31A-100 (3) 9 FEDERAL ST BP-2020-0257
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A- 100 CITY OF NORTHAMPTON
-Lot:-001 PERSONS CONTRACTING WITH UNREGIS I EREDCONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2020-0257
Proiect# JS-2020-000442
Est.Cost: $10000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: j ERIC DRIVER 97208
Lot Size(sq.ft.): 13721.40 Owner: WALDMAN AMY I&AMY MARTYN
Zoning:URB(100) Applicant: ERIC DRIVER
AT. 9 FEDERAL ST
Applicant Address: Phone: Insurance:
556 STAGE RD (413) 695-1947
CUMMINGTONMA01026 . ISSUED ON.813012019 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL METAL ROOF OVER EXISTING
ASPHAULT SHINGLES
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 Firelplace/Chimney:
Rough: Oil: Ins Elation:
Final: Smoke: Final:
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THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy I Signature:
FeeType: Date Paid: Amount:
Building 8/30/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (41J).587-1272
Louis Hasbrouck—Building Commissioner
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n � `Jf`he Commonwealth of Massachusetts
K F g $Board of Building Regulations and Standards FOR
J g rr\:) MUNICIPALITY
o c cc Massachusetts State Building Code,780 CMR;7`t''edition 'USE
a o Building Permit Application To Construct,Repair;.Renovate Or Demolish'a Revised.January
M M One-dr Two-Family Dwelling 1,2008
0 0 his Sgption For Official Use Only
N Building ermitNu ber: Date Applied:.
(3- 2q-
Signature:
�tq
Bur ding Commissioner/Inspector of Buildings Date
SECT➢ON 1:SITE INFORMATION
r .
1.1 Property d�r►'ess: ( 1.2 Assessors Map&•Parcel Numb9rs
dlr�� S� t®�eACe I
Pai
i,la Is this an accepted street?yes no Ma punber cel Number,�
1.3 Zoning Information: 1.4 Property Dimensions:
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Zoning District Proposed Use Lot Area(sq ft) Frontage-(ft)
. 1.5 Building Setbacks(ft) h
Front Yard I Side Yards, Rear Yard
Required Provided Required Provided Required' Provided
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1-6 Water Supply:(M.G1.c.40,§54) 1.7 Flood Zone Information: 1.81 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal stem ❑
Public❑ Private CI. Check if yes0 R G p
SECTION 2: PROPERTY OWNERSHIP' y
2.1 Owner'of Record: p
Name rant) Address for Service:
til 3 rf S,-®-2 sI -/.
Signa Telephone
SECTIO 3:DESCRIPTION OF PROPOSED WORV(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed ork'.: y o
v s d Ou
• SECTION 4:ESTIMATED CONSTRUCTION COSTS f
Estimated Costs:
Item Official Use Only
(Labor and Materials
1.Building $
1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee (,
2.Electrical $ ❑Total Project Costs(Item 6)x multiplier x
3.Plumbing is 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire f
Su ression $ Total All F s:
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ® �� ❑paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construeti n Supervisor(CSL) C)
L—iceitse Number �tJ Expiration Date
Name of CSL-Holde
List CSL Type(see below),
Address T Description
U Unrestricted(up to 35,000 Cu.rt.)
Restricted l'&2 Family Dwelling
Signature �/ M Masonry Only I
RC Residential Roofing Covering
Telephone WS Residential Window,and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Rstered ome Im rov
c ie nt Qp9ttactor HI ,l
HIC C on Nam o C Regis ant e, . Registraf on Nu ber
•JXkpiratioA Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATIONN-.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.
Signed Affidavit Attached? Yes..........13 No.:.'•.......
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CbNTRACTOR APPLIES FOR BUILDING PERMIT
I, UJA e R 11A�Jv as Owner of the subject property hereby
authorize -Y_' P r e— - to act on my behalf,in all matters
relative to work authorized by this building permit application.
i
Si ature o Owner Date
SECTION 7b:OWNEV OR AU BORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
,r�, ( C- [ F) P. 1 /
Print Name
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Signature of Owner or Authorized Agent Date
Si ped under the pains and nalties ofperjury)
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 HBC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR.Regulations l OX6 and l IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square�ootage"maybe substituted for"Total Project Cost"
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The Commonwealth of Massachusetts
Department of Industrial Accidents
0 1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elce7icians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Alpplicant Information Please Print Legibly
Name (Business/Organization/Individual),:��
Address: �� ✓ ��J
City/State/Zip: tD/� C?A Phone
Are you an employer?Check the appropriate box:
Type of project(required):
1.E]I am a employer with employees(full and/or part-time).* 7. 0 New construction
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2.F�I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
). El Demolition
3.F1 I am a homeowner doing all work myself[No workers'comp,insurance required.]t
I 10 0 Building addition
4.[:]l ant a homeowner and will be hiring contractors to conduct all work on my property.-I will
ensure that all contractors either have workers'compensation insurance or are sole 11.171 Electrical repairs or additions
proprietors with no employees.
1.2.Fl Plumbing repairs or additions
5.❑I am a general contractor and I have Mired the sub-contractors listed on the attached sheet. 1 3. oo f repairs
These sub-contractors have employes and have workers'comp.insurance.t
6.02,W-are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Othor __
152,§1(4),and we have no employees.[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 indiicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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. k
I am an employer that is providing workers'compensation insurance for my employ s. B I[ow is the policy a;rd.job site
information. f 1
Insurance Company Name: /141?J'L
U �2�(� i
Policy#or Self-ins.Lic.#: Expiration Iration Date:__ 4 120
Job Site Address: ���Ce City/State/Zil�: �lG���/�
Attach a copy of the wo ers' 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 ORDLR and a fine of up to 5250.00 a
day against the violator.A copy ofthisstatement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify, :der theQmin i and pe s of perjury that the information provided r lb ve is tr rea nd correct.
-` Q l
Signature: Date:
Phone#: —1,6?
Official use only. Do not write i it this area,to be completed by city or town official.
City or Town: Permit/License# _
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspeci(or 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
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'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 einployer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint 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
reneH-al 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 bill out the worl<ers' 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 number(s)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. If an 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 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'fown 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 nits(submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy inliormation(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 is 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 burn 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 02-7.3-15 www.mass.gov/dia
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City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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 Eby this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work:
The debris will be transported by: V�
The debris will be received by: (�
Building permit n l mber:
Name of Permit Applicant
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Date Signature of Permit Applicant
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