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31A-283 (4) 106 WASHINGTON AVE BP-2019-0097 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31 A-283 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-2019-0097 Proiect# JS-2019-000156 Est.Cost: $4685.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sa.ft.): 37330.92 Owner: SOLEIL JOANNA V DONAHUE Zoning:URA(93)/RR(7)/WP(6/ Applicant. BOB THIBODO ROOFING & SIDING AT.- 106 WASHINGTON AVE ApplicantAddress: Phone: Insurance: P O BOX 201 (413) 527-7663 O WC NORTHAMPTONMA01061 ISSUED ON.7/25/2078 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE LEFT SIDE OF MAIN ROOF AND REPLACE 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 7/25/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner B Bnil gas �ity 0 hampton Staftai nc di partiment Pe it "I 11IN" ull 2 Street A.Ai 100 Wated/Welt- 'a 41, W NERtha MA 01060 Two- of 111 k 411-'587- Fax 413-587-1272 PI YP jOther I APPLICATIO TO CO R,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING P, 7 SECTION 1.SITE INFORMATION - This motion to be completed by office 1.1 Property Address Map A Lot ;; 1913 Unit 0 Y-N (3Zone -Overlay District Elm St District CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record GwentMailing Addrs (0 Telephone X11 9 Signature 2.2 Authorized Agenrim - 'Ap Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COST Item Estimated Cost(Dollars)to be Official Use Only completed by permit a22licant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6) 3, Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3-4+5) Check Number A Qq 7 This Section For Official Use Only Date Building Permit Number Issued: Sig Building Co sionenhispector W BUIWIng5 Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All information Must an Completed.Peron Gn Be penied We Tc ircomptete Information Existing Proposed Required by Zoning this column m be filed in by auiiding Depamnou Lot Sim ' °--- Frontage Setbacks Front - . --- Side L_._R:. L:—R_ Reaz Building Height -- Bldg.Square Footage % " Open Space Footage % - o-cl.aminusbldg&pavN .. ...... . _ arka d of PatkinQ$ aces ... _.__.! Fill: __... .. .. (,vd.a,&Location)A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO C) DONT KNOW Q YES 0 IF YES: enter Book Page and/or Document k B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES Q 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 0 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 0 IF YES, describe size, type and Location: E. Wtll the construction activity disturb(cleanng grading,excavation, or filling)over t acre or is it part of a common plan that will disturb over i acre? YES © NO a IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED 7(chackoll hlelNew House ❑ Addition nt Windows Alteration(s) Roofing ❑Accessory Bldg. ❑ Demolition [❑1 Decks [p Siding [Ell Other[01 Brief Desc ' n of Proposed ('' 1 \ C M \ Work: o -th LrF Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet r,a.H New houseandor addition to existing housing.cornolets the following: a. Use of building '. One Family Two Family Other b. Number of roams 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 tone attached? h. Type of construction i. Is construction within 100 h.of 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 Ib dr'1 l� as Owner of the subject property (� n 1 hereby authorize , to act on my in all matters relative to work author, d by this building permit application. Signatureof Ovmer 1 ` 11 Date \ I, X19_ - \ O a A as Owner/Authorized Agent hereby declare that the stale a is 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. Pant Name ����11 J y I's Signature of Owner/Age Date SECTION 8•CONSTRUCTION SERVICES e.t Licensed Constru ionu ferw � r: Not Applicable 0 Name of License Noitle License Number ii s m uCl It sig _ Atltlress y(. 5 y- Expiration Date Signature Telephone Reacifirtered HawraI,1 Not Applicable ❑ , < a\'1 }- m aNa -e Registration Number Address Expre� inD TeleP 1 S• 1 t SECTION 10•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.U.152,§25C(8)) Workers Compensation insurance affidavit must be completed and submitted with this application.Failure to provide this affitlavit wilt result in the denial of issuance of the buil ng permit. S ned Affidavit Attached Yes,...._ Ni ❑ City of Northampton Massachusetts { DEPARTNENT OF BUILDING INSPECTIONS 2 .ham 212 Main atvaat lNnieipal Build-, `� \��✓/ p6 Northampton, M 01060 ry.