23B-036 13 DANA ST BP-2019-0698
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23B-036 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-2019-0698
Proiect# JS-2019-001140
Est. Cost: $12984.80
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: DICKY MATOS 105917
Lot Size(sq.ft.): 17816.04 Owner: SIMON ALEXANDER&KAI
Zoning URB(100)/ Applicant: DICKY MATOS
AT. 13 DANA ST
Applicant Address: Phone: Insurance:
3 GLEN ST (413) 530-5335 WC
HOLYOKEMA01040 ISSUED ON:12/11/2018 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 signature:
FeeTvae: Date Paid: Amount:
Building 12/11/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
Building Department ,t '
212 Main Street
Room 100 `
Northampton, MA 01060`
phone 413-587-1240 Fax 413-58 -1272
R. QEI
APPLICATION TO CONSTRUCT,ALTER, REP IR, ENOVATE OR DEMOLIS i A NE OR TWO FAMILY DWELLING
DEC 0 2018 42
SECTION 1 ,SITt*INFORMATION
1.1 Property Address: DEPT o ' ua�r�rnr IrS
I tia be cril�t+sei by
NO PT iAMOTON MA Ql46Q
{ 3 - 15
No�rI-►�,am p-bn rY1 a. �► l o� •
SECTION 2-PROPERTY OWMERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
,Okmac-ler
Name(Print) Currena'lin�Address•
1 �
Teleph ne
Signature
2.2 Authorized Aaent:
Name(Print) Curr t Mail' g Address:
1 �3 -
Signature Te phone
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)`Buildingg Permit Fee
2. Electrical (b);Estimated Total Cost of
Construction fom 6,
3. Plumbing Sullding Permit Foo
4. Mechanical (HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Qfttetal Use Only
Building.,hermit Number:" Date
Issued:
Signature:.
Building Cornmissianer/inspector of BuIdings bate
0 @ i � cow
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 in by
Building Department
Lot Sizex ..
Frontage {
Setbacks Front '.'....
.
Side
R. _..4.. LL---. R.�,.,__
Rear ,, v„
Building Height
Bldg. Square Footage 1 F., % .
r
Open Space Footage % n ; . _
Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: I
volume&Location t s
_a,
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES :®. ::;.
IF YES: enter Book Pae and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 NO
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: r
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.
N 2E JeBQPMR W28K L09A 11_1 ,U
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other[a
`I'aclr aFFPQ1lre YGOC Sns pe �?l wc+ Tns�u/l�ci=wnyC� ctrritr,"�hSiu-il S'Inthet,C..underl awe
Brief De cription of Proposedsns // /;M,yeCf/; /;,,, ,q,,k Shi lc i,Seal dir -d?4- �
Work: mt5\/#_ all 4vash a-njs Ja,.'j -Tr\sial/ yam.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _ No
Plans Attached Roll -Sheet
tw
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 U-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPUES 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
I, as Owner/Authorized
Agent hereby declare t at the sta ements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Si ed under the pains and enaltie of perjury.
Print Name
Signature of Ow /A t Date
IECTON.8-CONSTiRUCTIQN SERVICES
8.1 Licensed Construction Su ervl r: Not Applicable 0 a '�7
Name of License Holder: t, l�J � 'v J
License Number
63 1 ?)DI kib 1
Address 7 Expiratio Date
(,qI3 530 5
Signature Te hone
N
of Applicable ❑
L
ry)atw lq6nfl 06I Lo Lo
Company Name U Registration Number
3 54 �iok�,1Mma 01691) 05 10 t 202,E
Address ! Expiratio Date
Telephone � 53x5
SECTION 10-woRKERS'CQM1APENSArQN'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' g permit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
Massachusetts ,cam
7 fir,"
DEPARThENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building �V "
Northampton, MA 01060TM- �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 x- 15 fi(Aoa- S+ ' lA64hCt ,�m� o�
(Please print house number and street name)
Is to be disposed of at:
a -
(Please print name and lo0a ion of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
P, r
Si �rr i App' ant 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 Industrial Accidents
I 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.
Aimlicant Information Please Print Le ibl
Name (Business/Organization/Individual):
Address: �'
City/State/Zip: rn k Phone#: / 5, S S�"
Are your an employer?Check t e Appropriate box: Type of project(required):
1. I am a employer with employees(full and/or part-time).* 7. C]New construction
In 1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp,insurance required.]
9. ❑Demolition
3.F1I am a homeowner doing all work myself[No workers'comp.insurance required.]'
10 C]Building addition
4.[:]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. to0f repairs
These sub-contractors have employees and have workers'comp.insurance.
6.M We arc a corporation and its officers have exercised their right of exemption per MGL c. 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: 4T A04 0
Policy#or Self-ins.Lic.#: K 'y��9 ,Z,(� Expi4 tion Date: !
Job Site Address: / ��� �i t'IQ��S� City/State/Zip: drih dl/off
Attach a copy of the workers'compensation policy declaration page(showing the policy number and kXplirition 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 tine 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 certify un r the pai and penal of r* ry that the information provided above is true and correct.
Si nature: jv� Date: V '— '
Phone#: m4ak
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#:
00fts
10
Dec 3, 20-16
Alexander Simon
13-15 0ana St
Northampton Ma 01108
NEW ROOF 9,500-00 9,500.00
Chirnney 0.00 0.00
REPLACE SHEATING 52.80 3,484.80