23B-029 (6) 16 DANA ST BP-2020-0375
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B-029 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-2020-0375
Project# JS-2020-000639
Est. Cost: $16000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SOVEREIGN BUILDERS INCO60176
Lot Size(sq. ft.): 12545.28 Owner: GONSKI WILLIAM W JR&ALICE C C/O EDWIN J SCAGEL
Zoning: URB(100)/ Applicant: SOVEREIGN BUILDERS INC
AT. 16 DANA ST
Applicant Address: Phone: Insurance:
135 SOUTHAMPTON RD (413) 527-8001 Workers
Compensation
WESTHAMPTONMAO 1027 ISSUED ON:9/23/2019 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 9/23/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northa ptoP ? n SlEbtus f Permit
Building Depart en t �E Curb C t/Driv�way Permit
212 Main Str t eptic Availability
Room 100 OF rut�OtN Nt tGr +-Availability
Northampton, MA 106�"'O kT"IAX wo Sets of Structural Plans
phone 413-587-1240 Fax 13= -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6P�4— 3 76
1.1 Property Address: This section to be completed by office
Map Lot_ Unit
16 Dana Street
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Edwin Scagel 16 Dana Street, Apt B
Name(Print) Current Mailing Address:
�+ 413-250-7460
Telephone
Signature 1CI OF
2.2 Authorized Agent:
Todd Cellura/Soverei n Bui ers, In 135 Southampton Road, Westhampton, MA 01027
Name(Print) Current Mailing Address:
(413) 527-8001 / (413) 977-6608
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (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
Al
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
BuildingPermit Number: Date
Issued:
Signature: ul
Building Commissioner/Inspector of Buildings Date
tcellura@sovereignbuilders.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing CK
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[E3] Other[O]
Brief Description of Proposed
Work: Strip Slate Rnnf R Install Fxnnsed FastPnPr Metal Roof
Alteration of existing bedroom Yes X No Adding new bedroom Yes _X No �/
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, 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 construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves 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 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 APPLIES FOR BUILDING PERMIT
I, Edward Scagel as Owner of the subject
property
hereby authorize Todd Cellura of Sovereign Builders, Inc
to act on my behalf, in all matters relative to work authorized by this building per it ap lication.
Signature Owner Date
Todd Cellura 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.
Todd Cellura
Print Name
Signat re of Owne Agent Date
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Todd Cellura CS-060176
License Number
135 Southampton Road 01/19/2021
Address Expiration Date
Westham to A 01027 413) 527-8001 / (413) 977-6608
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Sovereign Builders, Inc 158240
Company Name Registration Number
135 Southampton Rd 05/29/2020
Address Expiration Date
Westhampton, MA 01027 Telephone(413) 527-8001
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.
Signed Affidavit Attached Yes....... M No...... ❑
City of Northampton
lr. . Massachusetts
A DEPARTMENT OF BUILDING INSPECTIONS 6
212 Main Street • Municipal Building vty iCs
Northampton, MA 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 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 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:Strip Slate Roof& Install Exposed Fastener Metal Roof Est. Cost: $ 9.800.00
Address of Work: 16 Dana Street, Apt B
Date of Permit Application: 09/19/2019
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:
09/19/2019 Todd Cellura of Sovereign Builders, Inc # 158240
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
DEPARTMENT OF BUILDING INSPECTIONS y. `
212 Main Street •Municipal Building
Northampton, MA 01060 rsy.....
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 111, S 150A.
The debris from construction work being performed at:
16 Dana Street, Northampton
(Please print house number and street name)
Is to be disposed of at:
UVM Holdings, 686 Main Street, Holyoke, MA 01040
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Associated Building Wreckers Inc., 352 Albany St., Springfield 01105
(Company Name and Addre )
J,
jj
i
Sign6ttirg dyPerrbiicant 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
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
lVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Al)Plicant Information Please Print Lezibly
Name (Business/Organization/Individual):Sovereign Builders, Inc.
Address: 135 Southampton Road
City/State/Zip: Westhampton, MA 01027 Phone#:(413)527-8001 / (413)977-6608
Are you an employer?Check the appropriate box: Type of project(required):
1.®I am a employer with 5 employees(full and/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.insurance required.]
9. El Demolition
3.E]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 [:]Building addition
4.❑I am 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 I L[]Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.®Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
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 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 isproviding workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name: Selective Insurance Co of Southeast
Policy#or Self-ins.Lic.#: WC '9057080 Expiration Date: 7/1/2020
Job Site Address: 64 Sovereign Way City/State/Zip: Northampton, MA 01060
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 state nt may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certifyFunhe pains penalties of perjury that the information provi�dyed abov is true and correct.
Signature:,,) Date: b
Phone#: (413) 5 7-800'1 /(413) 977-6608
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.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: