29 3 Glen St .
Holyoke, Ma 01040
413-530-5335 Number
CS 105917
HIC-166207 Date Jun 19,2018
P.O.
Terms
Bill To
Rick Fitzgerald Ship Via
175 Overlook Dr Ship Date
Florence, Ma 01062 p
Description Unit Ext
NEW ROOF 370.00 7,770.00
Tear off entire roof
Inspect plywood (if any damage will be and additional cost of 60.00 per sheet 1/2 inch and
75.00 3/4 plywood.
Install ice water barrier 6 ft and valleys
Install syntectic underlayment to rest of the roof
Install limited lifetime warranty architectural shingles
Seal all pipes and vents
Install 8" drip edge
Remove all trash and debris
Install a Tamko Rapid Ridge Vent
Building Permit included
Chimney 450.00 450.00
Install lead flashing to waterproof
Iko dynasty shingles 650.00 650.00
Add for premium shingles
Subtotal $8,870.00
iii 7ti?tU;-r
Discount $400.00
/� Total $8,470.00
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information Please Print Le ibl
Name (Business/Organization/Individual):
Address: 3 Ge—n S+
City/State/Zip: A C Phone#:`t(> 5 30 5-3 3 '
Are you an employer?Check the appropriate box: Type of project(required):
1`E�l am a employer with_ employees(full and/or part-time),* 7. New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling
any capacity.[No workers'comp.insurance required.]
❑3.3.F19. Demolition I am a homeowner doing all work myself[No workers'comp.insurance required.]t
4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.�ROof repairs
These sub-contractors have employees and have workers'comp.insurance.*
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.[:]Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
+Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: jC_ hrt n Caf7' \
Policy#or Self-ins.Lic. �� ) �����/� �0 Expiration Date: 10 •�lG
Job Site Address: ��`5 aver IcA br, City/State/Zip: F`()f f na ,rAn
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certifyder t e pains ar per lties of perjury that the information provided above is true and correct.
Si nature: Date:
Phone 0 91-3 — 5 3
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):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
MassachusettsG
DEPARTAXNT OF BUILDING INSPECTIONS i
212 Main Street •Municipal Building
Northampton, MA 01060 " �1
Debris Disposal Affidavit
In accordance of the provisions of MGL c 44, 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:
(Please print house number and street name)
Is to be disposed of at:
0-a -v"[ (r, �k)at Yf
(P ease pNnf name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
4
1
gn e oPerm' ppfca6t 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.
City of Northampton
a Massachusetts �?,r
' DEPARTMENT OF BUILDING INSPECTIONS �z
212 Main Street • Municipal Building ;
Northampton, MA 01060~0
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('-MC").
M.G.L. Chapter 142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing 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: Roue --' Est. Cost: C,
Address of Work: (V(11(�J)�
Date of Permit Application: — —C-�,u
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job 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 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:
dO 711CCu YAaA05 ILA a3c+
Date Contrac 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 Signature
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: [)ic 6 1 Hclh5 C'S{015q1)
Czkn ,(:�+, 1-��intcf[jn (�
, License lumber /
�, 1 V
Addres Expirati Date
I) L e&CSa:) Q •S
9� Telephone
tNot Applicable ❑
-It aC4-
Com an Nam Registrtion N tuber
3 - �Dc
Address /i [ Expiration Date
TelephoneL
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 building permit.
Signed Affidavit Attached Yes....... No...... ❑
"SECTION 5-DESCRIPTION OF PROPOSED WORK(cel ill applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [Cl] Decks [0 Siding [p] Other[l71
Brief Description of Proposed-Ra r af-Ce rC i()SO�C-F1'� WOC�CI,ins II i CQ lam( r QUC�I�Qt(S;Si�s���Syn�4
I eration existing bedroom es No � Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
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?
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?
h. Type of construction
i. 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 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
ahsI, , as Owner/Authorized
Agent hereby dectre tha ffie statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and Rena of perjury.
Print Na
Sin of Owner/A t Date
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 in by
Building Department
Lot Size i
-------
Frontage 1
Setbacks Front
I ,
o
Side L ... ,,.. ' R ..._.-ta: L:f L--j R
�,._J _€
Rear l _.
Building Height
Bldg. Square Footage -----`»" < %
M
Open Space Footage
(Lot area minus bldg&paved a
parking)
�,.
#of Parking Spaces
Fill:
s
volume&Location b a... x 3._M ._ »a
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW 0 YES 0
k .. ».......,,......ate,».»....,
IF YES, date issued:=
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES
IF YES: enter Book i Page and/or Document#a
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued F._
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO 0
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton h
Building Department
212 Main Street
Room 100
k ' k
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
_ rid• .-,
APPLICATION TO CONSTRUCT,ALT R, R II
MOL ISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION I NOV - 8 2018
s.s�ctlan to l*cod ftice
1.1 Property Address: T iY �te �o
DEPT OF E UILDINCi tGTIC?NS
NORTHAMLot unit
�-� �-( -, �r PTOfd,
l I'��C�C.. , HC, V I bl� zone Overlay r >strl+ett
Elm$t:lxsttid ca District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) �nLMaili �{r�,�;� i
Telephone
yE�l
Signature
2 Authorized A ent:
hl"CL-1 3 (-)k n
Name(P n) Current Mailing Address:
1,� 5 5 3
S n Telephone
10 3-ESTIMVED CONSTRUCTIONT
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building I 00 (a)Building Permit Fee
2. Electrical `-� ` (b)Estimated Total Cost of
Construction from 6
3. Plumbing Bull ding Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 +2+3+4+5) u Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: I tl 13 t16
Building Commissioner/inspector of Buildings Date
tn rb0fi n nl- @ i'r C c)
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
175 OVERLOOK DR BP-2019-0579
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-578 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-2019-0579
Proiect# JS-2019-000939
Est.Cost: $8470.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DICKY MATOS 105917
Lot Size(sq. ft.): 20778.12 Owner. FITZGERALD ALICE F&HAROLD R FITZGERALD JR
Zonina: Applicant. DICKY MATOS
AT. 175 OVERLOOK DR
Ainnlicant Address: Phone: Insurance:
3 GLEN ST (413) 530-5335 WC
HOLYOKEMA01040 ISSUED ON:11/15/2018 0:00:00
TO PERFORM 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 sienature:
FeeTvpe: Date Paid: Amount:
Building 11/15/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner