25A-110 (9) 323 BRIDGE ST BP-2019-1114
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block:25A- 110 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
Perron# BP-2019-1114
Project ft JS-2019-001810
Est Cost $8685.00
Fee: $40.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sp. ft.): 52707.60 Owner: SALEM KENNETH R&NADINE L
Zoning.: SC(82)/URB(18)/ Applicant: BOB THIBODO ROOFING & SIDING
AT: 323 BRIDGE ST
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527-7663 0 WC
NORTHAMPTONMA01061 ISSUED ON:4/9/2019 0.00:00
TO PERFORM THE FOLLOWING WORKSTRIP & 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 N 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 4/9/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
- SECTION? -SITE INFORMATION ' ' �8-- '10[9^
RILathe?'Edan
Thl'alsecbo plefed�by affce _
7.7 ProoeAddress: �za i "�,� `�`��
a u
rtv tIi"M- dIrdU
zZone:
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,11 Owner of Record:
Nam.(Pdnt) Cu ilia d S �-
Telephone
Siss�Wu a
2.2 Authorized Aaent: r� \\
UYI�1oMn
Name(Prin Current Mailing Address:
2� - 4 S--,s 1
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. -
Item Estimated Cast(Dollars)to be Official Use Only
completed bermitac licant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
I s Construction from 6 -
3. Plumbing -Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6, Total=(1 +2+3+4+5) Check Number ��
This3eo4on For Official llas Oin
Date
Building Permit Numb Issued:
Signature:
Building Commisslonerrinspector of Buildings - Oats
Section 4. ZONINGCCmplted. Permit Can Be Dented Due To Incomplete Information
Proposed Required by Zoning
Smileless
mlD.P. .t in by
Building Depum,eu[
Lo[Siza IFranSetbacks FrontC•Side :L_1 R>R.- L.J Building Heightr"�
Bldg.Squaze Footage
Open Space Footage
(.,area mlvaa'Ido&paved )—yl LTJ
arkiu
# fpailcin,Spaces
Fill: i i�
(wlume&Location)
A. Hasa Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:�=
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES
IF YES: enter Book ! Page and/or Document#C— ,
B. Does the site contain a brook, body of water or wetlands? NO ®. DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q - Obtained Q , Date Issued: -
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location: ` I
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0
IF YES, describe size, type and location: L I
E. Will the construction activity disturb(clearing,grading,excavation, orflling)over 1 acre or is it part of a common plan
thatwill disturb over l acre? YES NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
I
� 1
r ,
SECTIONS-DESCRIPTION OF PROPOSED WORKlcheck all aoolicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding[[]] Other[pj
Brief Descriptio of Proposed
werk� g�}sV\ i ShneMS r,�e � V1` ksr a+", �O- 5l�
Alteration of existing bedroom_Yes_No Adding new bedroom es No
Attached Narrative Renovating unfinished basement _Yes _No
Plans Attached Roll -Sheet
as If`Nevrhouse and or ad�fion-fo axis{inv ohoh usirig comic ate the followiriI:
a. Use of building :One Farl 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 ofstories?
I. Method of heating? Fireplaces or Woodstoves Number of each_
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. Is construction within 100 ft. ofwetlands?_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'-TOBE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1r\ �/,.y\{ �� as Owner of the subject
prcpeny
hereby authorize CZ\) 1 fel Vc� l _
to a on my behalf, in all matters relative to Work authorized by this building peri ppli ation.
e
Signature of Owners \^ -\ - Date
I, \ ' v\ l ) CJI�JJ as Owner/Authorized
Agent hereby declare at the statements and mformatien on the foregoing application are true and accurate to the best of my knowletlge
and belief.
Signed un rthe painsand enallies c(perju
Prirh Name
Signature of wner/Agenl Date
I
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable/E
Name of License Holder:�SZ �i t1 oa., �C
1� 1, Licenseumber
Address Expiration ate
Signature Telephone
9.Re Istered HPmelmnbvement Coirt2zYor -� -^i= "
Not Applicable £
esa, -, r
Company Name --Registratio Number
Address Explc'� vat on D to
p Telephone' r
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.J. E No...... £
114-"$ome 6wn E g Wi0ri
The current exemption for"homeowners"was extendedto include Owner-occupied Dwellines afar(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 108.3.5.1.
Definition of 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
swctures.A person who constructs more than one home in a two-Year Period shall not be considered a homeowner.
Such"homeowner'shall submit to the Building Official,on a form acceptable to the Building Official.that he/she shall be
responsible f U such work performed under the b.11cline Permit.
As acting Construction Supervisor your presence on the jab 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)ofthe Massachusetts General Laws Annotated,You may be liable for person(s)
you hire to perform work for you under this 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 ofdndustrialAccidents
"t Office of Investigations
600 Washington Street
F Boston, 34A 01111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Bufrlders/Contractors/Llectricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Orgaruzation/Indivi dual):
Address:17�_y— '�(�S'�1('��Q12
City/State/Zip: S o, _nI Phone #: y0 S� S
Are ou an employer? Check the appropriate box: Type of project(required):
1.�I am a employer with _ 4. ❑ 1 am a general contractor and I
Z
(full and/or part-time).* have hired tie sub-contractors 6. ❑New constmction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. EJ Remodeling
ship and have no employees These subcontractors have g, ❑Demolition
working for me in any capacity. employees and have workers' y ❑Building addition
[No workers' comp. insurance comp.insurance.;
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.,�❑//Plumbing repairs or additions
myself, [No workers' comp, right of exemption per MOL 12.LI Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.El Other
comp,insurance required,]
'Any applicant that checks box k]must also 5ll out the section below showing their workers'compensation policy information.
tHo mxcwo`c who submit ads affidavit indicating they azt doing all work nod then hire outside contractors must submit a new affldslit indicating such.
=Contractors that check this box must attached an addit..]sheet showing the name of the sub-conhaotors and state whether or not those notites have
employca. If the sub-coahacmrs have employees,they must provide thetr workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information. � ' \,
Insurance Company Name
Policy#or Self-ins.Lic.#: OU �0a✓ Expiration Dater
lob Site Address: - 1 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 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-year imprisonment, as well ascivilpenalties in the form of a STOP WORK ORDER and a frac
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.
I do hereby certify
\under the pains and penalties ofperjury that the information provided above is hue and correct.
Sicaat=2:�a \(' L1h AA,� — Date ``\ \ e,Phone#, S� S, ) GI
LL
use only. 'D not write!n this area, [o be completed by city or town official
Town: Permit/License#
Authority(circle one):
of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Person: Phone#:
City of Northampton
r,. Massachusetts
x
I s DEPARTMENT OF BUILDING INSPECTIONS
212 Main Stzeet • M»cip al Building '
Nostbampton, MA 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 ad 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 shall 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
foundation/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 i
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, Nor fnampton, MA 01060
Solid Waste Disposal Aff davit
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 MGLLc 111, S 150A
Address of the work:
The debris will be transported by:
The debris will be received by: CA WC 1
Building permit number:
Name cf Permit Applicant
Date Signature of Permit Applicant