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29-165 (7) 22 GILRAIN TER BP-2019-1064 HIS#: COMMONWEALTH OF MASSACHUSETTS Man Bio k:29- 165 CITY OF NORTHAMPTON .ov-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Categor4C ROOF BUILDING PERMIT Permit 4 SP-2019-1064 Proiect4 JS-2019-001731 Est. Cost: $18872.00 Fee: 0.0o PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DAVE MINER 99953 Lot Size(sn.A.): 27573.48 Owner., MACARY HOPE Zoning: Applicant: DAVE MINER AT. 22 GILRAIN TER Applicant Address: Phone: Insurance: 347 NEWTON ST (413) 533-0481 WC SOUTH HADLEYMA01075 ISSUED ON3/2712019 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: 91 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 Occuoancv Signature: FeeTvpe: Date Paid: Amount: Building 3/27/20t90:00:00 S40.00 212 Main Street,Phone(413)587-1240,Pax:(413)587-1272 Louis Hasbrouck—Building Commissioner Difierimumuseon W City of Northampton Building Department 0 it 212 Main Street labilfty ":11$1 Room 100 A.,Hfikv 611� a Northampton, VIA 01060 4#11ruckind Phan phone 413-587-1240 Fax 413-587-1272 Plops L Q), W APPLICATION TO CONSTRUCT, ALTER REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Phopern,Address This section to be completed by office Map Iq Lot 0 unit— Zone --Rqkf�m —MV Elm at District CS DwwicL----r SECTION 2-PROPERTY OWNERSHIPIALITHORIZED AGENT MAR 21 7 2019 9 2.1 Owner of Record: —j ell, D OF UD'%G l"F0TK1:'S "T Name(Print) Current Mailing Address. C,�yc.tr Telephone Signature 2.2 Authorized Agent DA- ,c rt kit r 4— 7 Y -7 /L'� If A Name rPm-h Current Mating Morass: 77 Y^ c,71 c> S'qn.two Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $71 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee L10',y) 4. Mechanical(HVAC) 5. Fire Protection 6, Total=(I -2.3+4+5) Check Number F This Section For Official Use OnIDatev Building Permit Num Issued. 2 Signature: Z7- WE Building CommissionerAnspector of Buildings Data EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Mus[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 Frontage Setbacks Front Side L R:.._ L::.,. R .. _... Rear Building Height ---' -- "' Bldg.Square Footage '-' % -- - Open Space Footage pi (Lot area mars bids&paved aAuv 1 #of Parkin Spaces -- ---- Fill: .__.. ".. __ ..... vnlume&Locution __.... .__.". A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW © YES O IF YES: enter Book Page and/or Document k B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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 © 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 O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Atltlltion ❑ Replacement Windows Alhirm ion(s) ❑ Roofing ❑ 0r Doors D Accessory Bldg. ❑ Demolition ❑ Now Signs [O] Decks [q Siding jO] Other[a Bnef Description of Proposed Work: fln.o Alteration of existing bedroom_Yes_No Adding new bedroom_Yes No Attached Narrative Renovating unfinished basement _Yes NO Plans Attached Roll -Sheet Ss.If New house and orxaddition to existing houslna. complete the following. 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 J. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodsloves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? In. 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. 1. 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 {{c)2e /"I BCq/r as Owner of the subject property yy�� ,wl hereby authorize /HlC / " 7>!f` to act on my behalf, in II matters relative to work authorized by this building permit application, Signature of Owner Date I, D6--1C /-nInim ,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 nunder the pains and penalties of perjury. IJIV"'� i^y /rbr/L Print Name Sig nature of OwnerlAgent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicabblle� ❑ Name of Llcanse Holder: Qj License Number L- tg dm 3rf? wee sl- 5.. AIIA,4 AddmS�s Expiration Dale �-- 37Y —o) 2,, Signature Telephone 9.Reoiemred Home Improvement Contractor: Not Applicable ❑ 0 Pi,-rr ("I f Ai, — PHf, r, Y"r -T-,, G L C / Company Name Registration Number d 3Y7 ^ � F S� s�-K l�dil /.2 i /9 Address Expiration Date Telephone 7,7 (-c>xR0 SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152, 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...... ❑ City of Northampton Massachusetts tG t' DEPARTMENT ea a LDXNGMunicipal INSPECTIONS 'b 212 Main rthaz o Municipal Builtling Jyr �Cb Noxtaampton, 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 most 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 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 renistered contractors. Note.tf the homeowner has contracted with a corporation or LLC, Ihat 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$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: �1a11i � 1 t0 VU,Y t ��sa2 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 D212 mmMENT OF BUILDING INSPECTIONS 212 Main Street • Nuv 010 BuilAing Noxthampton, !P 01060 -3niM1J Massachusetts Residential Building Code Section I I O 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.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.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 Massachusetts I DEPARTMENT OF BUILDINGINSPECTIONS Nair 212 6tiaat N ciP s eulldi \ti�// Northampton, Y 01060 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: D.) TVnaf.« (Please print house number and street name) Is to be disposed of at: Vl kk 7 r ycl„ (Please riot name an location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Pennit 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 Industrial Accidents 7 Congress Street,Suite 100 Boston,MA 02714-1077 wwly mass.gov/dia WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumhers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Informationr� Plea Print L ebly Name BasinesstOrgermatioNlndividual): D.4-c M/att-n Address: ?tl7 S1- City/State/Zip: So A,4//1z9 ",a?