06-043 (9) 271 HAYDENV ILLE RD-Route 9 BP-2019-1410
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:06-043 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2019-1410
Project# JS-2019-002277
ESL Cost:$2500 00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: JAY WATSON 177571
Lot Size(sp.R.): 30622.68 Owner., CHAPIN-BISHOP CATHERINE A&PETER E BISHOP
Zoning:SR(100)/ Applicant: JAY WATSON
AT. 271 HAYDENVILLE RD - Route 9
ApplicantAddress: Phone: Insurance:
50 MAPLEWOOD DR (413) 522-7769 0 W(
AMHERSTMA01002 ISSUED ON.•6/17/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE ROOFING ON TWO DORMERS
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: Qik 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 6/1720190:00:00 $40.01
212 Main Street, Phone(413)587.1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
-
,-,a
p• City of Northampton StealxDepartment use only
Status of Permit
Building Department Curb Cutf[mveway Permit
F. A 4 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587.1240 Fax 413587-1272 PIodsite Plans
Other Sp Ty
---PFfcp RPM
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLIS A O E OR TWO FAMILY DWE LING
SECTION 1 -SITE INFORMATION I I
JUN 1 02019
1.1 Property Address'. This i bCIJ0tj2,gg&2ggWid@dJLxaKwA
DF�T OF UamNG INSPECTION{
AY DE✓ V u ��G R A. Map . •nr1ON.MAmom
01 L)S 3 f e 0 1 zone Overlay District
Elm at.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
P aTIli X C:S I•I DY "awl h1A-f oo tJ v, \L€ 1L ofo5 )
Name(Print) Current Melling Address:
41} S XC,—`14U )
Telephone
Signature
2.2 Authorized Agent
,3 AY w /1.500wvOO dr . A..,�ce1)
Name(Prig) Current Mailing Address:
1 413 S2z i tbi
Sgnalure Tesimi
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1. Building ,as lJ (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Few
4. Mechanical(HVAC) (]lJ
5. Fire Protection `I�j
S. Total=(1 +2+3+4+5) 1 TSOL Check Number ( 5
This Section For Oficial Use Only
Building Permit Numb r Date
ssued:
Signature:
Building Commissioner/Inspector of Buildings pale
131GkaF(ia-b U~1 @ NuirnoL l• �TAv�
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Wet be Canpleted.Pennit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column w h filled in by
Building Dryntorwt
Fr
Stt acks rf}}(F�ront
"Side L R' L: R: _... _.. _...
1
Bw mgTteight-
Bldg.Square Footage % —
Open Space Footage %
1�ew minus Ndg&qvN
ukw
#of Parking Spaces
Fill:
wl,me@Lomdaol A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Boric Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT 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 0
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 construction activity disturb(d Bring,grading, excivafion, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTIONDESCRIPTION OF PR k II applicable)
Now House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doom
Accessory Bldg. ❑ Demolition ❑ New Signa [0] Decks (C) Siding(01 Other(a
Brief Description of Proposed
Work KA.PLa�".. i. Peo
Alteration of existing bedroom_Yes_No Adding new bedroom_Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
Sa. If New house and or addit]o o exist]n housin complete the following
a. Use of building: One Family Two Family Other
b. Number of rooms in each farnily 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 Woodstuves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. 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 cella floor below finished grade
k. Will building conform to the Building and Zoning reguladons? 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
I, as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Ower Date
now
I J pY t..� n TJo
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.
