29-309 (2) 366 ACREBROOK DR BP-2019.1213
GIs#; COMMONWEALTH OF MASSACHUSETTS
Mamfilock:29-309 CITY OF NORTHAMPTON
Lav.001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catcaorv: ROOF BUILDING PERMIT
Permit# BP-2019-1213
Proiect# JS-2019-001964
Est.Cost:$2000.00
Foe:$40.0o PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use croup: Homeowner as Contractor
Lot siae(so.R.): 10018.80 Owner., NATALF JAMES F 3R,&CLAUDIA 1
Zoning: Applicant. NATALE JAMES F JR & CLAUDIA J
AT. 366 ACREBROOK DR
A, aeiicantAddress: Phone: Insurance:
382 ACREBROOK DR (413) 586-0358 0
FLORENCEMA01062 ISSUED ON:4/3011019 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER EXISTING 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 Deoartmsut Fireplace/Chimney:
Rough: 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 sanatu":
FeeTvvel Date Paid: Amount:
Building 4/30/20190:00:00 $40.00
212 Main Street,Phone(413)98'/-1140, Fax: (413)587.1272
Louis Hasbrouck—Building Commissioner
RECEIVE "
Building D art ant orb riveway,Permit
212 Mai St t APR 3 0 2019 r cA"itabi�y
Room 100 alar all Availabiliy
Northampton MA vro of Structural Plans
phone 413-587-1240 Fai �° '(' ,-q°'F'peri Plena
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Properly Addd//}W: /(/� This section to be completed by office
Map 6,C/
3qy i/C L[�V�QO� V Lot "69 __Una
Zone Overlay District
Elm SL DlMdCI CB Dlstrkt
SECTION 2-PROPERTY OWNERSHIP/AUT14ORRED AGENT
2.1 Owner of Record: l/'i1zx ww
� -?, l IFL Rao% 102-
6 (Prim) / Current Maili daress: / 2
// / rte
lM
tiQC,/, Telephone `7 (/ � J
ure
22 Aulhprlzetl Aceto:
Name(Pant) Cumni t Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
m idled b it applicant
1. Building ;01
d." (a)Building Penng Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 0
5.Fire Protection
8. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Nu r: Issued: 1-' M
Signature:
Budding Commissionerpnspector of Buildings Date
C,jcnctc & @.gnczil,Ca,n
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK formic all aunllcablel
New House ❑ Addition ❑ Repla rmmt Windows AKeratlon(s) E] Reefing
is Doors [7
Accessory Bldg. ❑ Demolition ElNew Signs [C3) Decks [p Siding [O] Other[[:q
Brief Description of Proposed
Work:
Alteration of existing bedroom_ es No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Be.M New house and or addMon to exlsUna 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?
I. 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 it 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 as Owner of the subject
party
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
a nature of Owner Data
I,�T/ as wne ulhorized
Agent hereby declare that a statements and intorrnation on the foregoing application are true and accurate,to the of my knowledge
and belief.
Signed under the pans
ya�il penalties of perjury.
�P GE
Pri N e
ign of Owner/Agent Date
The Commonwealth ofMassachuse[tc
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www nassgov/dia
MA.11ters'Compensation Insurance Affidavit:Builders/Contractors/Hlectrfcians/Piumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
� J7Cio�Z�`�00o/j',. 1���✓l I
rop
Please Print
bl
Name (RusinesvOrganizattioMndividdual): 9&S,
Address: JOOrG
City/State/Zip: /5411e, & 9 d/d-/ZPhone#: `- f?-
Ae
you em employer?Cheek the approprhate box: Type of project(required):
1.[]I son.employer,with employees(full anNor pan-time)• 7. ❑New construction
2.❑I nm a sole proprietor or patmership and We no employees working forme in g, ❑Remodeling
t,�m y capacity.Mo workers'comp.msmance retorted 1
3RII im a hosrnoo rdoing all work R No workers'mm 9. ❑Iuildin ion
�^� [ryse t p.imman«retniredlo
a.❑I ann a nomeowmm mrd win he Hiring cono-acmrs m sondmi all wodr on mr pmcemI win l0❑Building addition
no,thm all contractors either We wod:ms'comcemmion mom me,or are Bole 11.❑Electrical repairs or additions
proprietors with no employms. 12.❑Plumbing repairs or additions
s C]I ran a general connortor and I have hired the snbc arasnors listed on the nmehM shm, 13.®Roofrepairs
These sub contractors have employees and We workers'comp.insman 1
6.❑We me a wrpxmtion and its officers have exercised their m
eir right of tier MGL c. IQ'❑Other
152,§I(4),and os,have no employees.Mo workers'comp.iramance required]
*Any Whemt th,checks hiss#1 most also fill on the section below slnwing their workers'compensation polity in so mmom.
t Homeowners who submit the,noidynt inheriting they are doing au work and then hire outside rormwlors must submit a new affidavit indicating Such.
=Conirmons Nat check this box met attached an additiorml shat stowing the mme of the ma,-er rsebrs and state whether or not those entities have
ertpinyees. Ifthe subcontracmrs have employees,Ney must povide their workers'comp.policy numbrr.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 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 he forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do here6 under the and pens perjury that the information provideriabove is
true a correct.
ewn / T- Q Ut ,
Phoned V- J -�-T
Official use only. Do not write in thio area,lobe completed by city or town o,0iciaL
City or Town: Permit(License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/To"Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone M
nssacnusetcs
D6Fa � T OF B1XrWZitG = CTISS
232 BiSt icipaz BIdtl i~w�
i
BOU nn, 6S
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:
37V�Ll OD�4;��
(Please print house number and street name)
Is to be disposed of at:
//t� /ze-YC/o/ �l�oro��nd✓�/�
(Ple,ate print name and tion of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
bV,ga/tuWr—eof Pe d Applicant o ner 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.
.y Massacnusetts
U
/ LgPAR1�S OF HVZLDIDG IDSPSGTIOHS212 win street a Municipal B ilai rthampton, 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 must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
impmvement, removal, demolition, or construction of an addition to any pre-existing owneroccupied building containing
at least one but not more than four dwelling units or to structures wtdch am 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 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.
Date Contractor Name HIC Registration No.
OR:
No iths ding the abov no ce,I hereby p ly or a building permit as the owner of the above property:
e Owner Name d Signature