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31B-314 (14) 15 A PARK AVE BP-2019-1127 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 31 B-314 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: ROOF BUILDING PERMIT Permit# BP-2019-1127 Project# JS-2019-001832 Est.Cost: $800.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SHUMWAY ROOFING 105743 Lot Size(so.h.): Owner: CAMPE CHRISTIAN&ELIZABETH WADHAM Zoning URC(100)/ Aanlicant: SHUMWAY ROOFING AT. 15 A PARK AVE AmlicantAddress: Phone: Insurance: 625 EAST PLEASANT ST (413) 549-4658 0 AMHERSTMA01002 ISSUED ON.4/122019 0.00:00 TO PERFORM THE FOLLOWING WORK:PORCH ROOF REPAIR 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 4/12/20190:00:00 540.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Statulwof Permit. Building Department Curb CuVDriveway Permit 212 Main Street Sewer/Septic Availability i Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A/nONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1,I" lq- d 1.1 Property Address. This section to be completed by office �/ '��A ' cMt vt k Ave- Map Lot Unit Ml / hnD(O6OZone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 caner of Record: g((XC„ "AKA l( vC/ Nam r t) Current Mailing Address'. "A 01060 If Telephone 62 -99 Sol Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee I/zg 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+ 3+4+5) 1 Check Number This Section For Official Use Only Date Building Permit Number. Issued: ��,^1 Signature: q- �) W�q Building CommissionerlInspector of Buildings Date 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 Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot arca minus bldg&paved parking) #of Parking Spaces Fill: volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DON'T KNOW O YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# 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 0 , 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 O NO Q 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ FRepllac,,erent Windows Alteration(s) ❑ Roofing Accessory Bldg. ❑ Demolition ❑ gnns��� [0] Decks [t7 Siding (0] Other[a Brief Description of Proposer. nG� c Work'. I` / C— Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba. If New house and or addition to existing housing, 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? 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? IF, 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 1 ary (54l0l� � r; 1 ( aLU�PQ � ft�� '-AaA'-1 as Owner of the subject property hereby Forize SeAi o y ben ,in all matters relative to work aut rize by this building permit application. C CD Signature of OwnerDate II I. 0"/ 1 S kv/ t `t 7 as Owner/Authorized Agent her y declare ih t the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed and a pains and penalties of perjury. l7�VN V c Print Nam Signature ofO r/A n Date SECTION 8-CONSTRUCTION SERVICES 106W3 7151A 8.1 Licensed Construction S endsor: Not Applicable ❑ n Name of License Holder k✓y"1"a I n S - VI License Naber Adtlressl Expiration Date Signature Telephone 9 Registered Home Improvement Contractor: Not Applicable n Company Name RegistratioNumber I 0-1 a Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affda,yit must be completed and submitted with this application. Failure to provitle this affdavit will result in the denial of the issuance of the buiVring permit. Signed Affidavit Attached Yes....... v No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS Z 212 Main Street * Municipal. Municipal Building Northampton, rm 01060 ''sbh. P�rD 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("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 lour 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 he registered. Type of Work:_ L( /����,.- Est. Cost_ 619 f=_ Address of Work: �SDate of of Permit Applicatiom_ � / I hereby certify that: Registration is not required for the following reason(s): _W 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: 1Q / Iti w Dale Contractor Name HIC Registration No. OR: Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature The Commonwealth of Massachusetts W, Department of IndustrialAccidents 1 Congress Street,Suite 700 Boston, AIA 02714-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Ifo t' Please Print Legibly Natlle (Business/Organization/Individual): z T Address:qn, Ps T n City/State/Zip: �e Phone Are you an employer?Check the ap opriate box: Type of project(required): 1.[]l am a employer with employecs(full and/or pari-time)" 7. ❑New construction 2.❑lam a sine proprietor or partnership and have no employees working for me in $, ❑ Remodeling any capacity.[No worker, comp_Insurance required] 3.❑I am a fiameowner dong.11 It kers'emo -ed q. [1 Demolition ga .,,off [No wor p.insurance reyuu l' y.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 E] Building addition ensure that all contmdorsenher have workers'compensation msuraaccor are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. lam eneral contraclorandl have hired thesub-contraemrs listed on the attached sheet. ❑ 13.Er-of repairs T se subconoadors have employees and have workers'comp.insurance: 6. We me acorpomtion and its officers have exercised their right ofcxemption per MGL c. 14.❑Other 111-41(,n,and we have no coalesce,.Mo workers'wrap.insuranconcerned 1 "My applicant that checks box 41 must also fill out se^_tion below showing their workers'compensation policy Information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContrauors that check this box most attad ed an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees_ If the subcontractors have employees,they must provide their workers'camp_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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 certify n (7�B�pains an-d pens/ties o -edury that the information provided above is true and correct. Signature: =pains q 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 SS' S ' Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Stceet -Municipal Building „r— Northampton, M 01060 s�N 3q`J Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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: S oil /t GL— (Please print house numb6r and street name) Is to be disposed of at: �hl I (SPI ase print name and location of fatality Or will be disposed of in a dumpster onsite rented or leased from: Co any Name and Address)' Signat a of P it 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.