetime warranty architectural shingles Seat all pipes and vents Install T drip edge Remove ail trash and debris Install a Teri Rapid Ridge Vent Building Permit included Il dynasty shingles 750.00 750.00 Chimney 450.00 450.00 Install lead flashing to waterproof REPLACE SHEATING 60.00 4,500.00 Replace all new sheeting Included in roof price CGStIz 9re� Total $15,200.00 '. 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Re9rvd6al: 180207 TVDO: Individual FvhYftr 8171=9 TI 266606 DICKY MATOS DICKY MATOS 3 GLEN ST. HOLYOKE, MA O1040 apdwAAd&m nd nun sad.MYek nm06orchmuM ❑Addes Wsewal ampbinaN ❑ I.oetl,ord anal a eoatmn LWowar rgpdmdmVYad far hdMdnl monly oem ra.os.lmlr.dl Mi1ut YaArolbeapindlm data vandraucooe tA_ 06atestOawearAaiga gdBYdme 8geistlse a a8e1114t8 Idadtlnal 16►e#PIW-ORW3170 DRW WTOS aaeaaY.MA 02114 DICKY MATCB 3 GLEN 0T. �,f•-�vT.� F10LVOKE,IM 01010 Undersecretary NocvalM wlthosaclYndre