-.e 11J 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 few 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 preexisting owner-0ccupied 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: Al ^ Est.Cost: L-1 (�T_S Address of Work' k O O Date of Permit Application: 1 .F I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Sob under$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 RESPONSIBHdTES 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: �) ��k !z e�) TliIb �de 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 jS C '1 '� DEPARTMENT OF BUILDING INSPECTIONS moi/ 212 Main St.t * xsanicipnl Building Borthn ton, MA 01060 Massachusetts Residential Building Code Section l i0.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 11025.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR I IO.RS, 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 hZ (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 Massachusetts iDEPARTMENT OF EDZLDING INEPECTIONs a, 212 Main Streetatfrinpicipal01060 BuilClnq Northampton, 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: \ �7 �d l`� Gg� ntki �1/ 1 (Plea print house number arld skreet name Is to be disposed of at: V 9\ 1c c ' — (Please p nt name and loc bn of facil ) Or will b(e'�disposed —off in`a dumpstter onsite rented or leased from: ll till 1 (ll r1 Cl CLC) (Company Name and Address) r Signature of PermitApplicant 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 rnfMassachusetts �� Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 wnm:mass.govtdia Workers*Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information- Please Print Legibly Niune{RustnesnOrganizafiaNlnCividou2): l Address: City State/Zip: C AYT 1 Lh..RC f -n"Y�\`yPhone it: S L '1 Are y u anemployer?Checrktth appropriate how-- p Type ofroject(required): 1. lamacmpmyer w;m d� eu+pwyccs ttw:amdcor pan-thrn)' 7. New,construction 2.❑lamasnle MwMemrorpen mbipmdhavemcmployeeaworking named S. Remodeling anv c-paeay.[No workexv corn,ieadeanec required J 9. []Demolition 1❑1 am a homeowner doing all wart,myself INo workers'earn,.insmence moored]' 4.Fldm-homeownerand wiu hebran&mnaammt to cranks,all work en my pmpeny. I will IO Building addition u mat all e.dtha hove varlans'ec ape—t o,uouv nt arc sole t LQ F lul ica]repairs or additions proprietors with no einpleyees. 12.tLr^hJ,y's`lumbing repairs or additions 5[31are agemmi-masa.,seat i finevned the sub Crdiaceas tasted on the andlavl than. 13. RoofrepaiTs These sub eadar e.have employees and have workers'comp,trans cart b.❑we arc s mrpaideion door us-We—have vs red tev rixh�ofexemprinn per MGL c. 14.QOtF.er 152,$1(a),and we have.nn employees.[N. rid ors'com,.intumnoe redound I 'Any applicant mat chec1vb x ai mon es,511 eve tux manors Casa. town,de,¢washers eM ovdrafion've,Janne e—, 'Hnmcownem who submit this affidavit iadicmm&they arc doing air work and men hire outside conrneters mast submit a neweride,o ideating eeh. tContracturs chat check this Mx must-tushed an additional sheet showing the name ofthe subcontractors and xtat,whether cried those culdics have emp4ryees. atlas contractotsheve empWytts.they mestpmvida tM:u wohers'wm,.griicy numtar. I am an employer that is providing workers'compensation insurance for my employee'. Below is the policy and job site insurance C 1 1 1 1""� Insurance Company Name: '�l {�Jys,"e p—`1Tv-y7/�M YM1.—b.V'-411 policy#or Self-ins.Lic.tp: (p 47kipiration Job Site Address:l 10 40 L+7 h� (11r a t "'fit � { Cityistate/Zip: Attach a copy of the workers'compensation poli declaration page(showing the policy o tuber an expi tion date). Failurew secure coverage as required under MGL a 1.52,$25A is a criminal violation punishable by a tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP W ORK ORDER and a fine of up to$250.00 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. t do hereby certify nderthe Ides of perjury thatthe information provided above is arae and correct S,nnat Phone# Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/Licemse# Issuing Authority(circle one): 1.Board of Health L Building Department 3.CIty.Town Clerk 4.Electrical Inspector 5.Plumbing Inspector d.Other Contact Person: Phone#: 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,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 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 sub-contractor(s)morels),address(es)and phone number(s)along with their cenificate(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. 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 sure to fill in the pentrutdicense 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 town)."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, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or I-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 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 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,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 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 I Congress Street Boston, MA 02114-2017 Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Foran R--d02-23-15