38A-040 28LAURELST BP-2019-1025
GIS A,; COMMONWEALTH OF MASSACHUSETTS
MM.Block:38A-040 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catetorv: ROOF BUILDING PERMIT
Permit BP-2019-1025
Project# JS-2019-001681
Est Cost; S16000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group BOB THIBODO ROOFING & SIDING 065699
Lot Siu(sp.ft.): 27181.44 Owner: POUDRIER THOMAS R&ELIZABETH
Zoninw URB(100)/ Applicant. BOB THIBODO ROOFING & SIDING
AT: 28 LAUREL ST
Applicant Address- Phone: Insurance:
P O BOX 201 (413) 527-7663 0 WC
NORTHAMPTONMA01061 ISSUED ON:3/20/2019 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP & SHINGLE ROOF ON GARAGE AND
MAIN HOUSE
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 Sitmature:
FeeTvoe: Date Paid: Amount:
Building 3/20/20190:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-3272
Louis Hasbrouck-Building Commissioner
City of No 1ha CEIVE
Building D part ant
212 Mai I Stir et MAA
r! to arta I rx-a
Roo 100 la,, €Iivailablt �' . ps
Northampto , M 1060 qe o � a P� I" utis) 4is `.Ps � �I
phone 413-587-124 FaV2+j. rj481FP1�27LISP n
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A OHNE OR TWO FAMILY OWEWNG
SECTION 1 -SITE INFORMATION pp `/9- '/0
1.1 Property Address: 1rThl5 ystcyrGteomplefedyUrrffrc�e rr
Umt
LAU �
Zan if � %r vlehiip0lstri", a
SEI np t 21' ai" -i�+N'.,amBD0McYf r
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Recpr ^
IN
Name P Current Mailing Adtlress:
TelephoneU Q
Signa re 1
2.2 Authorii.edAggeentt,
}
Name(Pant) Cunent Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS:
Item Estimated Cost(Dollars)to be Official Use Only
com leted by permit a iment
1. Building '(a).Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from B '
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) lye
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
. This Section For Official Use Ord
Dale
Building Permit Num - Issued: on
Signature:
Building Commtssloner/inspector of Buildings " gate
Section 4. ZONING All Information Must Be Completed.Permit Can Be Dented Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be fillet in by
Building Department
Lot Size
Frontage I— --d
Setbacks Front rLr�
Side L:I_J—� R:0 L= R:O
Rear O
Building Height C�
Bldg.Square Footage
Open Space Footage P %
(Lot arta minus bldg&paved
arkin )
#01[parking Spaces �-
Fill:
volume&Locafion)
A. Has a Special Permit/Variance/Finding ever been issued far/on the site?
NO C) DONT KNOW 0 YES 0
IF YES, date issued:f=
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book F---I Pagel and/or Document#[
B. Does the site contain a brook, body of water or wetlands? NO Q DON? KNOW Q YES 0
IF YES, bass permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
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 Q
IF YES, describe size, type and location: I_
E. Will the construction activity disturb(clearing, grading,excavation,Drilling)over 1 acre oris it partof a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i
� 4
SECTION 5-DESCRIPTION OF PROPOSED WORK fcheck all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Q Roofing
Or Doors O
Accessory Bldg. ❑ Demolition
rr ❑ New Signs [0] Decks [� Siding(0] Other[0]
Brief Dpcpr�ti�on�o�tUosed�O 1 �� /� �Q S -
Work: v�lNN VV�Q cs ---�\— LC r(
Alteration of existing bedroom Yes L No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
,... _�
6a"Ff New &house and or"addiBdri to exisGna housing, Domofete thefollowindr
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 fcotage of new construction. Dimensions
e. Number of stories?
f. Method of healing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 fl.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, S as Owner of the subject
property
hereby authorize
to act on my beh all alters relative to work aulhonzed by this building per 't applicion.
1
Signature ofMn Date
as Owner/Authorized
Agent hereby c3edare 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 penalties of perjury.
r
Prin ame
Signature of Owner/ gent Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder: � )1,).� l`itJ r
L cans. umb
Address Fx 4tx ale
Signature Telephone
F#RdIpomemNot Applicable E
So?
Registration Number
C. °ate
�--r Expirah Date
Telephone'-y
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(fi))
Workers CompensationInsurance ffidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of th building permit.
Signed Affidavit Attached Yes_..... £ No...... £
11 '-Ho`tbineYEaemntion
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 1083.51
Definition of Homeowner:Person(s)who own a parcel upland 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 coustruets more than one he.in a two-year d shall not be 'd d a homeowner.
Such"homeowner"shall submit to the Building Official,on a farm acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building 't
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion ofthe 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)ofthe Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under flue permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature_
The Commonwealth of Massachusetts
Department oflndustrial Accidents
U9Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Ar you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I 6. F-1Newconstruction
employees(full and/or part-time).* have hired the sub-contractors
2.711 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
shipand have no employees These subcontractors have S. ❑Demolition
working for me in any capacity. employees and have workers' y [:]Building addition
[No workers' camp.insurance comp.insurance.t
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box#1 most also fill out the secdoobelow showing Iheh workers'compeosadon policy mimmation.
tHo meowners who submit this affidavit indicating they am doing all work and then has outside contractors must submit a new affidavit indicating such.
=Contractors that check Ibis box must attuched an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they mustpmvide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the pokey and job site
information.
Insurance Company Name: Aclsi&WA .
Policy#or Self-ins.Lic.#: ` Expiration Dater�
Job Site Address:11t l,-a„11Ya\ City/State/Zip: 7) C� SS
Auach a copy of the workers' compensation policy declaration page howing 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 a
fine up to $1,500.00 and/or one-yea 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certi under th ains andpenalties of perjury that the information provided above is true and correct.
Signature -,--�lx>—' Date
Phone#'
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/I.icense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Towit Clerk 4.Electrical Inspector 5.PlumbiEInspector
6. Other
Contact Person: Phone#:
City of Northampton
jaa Massachusetts
DEPARTMENT OF EUILDING INSPECTIONS
212 main street 0 Municipal Building
Northmpton, M 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner'as, "Person(s) who owns a parcel on which
he/she resides or intends 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 shalt not be considered a home owner."
The building department for the City of Northampton wants any person(s) who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
found ation/footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed) insulation inspection (if required) and a final building inspection
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing &gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
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: a �i" LCt \)Y--t,I� S ' 1
The debris will be transported by: � C 22 b o k
r
The debris will be received by:
Building permit number: (�
Name of Permit Applicant (
\C �
Date Signature of Permit Applicant