- Phone#: ,�? Yr- 0� 1c> Are you an employer."Check Ne appropriate box: Type of project(required): LPIYacmployer won—7— empleyees Man and/or parttime).¢ T ❑New construction 2 I am a sole pmpnemrorpmmemhip and have no mployres wmkmg f r me in any capacity [No veorkers'earn,Imre retuned_] I. remodeling 3D an a homeowner doing all work myself[No workem'comp.ilnuaace retuned.]' 9. Demolition 4❑I..homeowner and will he hiring cono-acton m conduct an work onm rop ry. Iwill 10❑Building addition ensp ore and all contractors either have workers'mmprnsahon msmmr<e or are sole 11. Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5 I am a general contractor and 1 have hired the sub-contractors limed on the attached sheet. These sun-vontrdcmrs have employees and have workers come moureace. 13.❑Roof repairs 6.❑wc are a connotation and to officers nave exeroised their right exemption per MGL c. 14.❑0ther lsz,§Iltl,mw we have vn emvlorees.Mo workers'comp.imumam u,—d,] *Any applicaat that checks box#1 must also fill out Ne seaion below,showing their workers compensation policy infamemon. 'Homeowners who submit this saidavit indicating tory are doing all work and then hire outside contracmrs must submit a new affidavit indicating such. :Co..,.that check this has must attached an additional sheet snowing the name of the sub-contentnrs and stain whether or not these entities have employees. from,sub-coatecmrs have employees,May must provide thou workers comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the poluy and job site information. Insurance Company Name: 2..)t I e k Policy#or Self-ins.lis. Expiration Date: Job Site Address:_ 1 GI ( rsm %z/f - City,'State/Zip: F/o/r-•c: /`rI¢ 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. t52, §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 oda STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy ofthis statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the inforcoalion provided above is true and correct Signature- � D t � Phone#: P7 (/- 07.) 0 Oficial 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): I.Boardof Health 2.11uilding Department 3.City/Town Clerk 41.Electricallrspector 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 to this statute,an employee is defined as"...every person in the service ofanother under any contract of lure, 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 m 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-contraetods)name(s),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. 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 Once 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)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 1-877-NIASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia D � Date: Extsrtor Noms Improvsmsnes (413) 533-0481 www.DaveMirorRooflng.com 847 Ndwton SUUK South Had18% MA 01076 MA Reglstn0on#111264 Customer Name: �,i. /i'iu �:-. �, Telephone Number - Address,City/Town, State: �- BETTER ROOF SYSTEM Landmark Pro • Strip off existing roof • Line all edges with S" aluminum drip edge • Install Q feet of ice&water barrier along eaves and up any valleys • Sandwich drip edge at eves between ice and water barrier • Install Diamond Deck water resistant underlayment • Install CertainTeed Landmark PRO architectural shingles to manufacturers specifications • Install starter strip along eaves& rakes • Install using 6 nails for maximum wind coverage up to 130 mph • Install a ridge vent along the length of house approx. 15"in from edge of roof • Install new vent stack collars • Replace step Dashing as needed along walls and chimney • Re-Dash chimney with lead flashing as needed. • Plywood _Install 1/2" CDX plywood Install 1/2"CDX plywood as needed *_L per sheet • CertainTeed SmeStart Plus 4-Star Extended Transferable Coverage (50 year non pro-rated full coverage warranty for material defects) • All debris removed from work site Protect siding and exterior of house • Protect trees and shrubs • Magnet ground for loose nails • See Other below for any additional work or comments Other Contractor Is not responsible for any damage to interior of home.Any lease articles on walls/shelves should be removed before work starts We Propose hereby to furnish material and labor-complete in accordance with the above specifications for the sum of: j � ��' � � r 7 ' - i --dollars($ A deposit of 1/3, is to be paid before materials are ordered A Payment of$ l S' - is due at the halfway point,and the balance of$ ;< '' ,? — paid upon completion. All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from the above specifications involving extra costs will be executed upon written orders,and will become an extra charge over and above the estimate. Our workers are fully covered by Workmen's Compensation Insurance and Liability Insurance, Authorized Signature: - Note: This Proposal maybe withdrawn by us if not accepted within 30 days Acceptance of Proposal--The above prices,specifications and conditions are satisfactory and we hereby accepted. You are authorized to do the work as specified.Payment will be made as outlined above. Signature: :'.--"'` Signature: Date of Acceptance: This agreement may be cancelled by Customer within 3 days of acceptance for any reason as detailed in the accompanying Notice of Cancellation Customer's Initials lill:N