3 w 1-3 E,
Print Name
Signature of Ownen�Apen Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Haider A TCN% — CS —l1V S
Lkense Number
S `� Mh''C�.lIwWY A'Mh [F) T IA I Zl.a
Add.. Eipi n
4j ; Szz -} "kG5
SipneNre Telephone
S.Registered Home Improvement Contractor: Not Applicable ❑
J6 w -,Cos ,. r".. �—t ;S� 1 -4 -+ 51I
Company Name Registe,on Number
SJ J" 4 � I1 12J2o
Address E><piraagn Date
(, IQ o 2 Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Ill Q 152,§25C(S))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this a/fidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No.. — ❑
City of Northampton
Massachusetts
OLPARTIBHT OF BMLDING INSPECTIONS
212 Min Sti t • Mnicipal auiltl ng
aortia ton, M 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,
improvement,removal,demolition,or construction of an addition to any pre-existing ownerb cupied 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 owneroccupied
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:
UIkaISG J ►3 Wcosw\ 1 -1 -1 I
Date 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
City of Northampton
Massachusetts
_ DBPMTl9,TIT OF BUILDING ZNSP=TONS
212 WinStrut 3 Municipal Building
NOrt=ton, W 01060
Massachusetts Residential Building Code
Section 110.85.1.2
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 I IO.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 110.125, 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 maybe liable for person(s) you hire to perform work for you
under this permit.
City of Northampton
{.
Massachusetts
c
s
Ik IWARSfffi2T 08 BOII:DIAG ZNSPHCTZOeS
212 l in Burt ON icipal Building Si gC
Ncuttmptun, M 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:
a. -+ l NA'ff —yam L,1 -�k
(Please print house number and street name)
Is to be disposed of at:
A—, ' aa�'1- 'I cn-.-, A �-n t1 —
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
L-zz::7—
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 ofMassaehusetts
Department of IndustrialAccidents
7 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
VWorkers'Compensation Insurance Affidavit:Buflders/Contrastors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lealls
Nadine(Business/Organaatiowindividual): ,1 AY Lir ATJ<_ Lia —IT,—+ 'u f (V
Address: 52 MAYle wood I ,-
City/State/Zip: A�\t Fc S'4 olxk6l Phone#: 415 S22 - - -�-(s�
Are yap an tmplayer?Cheakthe rppeoprite bon: Type of project(required):
LQ I am a cmployer with cmpmyces(full and/or pnn-tune) 7. ❑New construction
In 1wa sok pmpaewro arroarshipandhavenoempkymn waking farmeM
my rapacity.[No wars'decomp.iorwma reyui od.] 8. Remodeling
).❑1=a homeowner doing all work myulf.[No woken'comp Msumnce me uucd.]' 9. ❑Demolition
4.[]l an a homeownm and will be hviog conpectm to weductall wok an my property. I will 10❑Building addition
ew.thatan cooaactm either have wok.,coa,crr.oo imarancem arc rule 11.❑Electrical repairs or additions
,nometnrs with no employees.
12.E]Plumbing repairs or additions
5,C]1 m a grog d conionsoram I have sited me sab<onaaamas red on we adrehed:t m. 13.NRoof repairs
�..rTh� ese sub-Ma a me eve employ«S act have waken'Camp.Uwwawe,:
6.IVI We am a corporation and its oficm eve eaemued their sight of.crarv.R'r MGL c. 14. Other
T152.§I(4),and we have no a loyea.(No workers'comp.mmiance equitN.l
'My applicant Mat checks box el mutt also fill out the secaai below showing Mev wokers'compemaaon polity infammtion.
'llomeownm who submit this affidavit indicating they ac doing all work and Men hire outride coneucmrs must submit a new aflidivit oahcosing such.
:Conak,mrs Ma check Mrs box amt arched an additional shcet showing the Www ofthe subcomrvoars and ova whether or pot those entities have
cmployeea. Ifthe sub marmuns leve empbyrm.dw,must pmvde Mev workers comp policy numb
/am an employer that is providing workers'compensation insurance far my employees. Belowk,the policy andjob she
informaaon.
Insurance Company Name:
Policy#or Self-ins.Lia#: 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 requited under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
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 cerci un der the pains andpenalcies ofperjurythatthe informationprovided above is aueandcorrect
Signature: Date' 3�-+�^ jUi 2oty
Phone#: `j 17) S 2 't —}^} 6ck
Official use only. Do not write in thty area,to be completed by city or town official.
