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35-298 (5) 41 WOODLAND DR BP-2019-1246 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 35-298 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: ROOF BUILDING PERMIT Permit# BP-2019-1246 Proiect# JS-2019-002010 Est.Cost: $2900.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class Contractor: License: Use Group, BOB THIBODO ROOFING & SIDING 065699 Lot Size(sn. ft.k 39116.88 Owner: DOUCETT GARY Zoning: 5R Applicant: BOB THIBODO ROOFING & SIDING AT. 41 WOODLAND DR AppiieantAddress: Phone: Insurance: P 0 BOX 201 (413) 527-7663 0 WC NORTHAMPTONMA01061 ISSUED ON:5/6/2079 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF REAR OF HOUSE ONLY 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 5/6/20190:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner - - -1 4OF CEIV ussc1115: n K ol'No" amp - W Of el 111 5:4 ' City M Building D, rtm nt C 2 1 M 1, 2 a tree MAY 6 2019 Room 1 0 ii Northampton, AO 060 phone 413-587-1240 x 4"aNSPF ci APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ----------] SECTION I-SITE INFORMATION 6P- 1.1 Pnow.ftyAddress This section to be comislated by office Mapes Lot :;Zq Und 4 c) Zone Overlay District Etin St Dlsbrfct CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e C' L4 2� Conant Mailing Addls Telephone gnavxnr� 2.2 Authorized Agent ':�� -T`;"\:) - k. Name(Pnnh Cument Mailing Adidnass Signature Telephone SECTION 3.ESTIMATED CONSTRUCTION COST Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Budding (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection It 6. Total=(1 +2+3+4 5) C)<Z> Check Number if Lfv This Section For Official Use Only Data u Building Permit Number: Issued: Signature. 5- L- 20)9 Building Commissionedinspector 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 colwm to be filed m by Building Department Lot Size Frontage ....._. Setbacks From "- Side L R.__. L R:— Rear __ . .... Building Height Bldg.Square Footage - % -- Open Space Footage % .-... .. p.ot arca minus bldg&paved _-.� _ ... ...... erkin .. _. #of Parking Spaces -- -- Fill: ...... ..-_. Iyolume&Lucatonl t- --- —.-- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © 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 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 O NO O IF YES, describe size, type and location: E. Will the constructon 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required SECTION&DESCRIPTION OF PROPOSED WORK(check all aoolicable) New House ❑ Addition ❑ ReplacementWindows Alteratlon(s) ❑ Roofing gr Doos D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks IO Siding[1711 Other[a Brief DesydP!(on of Proposed Work: P" CiLAG Alteration of existing bedroom_Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet Be.if New house and or addition to existina hOUSine. 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 conslmchon. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? in, Type of construction i. Is construction within 100 K.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 APPLIESFORBUILDING PERMIT I, \ (�Y�1 ' — G-T \\ as Owner of the subject property hereby authorize � ,3-7,5100 C1 U-tl to act on Mm all matters relative to work authorized by this building Permit plication.\ signature vof=OOwwner Date O R 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 under the pains and penalties of perjury. Pdn' Signature of Owiwr/Agent Date �— SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction - 1tT Supe�rvjisor:� /NootAppliccable ❑ Name of License Holder'. �7 pZ\� 1 ' ,\�'O t/(O'5 , 9 =1 License Number Adtlress Expiration Data Signature Telephone 9.Raaist�ered Homs Im�oroyenom Contractor. Not Applicable ❑ 2 n6 1 r,\lJ A � I s I\ - a Company Name Registration Number 3� EPs qlc 5� Ew+4 6 it L4 — 1 —a,-\ Address , Expiration Date Telephone 5 6—n SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(Q 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 bui ing permit Signed Affidavit Attached Yea....... No...... ❑ r City of Northampton Massachusetts V i ' INT'AR OWT OF BUILDING INSPECTIONS 212 Nein 5[raat • Municipal Building NaitaemptOq !P OlOfiO �^O 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 owneroccupied 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 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: 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 ~ ., �\ pEPTE13ENT OF BpILDING INSPECTIONS 212 Hain street • Municipal HuilQL xv Morth ton, H 01060 Massachusetts Residential Building Code Section I10.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-yew 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 persons) 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 z DEPMTHENT OF HUZLDZNG INSPECTIONS 212 Msin St—t •Municipal B..Idl.q Northampton, . 01060 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: H I w- od\ar� 'Pr F\ vn c (Please print house number and street name) Is to be disposed of at: V o.\\t y � CSC\\v��l (Please print name and locati n of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit 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 ofMassachuselts V11Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02714-1017 www.ntass.gov/dia orkers'Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Amplimplat Information r�� Please Print L ibl Name(Business/Or mizatioWindividual). 9 1711 d Address: 3a. EP SVV \—R k5 �- City/State/Zip: S TIh. o, phone#: Ll 0 ci (e,--- Are you an employer?Check the appropriate box: Type of project(required): Lr�lamaemployerwith I_employees(full amicrprd-time)` Z ❑New construction x.E-]l am a sole pmpnetor or partnership and have no employees working for me N S. El Remodeling my calracity.[No workers'comp.resonance requited] 37 11 am a homeowner doing all work myself[No workers'con,insurance required.]t 9. E]Demolition 4.n 1 am a homeowner and will be hiring mnmactors to conduct all work on my progeny. 1 will 10 ❑Building addition ro ore Nat au nnntraaors either nave workers cnmpensatiov ivmance or are sole 11.E]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions s❑1 am a general contractor and I have hired the sub-comoecturs listed on the attached sheet. 13.2fRoof repairs These eaveo posemrs Mire employees and have workers'comp.on—,- 6.❑We are is corporation and in officers have exercised their right of exemption per MGL c 14.❑Other 152,§I(4),unit we have on employees.[No workers'comp mournnce removed.] "Any applicant tda¢hceks box dl must also fill out the section below showing their workerscompensation policy information. I Homeowners who submit this affidavit indicating they me doing all work and Nen hire outride contractors must submit a new affidavit indicating such. :Cnn.t.and check an.box must attached an additional sheet showing Ne name of the subcontractors and state whether m not those entities have employees. Ifthe sub-contractors have employees,they must provide their workers'comp.policy nomba- 7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �� f� Insurance Company Name:: ) FYI ��-A O`r6 Policy#or Self-ins.Lic.#: Q5 015 01`4 I L4 LJ Expiration Date- ��—�¢.s Job Site Address:i-A ) W o O (1� as'l qY City/State/Zip:T) �C`,C't Vf-Asr 5' 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 imprisomnent,as well as civil penalties in the form of 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. Ido hereby certify under the pains mud(penalaes of perjury thatthe information provided above is true and correct Sienature: L-'�a' T-ts<YO Date' S\�� Phone#: LA J — S - ( ect (n—) Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License H 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#: 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 of another under any contract of hire, 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 an 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-contractor(s)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. Ifm 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 ifyou 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 Office 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 ofthe 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. Anew affidavit must be filled out each year.Where a homeowner 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 Deparanent of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia