42-037 (3) 7 LADYSLIPPER LN BP-2019-0015
GIS# COMMONWEALTH OF MASSACHUSETTS
Mao:Block:42-037 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-2019-0015
Project# JS-2019-000019
Est.Cost:$8900.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sa. R.): 46609.20 Owner: MCGANNON WENDY
Zoning: Applicant: BOB THIBODO ROOFING & SIDING
AT: 7 LADYSLIPPER LN
ApolicantAddress: Phone. Insurance:
P O BOX 201 (413) 527-7663 O WC
NORTHAMPTONMA01061 ISSUED ON:7/52018 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# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: O L 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 Sig at re•
FeeType: Date Paid: Amount:
Building 7/5/2018 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
r
�ZoOP
Department use only
,-" . __ ity Of Northampton Status of Permit:
�E� B ilding Department Ourb SrHDrtvewey�'Permit
212 Main Street Sewei/Seplic Availability
i)+� Room 100 WarNJall Avaaablilty
ZQ�B No ampton, MA01060 wo'Sets of Structural Plans
phone 13- 87-1240 Fax 413-587-1272 Plo}/Slte Plans
Other Specihj
CT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
i.t Property Address This section to be completed by office
Map Lot 637 unit
Zone Overlay District
1•--�'T l] J Y I Elm SL District cq���c�'
fILVL�
SECTION 2-PROPERTY OWNERSHIPIAUTXORIZED AGENT
2.1 Owner of Record: y� Vsrb 2 b ZU,
_N (Ptlnt) Current Mailing Address.
Signnatureature � DEPf,OFAIaDMBINSPECTIofJ3
+ � Telephone
2.2 Authorized Agent:
IN (Ph n p Current Mailing Morass:
-S 1 S I
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official 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)
5. Fire Protection
6. Total=(1 +2+3+A+5) Check Number
This Section For Official Use On
Date
Building Permit Number: Issued:
Signature:
B di C m ie /Inspector of Buikings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
f
Section 4. ZONING Ad Information Must Be Completed. Permit Can Be Dented Due To Incomplete Information
Existing Proposed Required by Zoning
Tris column to be filled in by
Building Department
Lot Size
Fronto e
Setbacks Front
Side L R' _.. L ... R
Rear _._ ._ .....
Building Height
Bldg.Square Footage -- - % - — - -
Open Space Footage _ _ % -.
(Lotarcaminus bldg&pacW
actin
q ot'Par"kin Ilpaces --- ---
�A
Ftli
(vaeeeaiorarmr)_--.
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 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. Will theconstruction 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 O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check II II bl )
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 56
Or Doors 17
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [O Siding[O) Other[[:t
Brief ' tion of Proposed r
Work'
Alteration of existing bedroom_Yes_No Adding new I droom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.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
G. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stones?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. 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
vn` ,
��^'�^PY.f �,-� as Owner of the subject
property
hereby authorize01
A�Ua �l
to act on my behalf Ift rs relative to work authorized by this building permit application.
, 31
Signature of Owner Date
as Owner/Authorized
Agent hereby declare 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 penalt1}es�of perju1ry.
t-1C}
Print Name
Signature of Own rlAgenl Dale
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervi ;or: 4,
NToott Applicable ❑/+�
Nameof License Holtler: y 6S'rj G
License Number �
Address Expiration Dale
Signature Telephone
Realsteshed Home Improvement Contracor: Not Applicable ❑
�O�
Comoanv Narfie Registration Number
C- fir
Atldress � Expuation Date
Telephone
SECTION 10-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 build tg permit.
Signed Affidavit Attached Yes....... No...... Ll
City of Northampton
Massachusetts
f c
yj Y
DEPARTMENT OF BUILDING INSPECTIONS �y
212 Mein Street • Municipal Building
Northampton, MA 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 prerexisting 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:
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
Massachusetts
z
s
L DEPART BENT OF BUILDING INSPECTIONS f
212 Nein Street a Nunicipal Building
;. NorNas,ton, MA 01060
Massachusetts Residential Building Code
Section IIO.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 110.85.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR i 10.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
t l
Massachusetts +% i
DEPARTMENT OF BUILDING INSPECTIONS 5
232 Alain Street •Municipal Building
Porthagpcoa, NA 03060 spy�, �1n5'
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, 1 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.
—1 La Mo S�'A-R- N
(Please print house number add street name)
Is to be disposed of at: \\ --
1V 0 �T�w �hrf tN, ST
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
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.
The Commonwealth of Massachusetts
Department of lndastrialAceidents
1 Congress Street.Suite 100
Roston,MA 02114-20777
www aniss gov/dia
Workers'Compensation Insurance Affsul Builders)ContractorstElectriaians(Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(BvsinenaiOrgaoization7lndividual):
City/State/Zip: Phone
Me aemphone?Check the appropriate box: Type of project(required):
I_ em acmploycr wish�employaes(full and/or part time)' 7. ❑New[on3[NchOn
2rJ1 am a sole propdemrorpothumbip and have no employees working forrago S. 0Remodeling
any capnoity.[Nuc workers comp-insurance required]
3.r,I am a homeowner doin llworkm lt. No workers'cote -insurancem d 1 [3 Demolition
ga ysc [ p yuim ]`
4Q I am a homeowner and will be 6mog emmoo ..to rondun all work on my pioyexty- S will LO C)Building addition
vosum that all contractors either have workeo'eompensmimarwranca or am .to I I.Q Electrical repairs or additions
propdaors with no employees. 12.� umbing repairs or additions
5j-1I am agdaenal eommemrandI love hired thesub-,valmone,listed on d mmolusd ahcet 13. PRoof repairs
These sub-ndsanore have ongeo ve,and bave workers'comp-darrao
6E We am a corporation and its officers have oxemieed their right of exemption per MGL c. 14.❑Other
152.0dal,andwehavenoemployees.(Noworkers comp.insurancerequired]
'Any applicant acidness box dl must also nil out the section below showing their workers compemanon policy inforout9on.
'Hommanen who submit this affidavit indicating they arc doing all work and den hire ou.ids conuachn,most submit a new affidavit ushluting such.
fContmcmrs thacchmk die box must attdcbed'an additional sheet:hawmg the name of the sub-roopa¢ors and state whether or not those endue,have
employees. o du subeoptr erat,have emploleea.trey and.pcmidc their coakers comp.policy number.
I um an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information,Insurance y 0. i \
Insurance CompanyVame' ( 1�t O'e— 1� ���
Policy#or Self--ins.Lie.W: IQS_�._OV – is (\� Expiration Dale: �� C,
Job Site Address. ��� C� 1p ' 1.2.� City/State/Zip: J' G/xp
Attach a copy of the workers' cumpenss End policy declaration page(showing the policy number and eallAration date).
Failure io secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up ro$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 3250.00 a
day against the violator,A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerdfy under the pains and pemddes ofth rjury thatthe information provided above is true and correct.
S' to �r�rfF�
Date: a.(ey�
Ph.,
Official use only. Do not write in this area,to be completed by city or town ojrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant o 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 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,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 bean 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 sub-contractor(s)camels),address(es)and phone numbers)along with their certificate(s)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. Ifan LLC or LLP docs 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
of the 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 permulicense 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)and under"Job Site Address"the applicant should write"all locations in (city or
towel"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 burn 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, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 02-27-15 www.mass.gov/dia
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 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,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 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
of the 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 permudicense 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(re,a dog license or permit to burn 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
Forth Revised 02-23-15