City or Town: PermillLicense#
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 of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to you situation and if
necessary,supply sub-contractor(s)morels),address(es)and phone number(s)along with their certificam(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 tarty workers' compensation insurance. If an ILC 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 bosom
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 permitilicense 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-MASSAFE
Fax#617-727-7749
Revised 02-23-15 ww W rai ss.gov/dia
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SECTION 10-111FUCT L PEER UMMfM CNR 110.11)
IndepeMent$trWuldE .rem Slrudurd Peer Review Raguned Yu 0 No
RECTION II.OWPoft M TNNf-TO EUILSONO
ULETEO WHEN
(HOMEM AGENT OR CONTRgCTOR APPl1E8 FOR PFRWT
I. Pm�er 8714^(' .as ower of meautryed eaget,
leder
T. 1/IlR T S o n ro
TCl an, In 011 Npve to aulnenaea by inq drairg perms application.
N
I!� dpaar od.
L n WrerlAUlfxtnud
Agem ndeby dedtee Nat Ne stdm
eems text iofarmetwo on Me lom,mg applicabon aro too, cc
and ause.to me beat of my xnowleege
text belie(
Sgnq undte me pans aml penalbea of Ponurv.
FnM Nxw
syndum W(N ev Oda
SECTION 12-CONSMUCTKIN SERVICES
10A Llewae cpm4rclbn lupeniwr Nm AppYWbb O
Ny.NLlranr NolYr.
l:tanm NWIIYr
.reef E,p *n Dale
Sgwee fe tee
SECTM 13•WORKERS'CONPENSA PaRPIUNCE AFFMW IN.O.L.c.1R 1 M(Ste
Wwadf Compensation Inaurence efidevb must be canpleecl end submi iee wiN Ne Woncabon Fallure W proude Ne af00aMl eie Mob
In de denial of ma inuance of de butub .mat
SqW Affiant Attached Yef 0 No
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/ Vmioal]Commcniel Rufldin Pmmn Ma IS.Ipp
OMrananl uN oraY
City of Northampton BWw dParlM[
Building Department Cup 0A1Dnwwy Parma
212 Main Street bwlBpYc Aaa dWft
Room 100 WrawylWaS Ava ft
Northampton, MA 01060 TMo 8ayolblrvcWN PWW
phone 413-587-1240 Fax 413-587-1272 PNVsIM Pww
Oil si xity
APPLATATION TO CONSTRUCT.REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1-SINE WFORIMTIDN
1.1 Pranarla A4dres This eacti m w M complabC by anis
Map La Una
Ins O 'OlaWlal
EFn at OMta ea oww0
SECTION 1-PROPERTY OWNERSNPMUIHORQED AO:NT
2.1 Ower N Racxd: p
fejYr �;s.{r yp aT 1 hlaydra vrlle ., Gaa✓s oFS
C.Wiwi MYen
/F7a�Mil sn � Y/3 - X96
S' WYIL TNexroe
22 AUUIarlaad Asn1:
wme rim) �,Aixm lCpga
SgWNe TNryMpne
SECTION 3-ESTIIIATED LOMSTRIILTION fASTb
hem Es"ONo Cul(OWIm)to tw OlOnal Us ONy
oorivii4iolb,permit ePpl.rt
1. Build" (a)BuilMlq Pend Fs
EWGr¢al (al Ecbnxad ToIM CON OI
CanWucean from B
3, Plumbm0 BWMIna Permit Fs
a. IMW (HVAC)
5.Flm Praleuan
8. TOW-H +1+3+4•5) Cwdt Number
Tire,SSSan Far OISCW Us Only
Buoy,Pelma Number Oa0a
Isuw
SgwWm
CanruamraW ae Daw
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1 Commonwealth of Massachusetts
Dio1
Board dlf SWI Building ReReasslonal Licensure
gulations
Const, and Standards
11 0Agrvisar
CS-079105 ,o
FA
Pires: 10/09/2020
JAY BICKFO�yyA `-
+`0MApLE'Wpgp 02 ;+
AMHERST MA 0` =
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Bd
Commissioner 0 /�.