36-116 (5) 4 OVERLOOK DR BP-2020-0203
GIS#: COMMONWEALTH OF MASSACHUSETTS
MO Block:36- 116 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
Permit# BP-2020-0203
Project# JS-2020-000343
Est.Cost: $6000.00
Fee: $80.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sa.ft.): 16596.36 Owner: CONNOR RICHARD E&KATHLEEN M&M CONNOR-THOMAS& P
CZARNIECKI
Zoning_ Applicant: JAMES ROBERTS
AT. 4 OVERLOOK DR
Applicant Address: Phone: Iwsttrance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON.811912019 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & 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# 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 8/19/2019 0:00:00 $80.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
The Coin monwealth of Massachusetts FOR
* Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code, 780 CMR USE
Building Permit Application To Construct Repair,Renovate Or Demolish a Revised Mar 2011
tc P
One- or Two-Fandly Duelling
This Section For Official Use Only
Building Permit Ntunber: D e Applied:
Eyi�..� �oss B-IL-201q
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
l.lProperty Address: r"/,�— L2As ssors Map&Parcel 11'uml'r.
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: — Outside Flood Zone? Municipal 13 On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ON.i ' of ord: ��
Name Pri t) City,S ate,ZIP
Wo.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED MIOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of U 4s Other ❑ S ecify:
Brief Description of Proposed Work2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Lab and Materials)
1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fite $ Total All F ' T
Suppression) "� D
Check No. heck Amount; C�asbAmount:
6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction.Superv' r License(CSL) 4 d .
License Number Expiration Date
pd)treet
Holder
List CSL Type(see below)
Type Description
Vle U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted M2 Family Dwelling
City/Town,State, M Masonry
Roofing Covering
Window and Siding
SF Solid Fuel Burning Appliances
NandStreel
I Insulation
Email address D Demolition
Home Improv tt Contractor(HIC)
Regis ra ion tuber Expiration Date
me or gis nt NameEmail address
City/Town, Stat , Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insw-ance 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..........❑ No.......••••❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLI FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work author ed by this building permit application.
Me
Print %%ner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
t � C �� 15 6v/
/
Printint Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass. og v/d9s
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The City of 1
Building Department
c�yPORATEO JUIIE��1
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance with the provisions of MGL c40, s54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility as defined by MGL c 111, s150A.
The debris will be disposed of in:
Location of Facility
The debris will be transported by:
r
Name of Hauler
Signature of Applicant:_
Dater ��
� \ The Commonwealth of Massachusetts
Department Of IndustrialAccidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
Ivwlv.mass.gov/dia
Workers'Compensation Insurance Affidavit:Bit ilders/Contractors/Electi-icians/Plumbers.
TO BE FILED\'PITH THE PERMITTING AUTHORITY.
A>>licant information Please Print Lc ibl
Narne (Business/Organization/Individual): q.
Address: �--
City/State/Zip: Phone M
Are you an employer?'Check the appropriate box: Type of project(required):
1. 1 am awriployer with employees(full and/or part-time).* 7. ❑New construction
2. a sole proprietor or partnership and have no employees working for me in S. ❑Remodeling
any capacity.[No workers'comp.insurance required.] 9, ❑Demolition
3.❑I am a homcovnicr doing all work myself.[No workers'comp.insurance required.]t
10 E]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I Hill
ensure that all contractors either have workers'compensation insurance or are sole l LE]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑i am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13 •epairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per AML c.
14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t 14omeomiers veho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I aim an eiiiptol'er that is providing workers' onipen ation insure for niy emplgyees. Below is the policy avid job site
inforniation.
Insurance Company Name:
Policy R or Self-ins.Lic.d: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the 1vorkers'compensation policy declaration page(shott•ing 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 tip 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.
J do hereGy cerci p ender the ptrins and p fes f peryirrp that the iiifoimation provided above is true andecL
coi
Sit=_nature: -A
Date:
Phone#:
official use only. Do not write in this area to be completed by city or town official.
City or Town: Permit/License I
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
Contact Pei-soil: Phone
ti
The City of Easthampton
.�G. .- ti `" Building Department
1,
��1by 50 Payson Avenue
��Rn►enau�i�`'1 Easthampton,Massachusetts 01027
Phone(413)529-1402
Fax(413)529-1433
HOMEOWNERS' EXEMPTION ELIGIBILITY AFFIDAVIT
I, (full legal name),born
(month,day,year),hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners' exemption to the permit
requirements of the Massachusetts State Building Code,codified at 780 CMR 110.115.1.3.1,in
connection with a project or work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned
homeowners' exemption,does not involve the field erection of manufactured buildings
constructed in accordance with 780 CMR 110.83.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR
I I O.R5.1.2:
Person(s)who owns 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 home owner.
4. 1 do not hold a valid Massachusetts construction supervision license and,except to the extent that
I qualify for and will abide by the Massachusetts State Building Code's requirements for the
supervision of the project or work on my parcel,I am not engaged in construction supervision in
connection with any project or work involving construction,reconstruction,alteration,repair,
removal or demolition involving any activity regulated by any provision of the Massachusetts
State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or
work on my parcel,I acknowledge that I am required to and will act as the supervisor for said
project or work.
Signed under the pains and penalties of perjury on this day of A 20_
(signature)