29-321 (7) I
405 ACREBROOK DR BP-2020-0259
GIs#: l COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-321 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2020-0259
Project# JS-2020-000445:
Est.Cost: $1000.00 1
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JDR BUILDERS 074'105
Lot Size(sq.ft.): 14026.32 Owner: CHARTIER MAURICE J JR
Zoning: Applicant: JDR BUILDERS
AT: 405 ACREBROOK DR
Applicant Address: Phone: Insurance:
P O BOX 66 (413) 665-75 87 WC
WHATELYMA01093 ISSUED ON:8/30/2019 0:00:00
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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
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Underground: Service: Meter:
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Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fire place/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: I Date Paid: Amount:
Building 8/30/2019 0:00:00 $40.00
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212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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Department use only "
City of Northampton Status Of Permit:
Building Department Curb Cut/Driveway P rmit EC E I V E D
�.� 212 Main Street Sewer/Septic Availab lity
Room 100 Water/Well Availabilit AUG 2. 9
Northampton, MA 01060 TWO Sets of Structur Plan
phone 413-58711240 Fax 413-587-1272 Plot/Site Plans
.eci OF BUILDING INSPECTIONS
Other S
p fy .- NORTHAMPTON.MA01060
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY-DWELLING—
SECTION 1 -SITE INFORMATION C.��" C? �p1
1.1 Property Address: i This section to be completed by office
Map Lot ' Unit
Zone Overlay District,
Elm St.District I CB District
SECTION.2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
yMr4VP_4Cf_ YO
Name(Pr' t) Current Mailing,address:
Telephone
Signat re
2.2 Authorized Agent: tD
c�e5� �_ S `fix ( r OJo
Name(Print) Current Mailing Address:
L113-
Signature f Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
Completed by permit applicant l
1. Building jD ' (a)Building Permit Fee
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2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
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4. Mechanical(HVAC) i
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5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number:. Issued:
Signature:. . - ZD)�
Building Commissioner/Inspector of Buildings Date
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EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This)column to be filled in by
Building Department
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Lot Size
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Frontage
Setbacks Front
Side L:= R:= L:= R
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Rear
Building Height r�
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Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Perm it/Varianc /Findin ever been issued for/on the lite?
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NO 0 DONT K OW 0 YES 0
IF YES, date issued:
IF YES: Was the permit re rded at the Regist of Deeds?
NO 0 I ON'T KNOW � YES 0
IF YES: enter B k Pae and/or Document#
B. Does the site contain brook, body of water or wetlands. NO 0 1 DONT KNOW 0 YES
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IF YES, has a per it been or need to be obtained from th Conservation Commission?
Needs to be ob ined Obtained , Date Issued:
C. Do any signs a st on;the property? YES 0 NO
IF YES, des ibe size, type and location:
D. Are there a y proposed changes to or additions of signs intended for the pr erty? YES 0 NO 0
IF YES, escribe size, type and location:
E. Will the c nstruction activity disturb(clearing,grading, excavation, or filling)over 1 acre or is it part of a common plan
that will isturb over 1 acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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SECTION 5-:DESCRIPTION OF PROPOSED WORK(check all applicable)
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New House ❑ Addition ❑ Replacement Windows Alteration(s) E] Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q 1 Siding[0] Other[d]
Brief Description of ProposedJ;�4 n
Work: , ' yv1�I +lam 2�{� C-10t
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Alteration of existing bedroom Yes No Adding new.bedroom Yes I No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house ando.r addition to.existing_housing, complete the foll nwo i�a:
a. Use of building :One Family Two Family Other
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b. Number of rooms in each family unit:1 Number of Bathrooms
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c. Is there a garage attached?
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d. Proposed Square footage of new co i struction. Dimensions
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e. Number of stories?
f. Method of heating? r aces or Woodstoves Number of each
g. Energy Conservation Compliance. Masschec nergy Compliance form attached? .
h. Type of construction
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I. Is construction within 100 ft.of wetlands?Vgarade
No. Is construction in 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below fin
k. Will building conform to the Buildingland Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
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SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIESFOR BUILDING l PERMIT
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I, A/4 C4 � as Owner of the subject
property
hereby authorize A,41-C �. S
to a t o y behalf, in all m ers ative to-work authorized by this building permit application. I
g-Zgir � 5
Signatu a of Owner b Date
5 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 x , 55
Print Name
Signature of Own Agent Date
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SECTION 8-CONSTRUCTION SERVICES.
8.1 Licensed Construction Supervisor: Not Applicable ❑ .
Name of License Holder: .1 �r%5 �` Z55 (l ! C-/,/O
5- License d- L� 013-7-3
License Number
c S
Address Expiration Date
9-7
Sign�tur elephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Co r1VC I 4Y 75
Com any Name I Registration Number
66 IAJO--�' 6 —
P0 &�L- - d - blmP3
Address /' Expiration Date
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Telephone (O�
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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. j
Signed Affidavit Attached Yes...... No...... ❑
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City of Northampton
- = Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ayt '
.' 212 Main Street • Municipal Building
t rw� Northampton, MA 01060
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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 owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacentto such residence or building"be
done by registered contractors.'
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Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered
Type of Work: �"`� Est. Cost:
Address of Work: ycK—
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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):
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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.I SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
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Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
-go
Date Contractor Name IHIC Registration No.
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OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
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Date Owner Name and Signature
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City .of Northampton
Massachusetts
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
M i Northampton, MA 01060
Massachusetts Residential'Building Code
Section 110.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-year 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 homeiowner 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 may be liable for person(s) you hire to perform work for you
under this permit.
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City of Northampton
s
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060
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 1 1 1, S 150A.
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The debris from construction work being performed at:
(Please print house number and street name)
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Is. to be disposed of at:
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(Ple66 print name cinh locatio facility)
Or will be disposed of in a di mpster onsite rented or leased from:
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(Company Name and(Address)
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Signatur 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 of Massachusetts
Department of Industrial Accidents
a 1 Congress Street, Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORIT .
Annlicant Information CI Please Print Legibly
Name (Business/Organization/Indkidual):. >u)L�-b
Address: .
City/State/Zip: `,� sYiP • dl® 7 3 Phone#: l`3 3 �-74 `�
Are you an employer?Check the appropriate box:
Type of project(required):
1nI am a employer with e ployees(full ad/or part-time).* 7. ❑New construction
2.[:]I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling.
any capacity.[No workers'comp.isurance required.]
9 ElDemolition
3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
�4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 0❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5. I am a eneral contractor and I have hired the sub-contractors listed on the attached sheet.
❑ g. 13, Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t � p
6.❑We are a corporation and its officer)have exercised their right of exemption per MGL c. 14.[:]Other
152,§1(4),and we have no employi es.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners.who 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 am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information. I
Insurance.Company Name: I AL v e
Policy#or Self-ins.Lic.#: VV.� b Dl L1 —7 / Expiratio Date: /rC)Ml
Job Site Address: ��/ A, �i��.Q�1� City/State/Zip: �trd���t.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 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 ofthe DIA for insurance
coverage verification.
I do hereby certify an er th/°pa' _I and oalties ofperjury that the information provided above is.true
and correct
Signature: Date:
Phone#: 3 `�� �E 3
Official use only. Do not write)in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):1
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: